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




 
                                    IDEAS TO IMPROVE COMPETTION IN THE
                                           MEDICARE PROGRAM
                   __________________________________________________________
                   __________________________________________________________
                   
       
       
       
                                             HEARING

                                            BEFORE THE

                                      SUBCOMMITTEE ON HEALTH

                                              OF THE

                                    COMMITTEE ON WAYS AND MEANS

                                   U.S. HOUSE OF REPRESENTATIVES

                                  ONE HUNDRED FOURTEENTH CONGRESS

                                           FIRST SESSION
                                           ___________
 
                                          MAY 19, 2015
                                         ______________ 
  
                                        Serial 114-HL02
                                        ________________
 
                      Printed for the use of the Committee on Ways and Means
      
      
      
      
      
      
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]     





 

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                          COMMITTEE ON WAYS AND MEANS

                        PAUL RYAN, Wisconsin, Chairman

  SAM JOHNSON, Texas                               SANDER M. LEVIN, Michigan,
  KEVIN BRADY, Texas                               CHARLES B. RANGEL, New York
  DEVIN NUNES, California                          JIM MCDERMOTT, Washington
  PATRICK J. TIBERI, Ohio                          JOHN LEWIS, Georgia
  DAVID G. REICHERT, Washington                    RICHARD E. NEAL, Massachusetts
  CHARLES W. BOUSTANY, JR., Louisiana              XAVIER BECERRA, California
  PETER J. ROSKAM, Illinois                        LLOYD DOGGETT, Texas
  TOM PRICE, Georgia                               MIKE THOMPSON, California
  VERN BUCHANAN, Florida                           JOHN B. LARSON, Connecticut
  ADRIAN SMITH, Nebraska                           EARL BLUMENAUER, Oregon
  LYNN JENKINS, Kansas                             RON KIND, Wisconsin
  ERIK PAULSEN, Minnesota                          BILL PASCRELL, JR., New Jersey
  KENNY MARCHANT, Texas                            JOSEPH CROWLEY, New York
  DIANE BLACK, Tennessee                           DANNY DAVIS, Illinois
  TOM REED, New York                               LINDA SANCHEZ, California
  TODD YOUNG, Indiana
  MIKE KELLY, Pennsylvania
  JIM RENACCI, Ohio
  PAT MEEHAN, Pennsylvania
  KRISTI NOEM, South Dakota
  GEORGE HOLDING, North Carolina
  JASON SMITH, Missouri
  ROBERT J. DOLD, Illinois


                                 JOYCE MYER, Staff Director

                 JANICE MAYS, Minority Chief Counsel and Staff Director
                                     
                                 _____________________
                                                     
                                 SUBCOMMITTEE ON HEALTH

                                KEVIN BRADY, Texas, Chairman

       SAM JOHNSON, Texas                               JIM MCDERMOTT, Washington
       DEVIN NUNES, California                          MIKE THOMPSON, California
       PETER J. ROSKAM, Illinois                        RON KIND, Wisconsin
       TOM PRICE, Georgia                               EARL BLUMENAUER, Oregon
       VERN BUCHANAN, Florida                           BILL PASCRELL, JR., New Jersey
       ADRIAN SMITH, Nebraska                           DANNY DAVIS, Illinois
       LYNN JENKINS, Kansas
       KENNY MARCHANT, Texas
       DIANE BLACK, Tennessee




                                              C O N T E N T S

                                              ________________
                                                                                                   Page
    Advisory of May 19, 2015 announcing the hearing .......................................           2   
           
                                        WITNESSES

Mr. Joe Antos, Wilson H. Taylor Scholar in Health Care and Retirement 
Policy, American Enterprise Institute.............................................................   10

Joe Minissale, President, Methodist McKinney Hospital.............................................   19

Robert Steedley, President, Barnes Healthcare Services, on behalf of 
American Association for Homecare.................................................................   26

Rich Umbdenstock, President and CEO, American Hospital Association................................   39

                                  SUBMISSIONS FOR THE RECORD

Dr. Anne S. Hast, statement.......................................................................  127
Dr. Daryl List, statement.........................................................................  131
Michael Torn, statement...........................................................................  133
David Lippert, statement..........................................................................  137
Jason Leymeister, statement.......................................................................  139
Lafayette Surgical Specialty Hospital, letter.....................................................  140 
Medicare Rights, letter...........................................................................  146
Dr. David L. Sappenfield, statement...............................................................  148
Michael Russell, statement........................................................................  150
Sharon P. Pearce, letter and addendum.............................................................  152
American Medical, statement.......................................................................  162
Dr. Frederick E. Liss, statement..................................................................  167
Mark McDonald, statement..........................................................................  171
K&S Consulting, statement.........................................................................  174
Edward Kerens Jr., statement......................................................................  176
Mark Kennedy, statement...........................................................................  178
Robert Behar, statement...........................................................................  180
John R. Graham, statement.........................................................................  184
Blake Curd, statement.............................................................................  189 
Salina Surgical, statement........................................................................  199
Heart Hospital, statement.........................................................................  204
Richard Bruch, statement..........................................................................  211
Edward Ray, letter................................................................................  214
Sheree E. Barak, letter...........................................................................  215
Harold Kernodle, Jr., letter......................................................................  216
Karen F. May, letter..............................................................................  217
Candy Johnston, letter............................................................................  218
J. Mack Aldridge, letter..........................................................................  219
Kim Lyon, letter..................................................................................  220


                  IMPROVING COMPETITION IN MEDICARE: REMOVING MORATORIA AND EXPANDING 
                                                ACCESS
                                          _______________

                                       Tuesday, May 19, 2015
                                       
                                             House of Representatives,
                                             Committee on Ways and Means,                  
                                                 Subcommittee on Health, 
                              
                                                          Washington, D.C.


The subcommittee met, pursuant to call, at 9:59 a.m., in Room 1100, 
Longworth House Office Building, Hon. Kevin Brady [chairman of the 
subcommittee] presiding.

[The advisory announcing the hearing follows:]


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


Chairman Brady. Welcome to today's hearing on improving competition, within 
the important Medicare program. This is the first in a series of hearings 
this summer and fall on identifying solutions to saving Medicare for the 
long term. Today we are going to explore how much competition exists in 
Medicare, its impact, its benefits and savings for Medicare patients, as 
well as potential for improving Medicare access in choices through more 
competition.

We are also going to hear about two ideas to make Medicare more responsive 
to seniors' needs, while also driving down costs and expanding access. 
Competition is a good thing, it drives down costs and increases access 
while improving quality. Most importantly it empowers consumers. 
Competition and the choices it offers is how we discover information on the 
prices and quality.

It gives families the power to decide what they want to buy and how to 
stretch their dollars further. Competition is a critical component of 
virtually every sector in our economy save one, Medicare. While more often 
than not, Medicare stifles competition and choices through legislative 
action and agency enforcement. Medicare sets prices and sets the standards 
by which it determines quality. Rather than empowering consumers, Medicare 
program limits choices.

This system is set up so that providers are more likely to fight rulemaking 
decisions handed down from government agencies than they are to compete 
with each other, to offer better services to Medicare patients. The 
Medicare fee-for-service program is a perfect example. This fiscal year, 
Medicare's projected to pay $375 billion for part A and part B services, 
that is doctor and hospital services. The vast majority of that spending 
the Centers for Medicare & Medicaid Services is directly responsible for 
setting, implementing and managing these payments. In other words, the 
massive bureaucracy picks winners and losers among countless health care 
providers. Competition and choice and the preferences of Medicare seniors 
play little role in the administration of all that spending. It shows the 
program unfortunately is going insolvent.

By contrast, competition choices for seniors play a proven critical role in 
two successful programs, Medicare Advantage program, and Medicare part D, 
which provides prescription drugs. In these two extremely popular programs 
Medicare seniors are the ones in control, not the government. Plans compete 
fiercely for the health care businesses, offering services and benefits to 
fit the needs of Medicare patients, not Washington. If consumers are 
unhappy with their service, they can they can say no thanks and change 
their plan to one that meets their needs. It is that simple, and it works.

Right now, seniors have accessed more than 3,600 Medicare Advantage plans 
tailored to meet their specific needs. Competition is robust, and not 
surprisingly, patient satisfaction is high. The same is true of the part D 
prescription drug program, which is one of the few government health 
programs to actually come in under budget projections, and whose average 
base monthly premiums are as low today at $33, as when the program began in 
2006 at $32.

Preventive care prescription plans seniors have dozens of choices in each 
State and can pick a plan that works for them. Studies show this very fact 
has led to a decrease in their out-of-pocket costs which is great news for 
seniors. Competition has proven to work in Medicare Advantage and it works 
on the part D prescription drug program. So how can it work in the larger 
Medicare fee-for-service system?

Today we will look at two proposals that do just that. The first is 
expanding seniors' access to local physician-owned hospitals. This is an 
issue Mr. Johnson of Texas has been working on for quite some time. 
Physician-owned hospitals are full service community hospitals that serve 
both rural and urban communities, they specialize and providing essential 
health services in areas that are considered underserved. But since 2005, 
these hospitals have been prevented from growing to meet the needs of their 
communities. As a consequence, there are just over 230 of these kinds of 
hospitals in operation around the country compared to 3,400 national acute 
care hospitals.

The questions before us include should seniors continue to be blocked from 
access to these high-performing hospitals? What are the impacts pro and con 
of this discrimination against one model of acute care? And is the current 
ban based on quality of service, or desire to restrain competition? At this 
point, a decade into the temporary moratorium, it is the right time to have 
a thoughtful discussion on this issue.

The second idea seeks to improve the way Medicare currently administers the 
durable medical equipment benefit, Dr. Tom Price of Georgia has spent a 
significant amount of time looking at this issue, as well as other members 
of this panel and the Ways and Means Committee. He has been working on a 
reform that would inject a more market-based approach to help address some 
of the more serious concerns Members of Congress from both parties have all 
heard about from our constituents.

These two proposals have the potential for improving competition, end the 
benefits within Medicare. But ultimately, Congress needs to examine how we 
administer the Medicare program overall. The current program is critical, 
but unsustainable. It went from the program's own actuaries to nonpartisan 
scorekeepers like the Congressional Budget Office. Outside watchdog groups 
have worried about this, and warned us about this growing problem. Members 
of both Parties in Congress have a responsibility to save Medicare for the 
long term, improve and protect Medicare for today's seniors and for future 
generations.

We recently took the first important step by solving the way Medicare pays 
its doctors. The second step, we must turn immediately exploring how we 
improve the way Medicare pays its other health care providers, from the 
testing and evaluation leading into the hospital, to inpatient and 
outpatient care, and post-acute care after leaving the hospital.

The Health Subcommittee will continue to hold hearings on this topic over 
the course of this year. Developed reforms will put Medicare on a 
sustainable path.

So to help us get started, I would like to welcome today's witnesses, Joe 
Antos, from the American Enterprise Institute; Joe Minissale, president of 
Methodist McKinney Hospital in Texas; Robert Steedley, president of Barnes 
Health Care Services in Georgia; and Richard Umbdenstock, president and CEO 
of the American Hospital Association.

And before I recognize the ranking member, Dr. McDermott, for the purposes 
of an opening statement, I ask unanimous consent that all members' written 
statements be included in the record. Without objection, so ordered.

I now recognize Dr. McDermott for his opening statement.

Mr. McDermott. Thank you, Mr. Chairman. We are here today to talk about the 
second part of health care reform, that is, control of cost. Access under 
the Affordable Care Act is rising clearly where people have access to 
health care supposedly. The question is about how do you get control of 
costs? And we are talking today about improving competition in Medicare. 
Now I can't help but wonder, having sat here for a number of years, what 
this hearing is really going to accomplish. If this hearing were about 
competition, we would look carefully about how to drive down prices and get 
a handle on health care costs. That would mean reducing wastes and 
overpayment to industries that are profiting at the expense of the American 
public. The more the American medical industrial complexes enter the 
government pocket, the more it becomes our issue here.

Unfortunately, the proposals we will hear this morning won't control costs; 
instead, they are designed to appease the very interest that benefit from 
the waste in the system and contribute to higher health care spending. A 
hearing like this would make us ask ourselves, are we serious about 
controlling costs or would we rather just want to talk about it?

We are going to discuss ways to revise Medicare's competitive bidding 
program for durable medical equipment. Specifically, we will hear a 
proposal that will put a halt to the existing program, reduce competition 
and ultimately increase cost for Medicare and beneficiaries. The real irony 
of this hearing is, because I remember when it was Republicans who were the 
champions of competitive bidding. I have been on this committee long enough 
to listen to all of this, and the problem of health care costs in devices 
has been there. It was a Republican Congress that first introduced the 
concept to Medicare as a demonstration project in the Balanced Budget 
Amendment Act of 1997. And it was a Republican Congress that expanded the 
program in 2003 as a part of the prescription drug legislation.

Now despite some hiccups along the way, the programs it had remarkable 
success or at least measurable success. First round of competitive bidding 
saved over $580 million in 2 years, and HHS projects that over 10 years, we 
will save over $43 billion. Of course, we should continue to carefully 
oversee the implementation of competitive bidding, but proposals like the 
one that is before us today, to delay or undermine signals to the American 
people that Congress is more concerned about appeasing an industry than it 
is about controlling costs.

We are also going to discuss the moratorium on new and expanded physician-
owned hospitals. For many years, specialty hospitals enjoyed a loophole in 
the STOCK Act that allowed doctors to make referrals to hospitals in which 
they had an ownership interest. As long as the ownership interest was in 
the whole hospital rather than subdivision of it--you couldn't have just 
one department--physicians could make referrals that otherwise would have 
been illegal. The result was a rapid growth in physician-owned hospitals 
which skewed the market in troubling ways. Nonpartisan experts of MedPac, 
GAO, the Office of Inspector General, for years have expressed serious 
concerns that these hospitals increased utilization of services and drive 
up healthcare costs.

Now, closing this loophole is a cost saving measure that has always had 
bipartisan support. We pass temporary moratoriums during the Republican-
controlled Congresses, and we made it permanent as a part of the Affordable 
Care Act. This reform will save the American people $500 million according 
to the CBO. There is simply no good reason to reverse course and undue this 
progress. It will make the industry happy, but it will bring needless waste 
back into the healthcare system and ultimately harm the hardworking 
families of this country who are paying for this system.

Getting serious about controlling costs is more important now than ever. 
The Affordable Care Act continues to expand access, more and more people 
cover, everybody is clapping their hands and popping the corks on champagne 
bottles about how many more people. When all is said and done, more than 30 
million additional people have been brought into the system. As this 
happens, the healthcare system is rapidly changing, medicine is 
transforming from a profession into a business. Market powers consolidating 
in fewer and fewer hands as hospitals merge and swallow up independent 
doctors' practices. This raises a number of questions about competition, 
cost, and patient care that we need to answer. Until we take a careful look 
at what this trend means, we are sending a message to the American people 
that appeasing wasteful industry actors is more important than controlling 
costs.

I sent a letter to the chairman earlier about my concerns about 
consolidating hospitals and having less and less competition in various 
parts of the country, and I would ask unanimous consent to have that put 
into the record.

Chairman Brady. Without objection, so ordered.

[The information follows: The Honorable Jim McDermott Submission]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Mr. McDermott. I yield back the balance of my time.

Chairman Brady. Thank you. Mr. Antos, welcome today and you are recognized 
for the 5 minutes.

STATEMENT OF JOE ANTOS, WILSON H. TAYLOR SCHOLAR IN HEALTH CARE AND 
RETIREMENT POLICY, AMERICAN ENTERPRISE INSTITUTE

Mr. Antos. Thank you, Chairman Brady, and Ranking Member McDermott and 
members of the committee. Competition is central to obtaining good value 
for the dollars spent by beneficiaries and taxpayers in the Medicare 
program. Congress must avoid the temptation to smother competitive markets 
in Medicare through overregulation. Private plans must follow rules--
private plans and private providers must follow rules designed to protect 
consumers and ensure access to all necessary health services covered by the 
program, but the regulation should not be drawn so narrowly that healthcare 
delivery innovations cannot be adopted, or once adopted, cannot be altered 
or dropped. The rules should neither prevent the entry of new competing 
firms nor protect firms already in the market from competition. A 
competitive Medicare program must welcome change, while ensuring that 
beneficiaries and taxpayers are well served.

As the chairman said, the two leading examples of competitive markets in 
the Medicare program are Medicare Advantage and part D. Medicare Advantage 
is an increasingly popular alternative to fee-for-service Medicare. Even 
with payment reductions mandated by the Affordable Care Act, Medicare 
Advantage enrollment has grown from 11.9 million people in 2011 to 16.2 
million this year. More than 30 percent of Medicare beneficiaries are 
enrolled in Medicare Advantage plans. Clearly, for a growing number of 
beneficiaries, competitive Medicare Advantage plans are a better deal 
compared to fee-for-service Medicare combined with separate Medigap and 
prescription drug plans.

Part D, as the chairman said, has also been a remarkable success, and its 
cost has fallen hundreds of billions of dollars below CBO estimates. I am 
going to focus my remarks on the Medicare Advantage, my written statement 
has more detail about both programs.

There is growing evidence that Medicare Advantage--have I run out of time? 
The lights aren't lit.

Chairman Brady. I think you are in good shape on time.

Mr. Antos. Sorry, so evidence that Medicare Advantage plans provide higher 
value services, less cost to society than traditional fee-for-service. 
First of all, Medicare Advantage plans are more efficient in delivering 
care than fee-for-service. According to the Medicare Payment Advisory 
Commission, the average MA plan bid in 2014 was 98 percent of fee-for-
service spending. In 2015, the average bid was 94 percent. That means that 
MA plans are willing to pay to deliver standard benefits, 6 percentage 
points cheaper than fee-for-service can on average over the country.

HMO plans were, of course, more efficient, their bids averaged 90 percent 
for fee-for-service spending. Now why are they being paid more than that? 
Well, the answer is the payment formula, of course. The plans are paid 
their bid, unless they bid below the benchmark. The benchmark was set to 
ensure that essentially everyone would have access to Medicare Advantage 
plans, so it tends to be higher than fee-for-service. Benchmark this year 
is 107 percent of fee-for-service, so the amount that MA plans are paid 
based on their quality performance is about 102 percent of fee-for-service 
spending. That doesn't tell you anything about the efficiency of delivering 
health care, that says something about the peculiarities of the payment 
system.

Second, MA plans have a spillover effect that lowers health care costs more 
generally. Turns out that studies have shown that for every 1 percent 
increase in Medicare Advantage enrollment in the market, there is a nine-
tenths percent reduction in fee-for-service Medicare spending, and a 
general overall reduction in spending as well as on a per-person basis in 
the community.

Third, MA plans provide higher quality care. Beneficiaries in Medicare 
HMOs, for example, are consistently more likely than those in traditional 
Medicare to receive appropriate risk cancer screening, diabetes care, 
cholesterol screening, and so on.

And finally, the problem with favorable selection, which we have all been 
concerned about for many years, has largely been solved. This isn't just my 
opinion, this is Professor Joseph Newhouse at Harvard University and his 
colleagues pointed out the changes Congress made have improved the accuracy 
of payments in Medicare Advantage, and the lock-in procedure, the new 
method of risk adjustment, these are things that have largely eliminated 
favorable selection so that the payments to MA plans are not--aggregately 
reflect the costs to providing care to beneficiaries.

Competing private plans are strong incentives to provide health care 
efficiently and effectively to tailor the coverage and services of the 
needs and demands of their customers. By necessity, private plans are more 
flexibility and responsive to changing market conditions and consumer 
demands than fee-for-service Medicare. Satisfying your customers is a 
matter of survival. Doing so efficiently is the difference between a 
successful health plan and one that has failed.

[The prepared statement of Mr. Antos follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Chairman Brady. Thank you, Mr. Antos, very much. Mr. Minissale, you are 
recognized for 5 minutes. I know as a constituent of St. Johnson, our 
colleague here you have great representation here now.

STATEMENT OF JOE MINISSALE, PRESIDENT, METHODIST MCKINNEY HOSPITAL

Mr. Minissale. Chairman Brady, Ranking Member McDermott, members of the 
Ways and Means Health Subcommittee, thank you for having me here today to 
testify. I am the President of Methodist McKinney Hospital, which is in 
McKinney, Texas. Methodist McKinney Hospital opened in February of 2010 
just prior to the Accountable Care Act prohibition on physician ownership 
in hospitals.

Our hospital is a partnership with Methodist Health System, Nueterra 
Healthcare and local physicians.

Methodist Health System is a nonprofit health system that has for decades 
taken care of the underserved in Dallas, the indigent in the south part of 
the community. Over 51 percent of our profits go back to Methodist Health 
System to serve those in those communities. We accept almost all 
insurances, including Medicare, Medicaid, TRICARE, workers comp, most 
managed care plans, Medicare supplements. Our hospital employees are over 
119 full-time employees. We have over 230 members on our medical staff, and 
only 22 of those members on the medical staff are physician investors.

We paid over $2.5 million in taxes last year, something that not for-profit 
hospitals do not share the burden in. Our services include inpatient care, 
internal medicine, emergency medicine, imaging, surgery, pain management, 
physical therapy, among many other things. We have a broad range of 
specialties that include pain management, gastroenterology, ENT, general 
surgery, medicine and more.

We have an ER average waiting time of just 76 minutes compared to over 2 
hours at our competitors. The primary reason Methodist McKinney Hospital 
was developed was due to frustration with the local physicians over 
administration and health system management with the local hospitals. They 
wanted a hospital where patient care was always put first, not just the 
bottom line. So they decided to take matters into their own hands and build 
a hospital that was driven by the principles that physicians who spent 
their lives taking care of patients held dearly.

Having spent my career managing hospitals, I know one of the keys to 
success in hospital administration is to have good alignment between the 
hospital and the physicians. In a physician-ownership model, I feel like we 
have that much more than I enjoyed when I worked in other ownership models.

This culture has allowed us to endear ourselves to local physicians, nurses 
and other clinical caregivers because we care about the patient first and 
bottom line second. But we also care deeply about our employees and our 
community. We have won some good achievements and accolades to represent 
that. We received a 4 out of 5 star rating on CMS' Hospital Star Program. 
We are consistently above the 90th percentile on the HCAHPS, patient 
satisfaction surveys. We have been named a Dallas, Fort Worth, top 100 
employer in 2013, 2014. We have consistently been over 100 percent of 
baseline on the CMS value based purchasing program. And we receive the 
Joint Commission Gold Seal of Approval on Accreditation.

Thanks to strong support from the community, our hospital has been getting 
close to capacity in some areas. That is a good problem and a bad. We are 
in a growing community, Collin County in McKinney, Texas, have been 
expanding rapidly by growing more than 70 percent since 2000.

Patients can choose to go to a lot of good health care providers in our 
community, but many are choosing us. As a result, we are now at a 
crossroads where our board and our partners are going to have to decide, do 
we leave Medicare, Medicaid and TRICARE patients behind so we can grow the 
hospital and meet the growing demand and the growing community? Or do we 
just stop growing and stay where we are and just tell people we can't serve 
any more than we already are?

Twenty-seven percent of our current patient base has those insurances. It 
is very discouraging to think that we could spend years trying to meet the 
exceptions, and I am not sure anybody can meet the exceptions in 
accountable care. Even if you can meet it, it is going to be hard to prove 
and you are going to have to jump through a lot of hoops, yet our 
competitors do not have to do that. We don't want to leave the seniors and 
the military families behind so I would ask you to repeal section 6001 of 
the Accountable Care Act so we don't have to make decisions to not have 
access to those seniors and military families. Thank you.

[The prepared statement of Mr. Minissale follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Chairman Brady. Mr. Minissale, 5 minutes goes fast, but we have all your 
testimony for the record. So Mr. Steedley you are recognized for 5 minutes.

STATEMENT OF ROBERT STEEDLEY, PRESIDENT, BARNES HEALTHCARE SERVICES, ON 
BEHALF OF THE AMERICAN ASSOCIATION FOR HOMECARE

Mr. Steedley. Good morning. My name is Robert Steedley, and I am the 
president for Barnes Healthcare Services, a regional home care provider 
based in Georgia. I also serve as the voluntary chairman of the board of 
directors for the American Association of Homecare, which is the national 
trade association for home medical equipment, providers, manufacturers and 
other stakeholders in the home care community.

I would like to thank Chairman Brady, Ranking Member McDermott and members 
of the House Ways and Means Subcommittee on Health for holding this hearing 
on improving competition and Medicare. I would also like to thank 
Congressman Tom Price and Congressman John Larson for introducing 
legislation that would create a state-of-the-art, market-driven auction 
system, an alternative to the competitive bid program.

I am here today to talk about flaws in the current bids program, how those 
flaws impact noncompetitive bid areas and offer a better budget neutral 
solution. Both the association and I fully support healthy and fair 
competition. My testimony also comes from firsthand experience with the 
bidding program at Barnes Healthcare. Opening in 1909, Barnes Healthcare 
Services has 106 years of experience, employs more than 300 people across 
14 locations and serves 4 States. Experts in the past explain in great 
detail why CMS bidding program lacks transparency and restricts patient 
choice and access to the prescribed home medical equipment they need. I 
have also detailed these in my written testimony.

Fortunately, Congress recently passed legislation to help fix one of those 
issues of the program, the lack of a binding bid. AA Homecare would like to 
thank Congressmen Tiberi and Larson for introducing legislation that 
require binding bids. I would also like to thank the Ways and Means 
Committee for its consideration and approval of this bill which was 
included in the file SGR bill.

Requiring binding bids is a key provision in the Congressman Price and 
Congressman Larson's Market Pricing Program legislation, which is also 
known as MPP. The issues with the competitive bid program are not just 
limited to round 1 and 2. In October 2014, CMS also issued a final rule 
that applies the artificially low competitive bid raise to all non-bidding 
areas, including rural and underserved.

The artificially low competitive bid rates are only part of the problem of 
this final rule. The application of payment rates to non-bid areas is 
flawed and will disrupt Medicare beneficiary access to the home medical 
equipment items that they need.

In competitive bid areas, the suppliers try to make up for drastic cuts 
through increased volume. As a result of the CMS final rule, suppliers 
outside of those bid areas will receive the same drastic cuts without the 
exclusive contracts or increases in the volumes of business.

There is a better budget neutral way to achieve market prices for home 
medical equipment known as the Market Pricing Program. I have included more 
detailed information in my written testimony, but following are a few 
components of MPP. MPP includes the same items that are currently in the 
CMS bidding program, and it is also nationwide. There are two categories 
bid per geographic area, eight additional categories in that same area, 
would have prices adjusted based on auctions conducted simultaneously in 
comparable geographic markets.

Bid areas are smaller than the Metropolitan Statistical Areas, also known 
as MSAs and more homogeneous. Finding bids are required to ensure only 
serious bidders participate. The bid price is based on the clearing price 
rather than the median price of the winners. And finally, the same areas 
that are exempted from bidding under competitive bidding program from CMS 
will be exempted under MPP.

As committee members can see from my written testimony, MPP is simply a 
much better auction system than the current CMS competitive bid system. MPP 
uses auction principles supported by economists and auction experts. It is 
more transparent and efficient in the current program and it will achieve 
the goal of Congress to have true market prices for home medical equipment 
in Medicare.

AA Homecare was very thankful when Congressman Price and Larson introduced 
MPP, the Medicare DME Post Market Pricing Program Act in 113th Congress. 
This legislation has received strong bipartisan support with 180 
cosponsors. AA Homecare strongly supports this commonsense legislation and 
urges the subcommittee and Congress to do the same.

I would like to thank the committee again for the opportunity to provide 
this testimony. AA Homecare and I look forward to working with the 
subcommittee to improve competition in Medicare while protecting patients' 
access to the needed home care equipment. Thank you.

Chairman Brady. Thank you, Mr. Steedley. I was just told that our normal 
lighting system that gives you the yellow light and the one-minute warning 
to wrap up isn't working today, so I apologize for that. We will get that 
back on track soon.

Mr. Umbdenstock, thank you for your leadership of AHA and you are 
recognized for 5 minutes.

[The prepared statement of Mr. Steedley follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

STATEMENT OF RICH UMBDENSTOCK, PRESIDENT AND CEO, AMERICAN HOSPITAL 
ASSOCIATION

Mr. Umbdenstock. Chairman Brady, Ranking Member McDermott, members of the 
subcommittee. On behalf of our nearly 5,000 member hospitals, health 
systems and other healthcare organizations I thank you for the opportunity 
to testify today. Community hospitals embrace fair competition where 
facilities compete over quality, price and patient satisfaction. However, 
we are strongly opposed to the practice of self-referral, which skews the 
marketplace in favor of physician owners who self-refer the healthiest and 
wealthiest patients to their own facilities. Therefore, the AHA urges 
Congress to current law preserving the ban on physician self-referral to 
new physician-owned hospitals and retaining the restrictions on the growth 
of existing physician-owned hospitals.

Physician self-referral is contrary to competition. It allows physicians to 
steer the most profitable patients to facilities in which they have an 
ownership interest or potentially devastating the healthcare safety net in 
vulnerable communities.

Changing the current law would not foster competition. Instead, it would 
only allow these physicians to increase their profits. Current law 
represents a compromise that protects the current physician ownership of 
hospital arrangements and allows these arrangements to grow where increased 
hospital capacity is needed. However, some have proposed weakened 
significantly Medicare's prohibition on physician self-referral to new 
physician-owned hospitals and loosened the restrictions on the growth of 
grandfathered hospitals.

The AHA strongly opposes these changes, any changes that would expand the 
use of the whole hospital exception, beyond grandfathered hospitals or that 
allow grandfathered hospitals to expand or increase their capacity beyond 
what is allowed in current law for three primary reasons: First, physician-
owned hospitals provide limited or no emergency services, relying instead 
on publicly funded 911 services when their patients need emergency care. 
HHS's Office of the Inspector General reported that, quote, ``two-thirds of 
physician owned specialty hospitals use 911 as part of their emergency 
response procedures.'' And, quote, ``most notably, 34 percent of specialty 
hospitals use 911 to obtain medical assistance to stabilize patients, a 
practice that may violate Medicare requirements.''

Second, physician self-referral leads to greater utilization of services 
and higher costs, CPO, MedPac and independent researchers all have 
concluded that physicians self-referral leads to greater per capita 
utilization of services and higher costs to the Medicare program.

Third, physician-owned hospitals tend to cherry-pick the most profitable 
patients and services, jeopardizing communities access to full service 
care. GAO, CMS and MedPac have all found that physician-owned hospital 
patients tend to be healthier than patients with the same diagnosis of 
general hospitals. Further, MedPac and GAO found that physician-owned 
hospitals treat substantially fewer Medicaid patients. This trend creates a 
destabilizing environment that leaves sicker and less affluent patients to 
community hospitals. These selection practices place full service hospitals 
at a competitive disadvantage because they depend on a balance of services 
and patients to support the broader needs of the community.

The current payment system does not explicitly fund standby capacity for 
emergency trauma, burn services or the like, nor does it fully reimburse 
hospitals for the care provided to Medicaid and uninsured patients. 
Community hospitals rely on cross subsidies from better reimbursed 
services, the very services targeted by physician-owned hospitals to 
support these and other essential, but under-reimbursed health services. 
Resident loss to specialty hospitals can lead to staff cuts and reductions 
in subsidized services.

In addition, many of the physicians profiting from limited service 
hospitals will not serve on-call in the community's emergency department, 
or participate in wider quality improvement projects that benefit the 
community. These facilities duplicate services, further exacerbating the 
shortages of physicians and allied health professionals in some 
communities.

Furthermore, closing the whole hospital exception loophole in the Stark law 
reduced the Federal deficit by $500 million over 10 years, according to the 
CBO. Proposed changes to the current law would erase those savings and 
raise the deficit at a time when our Nation is trying to control increases 
in health care costs.

True, our competition could be fostered by making commonsense changes to 
law to allow greater care coordination and new delivery models. The health 
care field is rapidly changing, moving toward new payment delivery models 
that emphasize value over volume. As part of that change, hospitals are 
actively exploring clinical integration, a move away from working in silos 
toward emphasizing teamwork to coordinate care.

However, hospitals attempting to seize these opportunities to improve care 
and care coordination for Medicare beneficiaries and other patients face 
significant legal barriers. Chief among these are the outdated rules 
governing compensation relationships between hospitals, physicians and 
other caregivers. Portions of the anti-kickback statute, the Stark law and 
civil monetary penalty law.

Congress recently acknowledged the need for change to the CMP law through 
the work of this committee in the recent SGR bill, which limited the scope 
of this prohibition so that a hospital is only subject to CMPs for making 
payments that will reduce or limit medically-necessary care. We advocated 
for this change and are pleased that Congress lifted this barrier.

Chairman Brady. Mr. Umbdenstock, I apologize.

Mr. Umbdenstock. No problem, sir. Thank you very much.

[The prepared statement of Mr. Umbdenstock follows:]

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Chairman Brady. Thank you very much. Mr. Antos, in Washington, we like to 
talk a lot of about cost control, Washington sort of setting prices and 
then determining whether it is the right amount, or if you deserve this. 
You talked about competition as a more patient-centered way to find savings 
and efficiency. Can you talk about briefly--I have questions for our 
witnesses--can you talk briefly about which one better serves seniors while 
creating savings?

Mr. Antos. Well, thank you, Mr. Chairman. It certainly is the case that the 
fee-for-service incentives are to expand volume of services and to focus 
only on the part that you as the specific provider, whether it is a 
hospital or a physician or some other provider, but only your part of the 
patient's health care. So, in fact, I found that Mr. Umbdenstock's point 
about expanding services, I believe that that is endemic in the Medicare 
fee-for-service system. If you don't provide services, you don't get paid.

So as far as a competitive program doing a better job of serving patients 
and giving patients what they want, which is not only a good financial 
deal, but also good patient outcomes, then you really have to go to private 
plans, that I think we see in much of Medicare Advantage where they look at 
the whole patient.

Now short of that, fostering real competition, avoiding having CMS or 
Congress set prices, when, in fact, we don't know what the prices are, all 
we know is what the charges are. We need to introduce more competitive 
approaches in traditional Medicare, but ultimately, I think we are going to 
have to move to a more coordinated system, Medicare Advantage is not that 
way.

Chairman Brady. Mr. Antos, thank you. I notice in the prescription drug 
program, the Democratic alternative to the Republican plan set a monthly 
premium of $35 for Medicare part D. Here we are 10 years later after, and 
through cost increases, prices all that, the average price is still below 
the cost control price that originally buy the alternative through 
competition.

Mr. Antos. Well, that comes from several factors, perhaps the biggest 
factor is the competitive effect. The different drug plans know that if 
they are going to make money, they have to attract customers. If they are 
going to attract customers, they have to offer a good balance of access to 
drugs, including expensive drugs and low cost.

The remarkable thing about this program really, is, as you say, we have 
seen premiums basically stay level for the last 10 years or so. That is 
partly due to the fact that we have seen a slowdown in the introduction of 
expensive new drugs. But importantly, part D plans have really encouraged 
Medicare beneficiaries to use generic alternatives that has been very 
effective.

Chairman Brady. Thank you, Mr. Antos. Mr. Minissale, thank you for being 
here. We are told the problem with physician-owned hospitals is that they 
don't have an ER, that they self-refer so there is greater utilization 
among themselves at a higher cost, and that you cherry-pick the patients 
who come through your door. Can you talk a little bit about your 
experience? I think you served both in for-profit and nonprofit in our 
position on the House bill so you have seen the operations in all those 
models. Your thoughts?

Mr. Minissale. Yes, sir. First, I want to mention in terms of cherry-
picking, it should be pointed out that we serve TRICARE, we are a TRICARE 
provider, our facility, and one of two largest health systems in Dallas-
Fort Worth area, is not a provider, and I guarantee you, we are not doing 
that because of the high TRICARE payment levels. So that would be one 
example of cherry-picking.

We do have an ER, and we have advertised it since we have been open on an 
ongoing basis to try and get more people to come in and open those doors 
up.

Also, as you mentioned in previous positions, I have been responsible for 
facilities in the southwest side of San Antonio where we had physician 
ownership, and it was a very large indigent population there, underserved, 
the same situation in Congressman Eddie Bernice Johnson's district in north 
Houston where we had physician ownership, in Port Arthur, in Odessa. These 
are full service hospitals with physician ownership that were--didn't have 
the opportunity to cherry-pick.

Chairman Brady. You are 4 star rated?

Mr. Minissale. Yes, sir. Yes, sir.

Chairman Brady. That star rating takes into effect the complexity of the 
patients you are serving, correct? So if you are cherry-picking, in fact, 
you are punished in that star rating, correct?

Mr. Minissale. Yes, sir. I would point out that many of the physicians that 
work at our hospital bring most of their patients to our facility. 
Obviously we are a 21-bed facility, so they can't bring 100 percent, but, 
yes, I think the--in our circumstance, the cherry-picking is greatly 
exaggerated.

Chairman Brady. How many times have you called, your hospital called 911 
for emergency services.

Mr. Minissale. Actually, we have a process for strokes, we have a code 
STEMI, which those are the situations where, like, there are certified 
stroke centers and certified heart centers where time is of the essence 
where we would need to get that patient transferred to the highest level of 
care possible. In fact, there are not a lot of stroke certified centers 
even among the larger hospitals in our area.

Chairman Brady. So when you dial 911, it is to get the patient to the 
highest certified and qualified local provider?

Mr. Minissale. Correct, correct. And that has been very rare, but that has 
happened a few times I would say probably three times in 5 years, maybe for 
us.

Chairman Brady. Thank you. Mr. Umbdenstock, you raised points. We have 
heard as concerns, that these hospitals don't have functioning ERs, they 
self-refer to each other as physicians and they cherry-pick. Looking for 
common ground, in recognizing in the decades since this temporary 
moratorium was put in place, before profit and nonprofit hospitals have 
increased their beds easily more than double all the position on hospital 
beds in America. So you are allowed to grow to meet the needs of the 
community, which seems to me to make good sense.

So the common ground here with physician-owned hospitals, I can guarantee 
you they are not all in the best parts of town, while I have noticed 
nonprofit and for-profit do grow to meet the needs of the community. So 
would a compromise be if physician-owned hospitals had a functioning ER, 
that they are shown to not self-refer in high utilization like CMS, and 
their stars rating proved that they are not cherry-picking, but meeting the 
needs of their community. Is that an area where this discrimination against 
one model could end and we could have competition among all the hospitals? 
Is this a common ground you would consider?

Mr. Umbdenstock. Mr. Chairman, thanks for the question. Just a couple of 
points, first of all. As recently as the cab ride over here this morning, I 
double-checked the Web site for Methodist McKinney Hospital relative to the 
ER, and it says that our emergency department offers quick care for all of 
your bumps, sprains and minor injuries, 365 days, 7 days a week. That may 
be a very important urgent care function that is good for that community, 
but that doesn't sound like an emergency department to me.

Chairman Brady. Mr. Minissale, since this was raised, so you only treat 
bumps, scrapes and bruises in your ER?

Mr. Minissale. Absolutely not, sir. As I mentioned, we are not a stroke 
center, we are not a heart center.

Mr. Umbdenstock. From their own Web site. From the Medicare cost reports in 
2012 and 2013, the percentage of Medicaid, talking to the question of 
patient and payment selection, in 2012, the Medicare cost report showed 
zero patient, Medicaid patient discharges and accrued to 0.4 percent in 
2013. So a very, very skewed payment system.

So, that is the issue, sir. And that is what we are here to urge Congress 
to stay with, stay with a program that limits the growth of these hospitals 
where they are highly selective and picking off the most profitable 
services. You notice the services on which hospitals like this are focused. 
And I understand why. That is where the payment is.

Chairman Brady. Well let me ask you this.

Mr. Umbdenstock. Many hospitals don't have that opportunity.

Chairman Brady. One, I respect your opinion. Thank you so much for being 
here. But the stars rating program takes into account the types of patients 
these hospitals treat. So are they incorrect in their assessment, or are 
they fairly accurate?

Mr. Umbdenstock. No. Number 1, the stars rating program focuses on the 
HCAHPS scores, the experience of care or patient satisfaction as we 
commonly refer to it. If you have the opportunity to identify which 
patients are going to come to your hospital in advance, you can prepare 
those patients for that experience. A hospital, a general service community 
hospital, full service community hospital receive over 60 percent of their 
admissions through the ER; that is not a predictable source of who the 
patient is, number one.

Number two, if you are not treating a full array of patients from all 
socioeconomic strata, you are not likely--you are likely to have a much 
higher satisfaction rate.

Chairman Brady. Is that the criteria for adding new beds, is that hospitals 
of all models should only go to areas that have broad, certain percentage 
of Medicare, Medicaid patients, that that ought to be a criterion to 
supplied, to physician-owned hospitals, for example? Should that be--should 
this moratorium be applied to all hospitals equally to ensure that each 
facility meets a broad range of patients?

Mr. Umbdenstock. The current criteria for an exception recognizes several 
factors, but one is that the particular hospital in question serves at 
least the average or greater proportion of Medicaid patients as other 
hospitals in its area, that is already there.

Chairman Brady. I agree. Would that be a fair restriction on all hospital 
increases?

Mr. Umbdenstock. Well, it is not a matter of whether or not it has to be a 
requirement. Every --

Chairman Brady. But it is for a physician-owned hospital--I am just trying 
to find again common ground, because hospitals are serving both areas of 
town that don't have necessarily good culture of health care, and they can 
serve areas, perhaps, with higher private pay. They do that as systems, 
again, to try to make ends meet and try to meet their missions, either 
nonprofit or for profit. The question is, why shouldn't this model be able 
to do the same thing?

Mr. Umbdenstock. I think you will find that if you look across the Nation's 
full-service community hospitals, on average, they have about 15 percent of 
their patients, plus or minus, that are Medicaid; about another 25 or more 
that are Medicare; probably about 10 percent prior to the ACA expansion and 
coverage--admittedly, that number is going down--but about 10 percent no 
pay. So those hospitals are already taking that type of mix of patients. I 
don't see a need to require it; they are already experiencing it.

Chairman Brady. So you would be comfortable with a requirement for those 
types of services for new beds in all hospitals? Should we apply this gold 
community, broad community service to all hospital beds?

Mr. Umbdenstock. I would like to go back to your context that you used to 
set up this point, sir, if I might. Which was that hospitals nationally 
have, I believe, you said opened more beds than the total number of beds in 
the 250 or so physician-owned specialty hospitals. Number one, that is a 
very small percentage of the National bed complement. Number two, that may 
be true that some hospitals have grown at that rate, but we have also seen 
hospital closures across the full-service hospital spectrum in many areas, 
including in Texas, sir, as I know you are very familiar with. So I don't 
think that that is a rampant problem of hospitals adding more beds.

In fact, hospitals are trying to figure out how to skinny down their 
inpatient complement so that they can focus more and get more patients 
served in outpatient, and out into the community. So we are actually seeing 
the reverse phenomenon of the description. They are actually de-emphasizing 
inpatient care, particularly as they are more at risk.

Chairman Brady. I recognize that. I hope you will come to Houston some time 
and see the growth of hospitals. We are thrilled, in my community and 
throughout the area, and it tells a little different story. So again, 
looking to find common ground, I know what the concerns are, and I think we 
need to have a discussion on this.

Ranking Member McDermott, you are recognized.

Mr. McDermott. Thank you, Mr. Chairman. It is an interesting discussion we 
are having here, this is not to pick on one hospital, but it is an example 
we have in front of us here today, McKinney Hospital. Why would a hospital 
want to be a specialty hospital? Why would they just want to do certain 
things? Mr. Umbdenstock, I mean you have 5,000 hospitals, so why would a 
hospital specialize in only doing orthopedics or only doing cardiac or 
whatever?

Mr. Umbdenstock. Well, I assume there are several reasons, one of which 
might be that the focus of energy and resources, volume in order to improve 
technique and outcomes, but also, I would say that you have to recognize 
that the particular services that limited service hospitals focus on are 
the profitable services. I don't have a lot of competition for the non-
profitable services inside full service hospitals.

Mr. McDermott. What are the profitable services for hospitals?

Mr. Umbdenstock. Well, certainly you see procedure oriented services, so 
surgeries, speaking broadly, other forms of procedures as opposed to 
medical services, certainly your own specialty of psychiatry would be at 
the other end of that spectrum.

Mr. McDermott. So if a hospital had 83 percent of its patients in for 
surgery, somehow they would be skewing it in that direction so that is not 
the average in most hospitals across the country?

Mr. Umbdenstock. That would not be reflective of the average complement, 
the average balance of services, that is correct.

Mr. McDermott. So in some way, they selected who comes in by the services 
that they offer; is that correct? Is that how a specialty hospital works?

Mr. Umbdenstock. With that kind of imbalance, one would have to assume.

Mr. McDermott. And if you talked about the emergency room. Now I, like you, 
use the Internet and I think all modern people use the Internet, it says 
here that for Methodist McKinney, if you were experiencing any of these 
conditions, please call 911, immediately: Life threatening conditions, 
heart attack or stroke, open fractures, severe bleeding, signs of heart 
attack or chest pain, head injury or other major trauma, one-sided weakness 
or numbness, loss of consciousness, severe abdominal pain, uncontrolled 
pain or bleeding, poisoning, call the poison control center.

Now, if an emergency room is not going to deal with those issues, can that 
be called full service--what it says is they do take care of our stitches 
and staples for cuts, gashes and wounds, X-rays, fractures and sprains, 
abdominal pain for maladies such as appendicitis, colitis, pancreatitis. 
And general illness treatment virus, flu and dehydration. So it is kind of 
a doc in the box, it sounds to me. They say they have a doctor on call. Is 
that how that sounds to you when you listen to that description?

Mr. Umbdenstock. I would say, Mr. McDermott, that full service community 
hospitals run toward problems, trauma, emergencies, and want to be of 
immediate service to people. They have that type of condition; that is 
exactly the type of person we expect to see at our ER. That is our purpose 
and that is why we are there. Granted, we often have to then transfer the 
most acutely ill to the higher levels, full service hospitals or teaching 
centers. But yes, those are the kinds of things that we would expect to see 
and that we do see in full-service community hospital ERs.

Mr. McDermott. Explain to me how the Stark law operates in a specialty 
hospital? The doctors own everything, they own the MRI, they own the CAT 
scan, they own all the machinery. They can refer every patient they want to 
their own CAT scan or their own MRI; is that correct?

Mr. Umbdenstock. That is correct. They are free to do --

Mr. McDermott. And that Stark law prevents you from doing that if you are 
in another hospital where you have an MRI that is away from it that you own 
or own a piece of, you can't refer your patients to that MRI; isn't that 
correct?

Mr. Umbdenstock. That is right, it is called the whole hospital exception 
as was pointed out earlier. You have to own a share in the whole hospital.

Mr. McDermott. You have to own the whole thing. That is really what we are 
trying to stop. And have successfully stopped and saved a half billion 
dollars.

Mr. Umbdenstock. According to the CBO.

Mr. McDermott. According to the CBO. By the way, I want to say, I know this 
may be your last appearance before this committee, you have been working as 
CEO for AHA for us for 8 years, and we thank you for your service in this 
tough job that you had and we appreciate your work.

Mr. Umbdenstock. Thank you and thank you to the chairman as well for the 
sentiment.

Chairman Brady. I appreciate it. Thank you very much. Mr. Minissale, we are 
1,200 miles from your ER, your and Mr. Johnson's witness. Do you want to 
address the claims you just heard about your ER.

Mr. Minissale. Yes, sir. First of all, I would certainly appreciate any 
ideas or support from Representatives McDermott or Mr. Umbdenstock on how 
we could grow our ER business. As I have stated, we have not been very 
successful. We have advertised and advertised and advertised, and that is 
how a lot of those admissions do come into the larger hospitals. We have 
also seen a proliferation of free-standing ERs open up in our community, 
HCA opened two in the area, there are several others. So anything we could 
do to grow the ER and get more admissions, medical or otherwise would be 
great.

Chairman Brady. Thank you. Mr. Johnson, recognized for 5 minutes.

Mr. Johnson. Thank you, Mr. Chairman. Mr. Minissale, thank you so much for 
testifying today. I appreciate hearing all the great things Methodist 
McKinney is doing back home. I want to ask, given your unique experience, 
what do you believe the biggest difference is between physician-owned and 
other hospitals?

Mr. Minissale. I think, really, the directive is when we are making 
decisions, there is kind of a hierarchy in physician-owned hospital where I 
am at is patient care is first; physician desire is second; employees are 
third; and profits fourth. In previous experiences where I worked for other 
company, we were usually driven by corporate health system goals and 
profits.

Mr. Johnson. Thank you. Mr. Umbdenstock, thank you for your testimony 
today. I have a handful of questions so in the interest of time, I ask you 
to please keep your answers to a yes or no, if you would. First, are you 
aware that your testimony refers to the GAO, MedPac and HHS reports that 
are 8 to 10 years old, and only studied specialty hospitals, not all 
physician-owned hospitals. Is that a yes or no?

Mr. Umbdenstock. This debate has been going on that long, and we try to 
reference all sources that we can find throughout the last.

Mr. Johnson. Well, you didn't answer my question. So in your testimony, you 
argue that physician-owned hospitals cherry-pick patients, but did you know 
that after the GAO and MedPac reports were released, CMS changed how 
hospitals are reimbursed so a hospital is paid based on the severity of the 
specific patient, which means you can't cherry-pick. Is that true or false?

Mr. Umbdenstock. You can't necessarily --

Mr. Johnson. You can't do that either. Thank you. I would also like to --

Mr. Umbdenstock.--from the way you refer patients, not in the way a 
particular patient is paid for, sir.

Mr. Johnson. Okay. I would also like to refer you to the first quote on the 
screen from a Health Affairs study stating, ``Physician ownership is not a 
driving force in referring patients to specialty hospitals.'' I request 
that the full article be submitted for the record along with additional 
references.

Chairman Brady. Without objection.

[The information follows The Honorable Sam Johnson 1:]

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Mr. Johnson. Thank you.

Now, let me ask you: Do you believe that physician-owned hospitals 
destabilize community hospitals? Yes or no.

Mr. Umbdenstock. Yes.

Mr. Johnson. Okay. I would like to now refer you to the second quote on the 
screen by the Federal Trade Commission on the importance of competition in 
Medicare.

I would also like to highlight that the August 2006 MedPAC report your 
testimony cites stated that, ``Profit margins for community hospitals in 
markets with physician-owned hospitals were higher than those in markets 
without physician-owned hospitals.''

Next question: Do you believe that physician-owned hospitals lead to 
greater utilization of service and higher costs? Yes or no.

Mr. Umbdenstock. Yes.

Mr. Johnson. Thank you.

I would also like to submit for the record a list of cases with over $3 
billion in fines paid by non-physician-owned hospitals for the very things 
you claim physician-owned hospitals do. I think you have those, Mr. 
Chairman.

[The information follows: The Honorable Sam Johnson 2]

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Mr. Johnson. I would also like to submit for the record a statement by the 
Federal Trade Commission saying that physician-owned hospitals increase 
competition and reduce prices.

[The information follows: The Honorable Sam Johnson 3]

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Mr. Johnson. Lastly, I would like to submit for the record a study that 
shows physician-owned hospitals save Medicare almost $10 million over 10 
years.

[The information follows: The Honorable Sam Johnson 4]

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Mr. Johnson. Finally, your testimony argues physician-owned hospitals 
should not be allowed to expand because they offer limited or no emergency 
service.

But isn't it true that Medicare does not require emergency departments, but 
actually only requires Medicare providers, including physician-owned 
hospitals, to comply with conditions of participation and the Emergency 
Medical Treatment and Active Labor Act? Yes or no. That is for you, Mr. --

Mr. Umbdenstock. For me?

Mr. Johnson. Yes.

Mr. Umbdenstock. Yes. When 60 percent of your patients come through the ER, 
the ER is a very important part of a, quote, ``hospital.'' I would agree.

Mr. Johnson. Mr. Chairman, thank you for holding this hearing. And I am not 
here today to criticize one Medicare provider over another, but, instead, 
to discuss the important role physician-owned hospitals play in promoting 
competition in Medicare.

Instead of continuing the ObamaCare prohibition on these hospitals, which 
was included in the 2,000-plus-page law as a political favor to the 
American Hospital Association and others, we ought to allow patients access 
to the high-quality and lower cost care provided by physician-owned 
hospitals.

In America, we let competition pick winners and losers, not the government.

I will yield back the balance of my time.

Chairman Brady. Thank you.

Mr. Thompson, you are recognized.

Mr. Thompson. Thank you, Mr. Chairman.

Thank you to all the witnesses for being here.

Mr. Chairman, I would like to ask unanimous consent to enter a letter into 
the record from the U.S. Chamber of Commerce, who wrote stating that 
defending America's free enterprise system--they are in opposition to the 
self-referral to physician-owned hospitals.

Chairman Brady. Without objection.

[The information follows: The Honorable Mike Thompson Submission]

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Mr. Thompson. Thank you.

Mr. Minissale, I would like to follow up on the questions that both the 
chairman and the ranking member had asked you and give you an opportunity 
to respond. They were referencing the type of services that your particular 
hospital does or doesn't provide.

And the CMS data that I am looking at tells us that about 70 percent of 
physician-owned hospitals--fewer than 5 percent of their admissions are 
Medicaid patients and a little over 20 percent admitted no Medicaid 
patients at all.

And your hospital--and, specifically, I think that is what they were asking 
you about--in 2013 had 24 percent Medicare discharges and 0 percent 
Medicaid discharges.

Can you kind of explain why these hospitals, in general, and yours, in 
specific--and they are often located in proximity to full-service 
hospitals--aren't treating Medicaid patients. And isn't there a need to do 
this in these underserved areas?

Mr. Minissale. I assume you are not--I am not sure about the State of your 
citing, but I assume you are not referring to the hospitals in North 
Houston, Odessa, San Antonio, that had physician ownership that I have 
managed in my career.

Mr. Thompson. No. I am talking about the hospital where you are now, 
Methodist McKinney. You had 24 percent Medicare discharges and 0 percent 
Medicaid discharges.

Mr. Minissale. Yes, sir. That is geography. In my experience, the Medicaid 
population tends to go to the closest facility due to transportation 
challenges, and we happen to have built the hospital in an area where there 
is not an indigent population.

Mr. Thompson. So it is all geography as it pertains to your hospital?

Mr. Minissale. I cannot say it is all. We are a Medicaid provider. There is 
now a McKinney bus service that could bring them there, and we are happy to 
take care of them.

So other than advertise, have our doors open, let the bus come over, I 
don't know how you make patients come to your facility.

Mr. Thompson. Thank you.

In my home State of California, we have hundreds of community hospitals and 
there is no shortage of competition, competition that is operating on a 
level playing field. I have got some concerns about the self-referral 
model.

And in my full-service hospitals at home, they compete on the quality of 
their service, the geography, and their reputation, not on whether or not 
physician owners will win, you know, financial gain as a result of this. 
And I worry about changing this law and what it would do to destabilize the 
continuity of care that we have in my area and others.

Mr. Umbdenstock, I don't have any of these hospitals in my community right 
now, and from the testimony that I have heard so far today, I don't think I 
want any.

But if the law were weakened and they could come in, what do you think the 
impact would be on my constituents and the other constituents in other 
areas that don't have this type of unfair competition?

Mr. Umbdenstock. Well, I think it is the three things that I mentioned. One 
is that the patient mix and service mix that will shift in your community 
could very well jeopardize the ability of full-service community hospitals 
to continue to provide a full array of services. There is certainly the 
question of increased utilization and, therefore, increased costs. And 
there is competition for employees who are already in short supply, as we 
all know. So I think that we have got serious concerns about that.

And there is an exception process. So if a hospital feels that it needs to 
grow and it is in a growing area and there is a high inpatient census on 
utilization and they do take high proportion Medicaid patients, CMS has 
already approved one. I only know of two applications. They have approved 
one and one is pending. So there is a mechanism to handle that.

Mr. Thompson. What about the current law that requires physician-owned 
hospitals to report annually to CMS about the ownership and all the 
particulars? It is my understanding that that hasn't been done. And aren't 
we putting the proverbial cart before the horse with trying to do this 
legislation without first having all the data necessary to be able to 
assess what is actually going on?

Mr. Umbdenstock. I do know from what is up on the CMS Web site that they 
say that they have had a very low rate of response to their reporting 
requirements, so much so that they have yet again extended the submission 
deadline.

So, apparently, they are having trouble identifying those ownership and 
other indicators that they require. So one would think that that would be 
important information to have. Yes.

Mr. Thompson. Okay. Thank you.

Yield back.

Chairman Brady. Thank you.

Mr. Smith, you are recognized.

Mr. Smith. Thank you, Mr. Chairman.

And thank you to all our witnesses here today. I appreciate the insight 
that each and every one of you bring to the table here.

Certainly, as a representative of part of rural America, I can appreciate 
the challenges facing health care, facing the financing of health care. I 
have been here long enough to observe a lot of the arguments for and 
against various components of public policy as it relates to health care. 
And certainly, as a consumer from time to time of health care and as a 
patient, I think it is important that we observe what is going on.

Now, I get very concerned when there is an agenda of prohibitions and 
mandates. That could be inside ObamaCare or even beyond that, but I get 
very concerned. I know I have been working on an issue with critical-access 
hospitals in my district with a 96-hour precertification requirement that I 
think is burdensome, it is unnecessary, yet it is part of the long list of 
prohibitions and mandates that exist in health care.

And I would hope that we could have flexibility in our health care. I know 
that living in a community where we have, I think, a very vibrant community 
regional hospital, along with a Federally qualified health center and even 
some options for patients that would involve walk-in urgent care--I see the 
flexibilities that allow those to be used by patients. That is a good 
thing.

It is hard to say, perhaps--I mean, I don't know the exact financing 
mechanism of every patient, but I was just wondering if anyone could speak 
to the fact of prohibitions and mandates leading to actual cost savings. If 
any of our witnesses would like to answer that.

Mr. Umbdenstock. Yes, Congressman. I would be happy to.

Number one, this is an arrangement that has been arrived at over a 
discussion and a series of compromises over a dozen or more years. So this 
is an ongoing conversation in this industry.

Mr. Smith. But it is the result of a compromise, the prohibition?

Mr. Umbdenstock. Where we are today is the result of starting with new 
entries and limits on growth for the grandfather-in hospitals. Yes. This 
has been an ongoing conversation since at least 2003, that I am aware of, 
probably longer, number one.

Number two, the CBO has scored that this particular provision in the 
Affordable Care Act saved $500 million over 10 years. So, yes, it is a, 
quote, saver at the moment, and changing it would, obviously, in the CBO's 
opinion, unleash additional spending that would have to be paid for in some 
way under the Medicare program.

Mr. Smith. You said at least at the moment. So long term do you think that 
we need the current prohibitions and mandates that are currently in place?

Mr. Umbdenstock. Yes. And I think that we could ask CBO to score it again. 
But I don't see any reason why for the next 10-year segment they would come 
out with a substantially different answer.

Mr. Smith. Okay. Anyone else wishing to respond?

Mr. Minissale. Yes, sir. You mentioned cost and the prohibition. One thing 
that we have seen is our competitors employing physicians. Five of our 
original physician investors' practices have been bought out since we 
opened and many, many more in the community.

In my understanding, there is data showing--I believe it is in California--
from CMS that that actually increases cost. It doesn't decrease cost.

Our competitors are spending a lot of money on paid medical directorships 
to the high-paid procedurals. We don't pay medical directorships. We don't 
employ physicians.

I believe those things are part of the reason the data shows costs are 
going up. We would tend to focus on competition and quality that would 
lower costs and provide better care in the end.

Mr. Smith. Okay. Thank you.

Anyone else wishing to comment?

Thank you, Mr. Chairman. I yield back.

Chairman Brady. Thank you.

Mr. Davis, you are recognized for 5 minutes.

Mr. Davis. Thank you very much, Mr. Chairman.

You know, for many, many years we have had a great deal of conversation 
relative to how do we improve quality and contain cost at the same time. If 
we are still experiencing 60 percent hospital admissions through emergency 
rooms, does that say that our system needs to do anything in order to try 
and get to this real notion of cost savings?

Mr. Umbdenstock. Yes, Congressman. Thanks for that question.

It does, indeed. And that is why the American Hospital Association and our 
5,000 members are very much interested in new payment and new delivery 
system models.

It would indicate, as you say, that people are dropping into the healthcare 
system on an as-needed or ad hoc basis, not with any sort of long-term 
relationship to the system and certainly not a relationship that emphasizes 
early intervention, prevention, wellness, community-based services, and so 
on.

We believe that that is the right way to organize the system. We are trying 
to do that by coming together with other entities up and down the continuum 
of care.

As I mentioned in my oral statement and in our written testimony, there are 
significant legal barriers to doing that. But, ideally, that is what we 
would do. We would put the incentives for wellness and less utilization and 
align them between patients and providers.

Mr. Davis. Dr. Antos, can I ask you: Isn't it true that current law does 
not necessarily restrict or does not prevent increases in certain types of 
hospitals if they are needed in areas?

Mr. Antos. That is right, Congressman. There are exceptions that are 
limited. I assume we are talking about specialty hospitals now or 
physician-owned hospitals. There are some exceptions.

However, effectively, the provision under the Affordable Care Act 
effectively eliminates any chance that physician-owned hospitals can expand 
or that new ones can be created. The exceptions are very, very rare.

Mr. Davis. Is it not also true that, in many areas, many States, that 
locally determined decisions are made through health facilities, planning 
boards, and other entities that will allow or not allow a hospital to build 
or a new service to come in or a new service to start?

Mr. Antos. That is right. Certificate of need is the phrase. I live in 
Maryland, and Maryland has the certificate-of-need law.

I have to say my observation of the State of Maryland is that it is a 
difficult process and it is not at all clear that, in the end, you end up 
with decisions that would have been made in the market, decisions that 
would have been made by consumers as far as where they would choose to go 
for services.

Mr. Davis. Mr. Umbdenstock, let me ask you--current law requires physician-
owned hospitals to report annually to CMS on their status and to provide a 
detailed description of the identity of each owner or investor in the 
hospital and the nature and extent of all ownership and investment 
interest.

But the CMS Web site still does not include this information and CMS says 
that they are concerned about the accuracy of the data they have received.

So the agency has once again extended the deadline for submission. Of 
course, this means that the public has no data on how many of these 
hospitals actually exist or who the ownership actually might be.

Do you think we ought to have that information before making further 
decisions about the issue?

Mr. Umbdenstock. Yes, sir. Yes, Congressman. I do. Absolutely. Again, full-
service hospitals are under very rigorous reporting and disclosure 
requirements to the government about such issues. And I think it is 
disappointing that a particular segment hasn't been able to come up with 
that information, at least, again, as I reference the cms.gov Web site.

So they are obviously concerned. And, yes, I would think that that is 
important information to have before any significant changes are proposed.

Mr. Davis. Thank you very much.

I see that my time is about to expire. Thank you, Mr. Chairman. I yield 
back.

Chairman Brady. Thank you.

Mr. Marchant, you are recognized.

Mr. Marchant. Thank you, Mr. Chairman.

I represent a district around the DFW airport. We are very blessed in that 
we have several major hospitals that would be represented by your 
organization, but we also have an explosive growth in very highly 
technical, customer-oriented, private physician-owned hospitals.

And in my particular district, there is a great demand for that hospital. 
They are responsive. They seem to be a little more agile in filling market 
niches. They seem to be more responsive, in whole, to parts of my 
community.

Mr. Umbdenstock, where one of your hospitals is a partner with one of these 
physician-owned hospitals, what is the AHA's approach to that? How do those 
partners deal with this situation where they, in fact, are providing the 
capital and many times the loan and everything to start this other 
hospital, which is the case in my area?

Mr. Umbdenstock. Yes, Congressman. Thank you.

First of all, I would point out that some of our member hospitals are in 
such partnerships, as is the case present here today. The Methodist Health 
System is an AHA member and a fine member and a fine organization. We are 
very pleased that they have maintained being an AHA member and participate 
in our broader discussions and debates.

When we formulated our position on this, it was through a very 
participative process of hospital members with specialty hospitals and 
those without. And, frankly, on this point, some of my members have agreed 
to disagree.

So the situation is the same, whether it is a freestanding or partnered 
entity, and our position is the same. It has not been an easy position for 
us to take. We respect all of our members, but it is one that the vast 
majority of our members support.

Mr. Marchant. But that would explain why the major hospitals in my district 
perhaps are not coming to me and saying that, ``We are for this 
moratorium,'' where, in fact, many of them are telling me --

Mr. Umbdenstock. I haven't looked at it by congressional district, but more 
broadly on SMSA basis and so on where they have very different views. Some, 
as we saw during the debate of this particular provision, are very much 
opposed to it. Others had made investments and were supportive of it.

But I can tell you, sir, that the vast majority of our members are 
supportive of current law and not in favor of relaxing it. Not an easy 
position for us, but one that the members broadly support very strongly.

Mr. Marchant. Are you familiar with this group of hospitals across the 
Nation that, during the formulation of the Affordable Health Care Act, they 
started facilities, they had hospital wings or additions in various stages 
of construction and, when the Affordable Health Care Act was put in place, 
the Commissioner decided that, on a certain day, if those beds were not 
certified and accepted, that those beds would never be basically accepted 
for Medicare or Medicaid use?

Mr. Umbdenstock. The act was enacted in March of 2010, and people had the 
ability through the end of December of 2010 to bring these online and get a 
Medicare provider number. So, in the law, there was a 9-month delay. In 
reality, there was a longer delay because this provision was always on the 
table and being debated.

I was having conversations with my own members, again, some of whom were 
making these investments in these organizations, who wanted to know what 
that date would be. So people were on notice because of the conversation 
for much longer than 9 months. That date was in the law. Yes.

Mr. Marchant. But the fact is that several hospitals were caught in this 
period of time and now have beds that they fully intended to use for 
Medicare and Medicaid patients, but because of the prohibition, because 
they were excluded, cannot use them for that purpose.

Is it the position of your organization that these hospitals never be 
recognized and never be allowed to use those beds for Medicare and Medicaid 
patients?

Mr. Umbdenstock. That was the provision of the act. We are supportive of 
that provision. And, again, it was several years in the making. So there 
was a lot of lead time in that respect. We were counseling our own members 
that it was a very high-risk proposition.

Given the support for this measure, it would be a very high-risk 
proposition to keep going. Some members actually got their hospitals opened 
in that period of time. Others found themselves not able to do so before 
the well-publicized deadline.

Mr. Marchant. Thank you.

Mr. Umbdenstock. Thank you, sir.

Chairman Brady. Mrs. Black, you are recognized.

Mrs. Black. Thank you, Mr. Chairman.

I want to thank all of the panelists for being here today. Very interesting 
conversation on three very important issues.

Mr. Antos, I want to turn to you particularly about the Medicare Advantage 
plans. Many critics have suggested that the Medicare Advantage plans were 
overpaid and they don't provide a service that is more valuable than the 
fee-for-service. We have seen enrollment in Medicare Advantage plans all 
the way across the country, and I know in my district it more than tripled 
over the past decade.

And I know that what I hear from folks that are in the plan and the survey 
showed that seniors are more satisfied with their Medicare Advantage than 
they are with their fee-for-service program. All this has occurred while 
the Medicare Advantage has been cut dramatically.

We see that continuing, and in some cases where they said they were going 
to cut it dramatically, we have seen a little bit of a reduction in that so 
they weren't cut quite as dramatically as what was talked about.

Do you agree that this competition--that Medicare Advantage is overpaid for 
their services it provides? Do you agree with what is being said, that they 
are overpaid?

Mr. Antos. No. I don't agree. I mean, the fact is that Medicare Advantage 
plans do provide good value not just for the people who enroll in them, 
but, also, for the taxpayer.

You know, one of the interesting facts about this is that people say that 
it is the younger Medicare beneficiaries, the ones who are turning 65, who 
are the new enrollees in Medicare Advantage. Actually, that is not true.

It turns out that most people, when they turn 65, sign on to traditional 
Medicare and, after a few years, they often find out that that isn't the 
plan they want to be in. It is not a health plan as they know it because 
they have spent 30 years in more organized healthcare delivery systems.

So in terms of value, I mean, there is very little question here. The fact 
that the bids--the amount that they bid is below the cost to fee-for-
service across the country says that Medicare Advantage plans are able to 
provide full Medicare benefits at a lower cost than fee-for-service. The 
fact that they get paid more gets plowed back into additional benefits for 
beneficiaries.

Mrs. Black. And I am also interested--I heard you at another event talk 
about this very subject matter. And, in addition to that, one of the things 
that you did talk about is the research that you have done that suggests 
that the effects of the competition have actually seen the Medicare 
Advantage programs have that spillover effect on the fee-for-service in 
both lowering the costs and the increasing of the quality.

Can you talk just briefly about what you have done as far as the research 
there and how that has affected the fee-for-service in lowering those costs 
and increasing quality.

Mr. Antos. So, you know, an important point, too, for all of us to remember 
is that seniors are, in fact, the biggest customers of the healthcare 
system. And so, if the treatment for the senior population becomes more 
efficient and more effective, that is going to spill over on everything 
else that the health sector does.

In essence, what is happening is that Medicare Advantage plans are 
introducing better systems of coordinating care. They are especially 
focusing on the people with serious chronic diseases, the people who are 
the most expensive in the system. And when you have a sufficiently large 
volume of patients who are in those organized systems, well, it turns out 
the physicians also operate in the fee-for-service sector as well.

They don't change their practices just because the paycheck, which is going 
to go to some business office, comes from someplace else.

Mrs. Black. And, Mr. Antos, if I may--because I only have a couple of 
seconds left--I think this really makes the point of what we have been 
talking about, that when we look at the Affordable Care Act, we talk about 
repealing and replacing with something that is more market-based and 
something that is more patient-centered.

And I think this is such a great model, when we look at the research that 
has been done, to say, when you do that, when something is more market-
based and more patient-centered, we see a lowering of cost, at the same 
time an increasing of quality.

And so I am just really very interested to see more research done in this 
area that can show that, if you do that, the fee-for-service will actually 
follow because there is going to be competition on the other side to make 
sure the costs come down, but the quality is there.

Thank you so much, Mr. Chairman, for having this hearing today.

Chairman Brady. Thank you, Mrs. Black.

Mr. Kind, you are recognized.

Mr. Kind. Thank you, Mr. Chairman. Thank you for having this hearing today.

I thank the panelists for your testimony.

Mr. Chairman, the reason I was late getting to the hearing this morning was 
I had a few interesting meetings on the current long-term care system and 
market that we have in the country.

And I think this is another area ripe for oversight and some additional 
hearings so that we come to grip before the Medicare program absolutely 
implodes due to where we are going with long-term care in this country.

But, Mr. Umbdenstock, let me start with you. And staying on the self-
referral physician-owned hospital track, you cite in your testimony, both 
written and oral here today, that there are numerous studies from CBO, from 
MedPAC, from other independent researchers, citing that, with self-
referrals at least, they are seeing data that is showing that they have an 
increase in utilization in both services and, therefore, costs in the 
Medicare system.

My question is: If there are ways for us to accelerate reform within the 
payment area so that we are getting the value of quality outcomes as 
opposed to fee-for-service, whether that would help address the over-
utilization that you cited and that apparently exists based on these 
numerous studies out there?

Mr. Umbdenstock. Thank you, Congressman.

Yes. Overall, the AHA is very supportive of the various payment 
demonstrations and experiments that are going on at the moment to try to 
figure out a better approach to financial incentives that will drive a 
better organized and more coordinated delivery system so that we can move 
toward that system.

Unfortunately, right now nobody has come up with an agreed-upon approach to 
do that. So we find ourselves with experiments and demonstrations and 
accountable care organizations and primary care medical homes and so on, 
all very important learning experiences. And, hopefully, based on that 
experience, we will come to more of a consensus on how to move off to the 
next payment system.

Mr. Kind. You know, I have enjoyed working with many of your members and 
those in Wisconsin, in particular, that have been moving to a more 
integrated coordinated patient center and been real drivers in value in the 
healthcare system and that.

But they share frustrations I have had for some time. They say, ``Well, how 
can we accelerate this? How can we move from fee-for-service to a more 
value of quality and align the financial incentives done the right way?''

You mentioned the Accountable Care Organizations. Secretary Burwell just 
announced an expansion of the pioneer ACL program, which I think is 
helpful, the medical home models, maybe some bundling in that.

But are we just still in this era of experimentation and trying to find out 
what works and what doesn't or are there some payment reforms that really 
do show some promise that maybe we ought to be stepping on the gas pedal a 
little bit harder on?

Mr. Umbdenstock. Well, certainly, again, as you mentioned from your home 
State, very much one of an integrated delivery system, large groups 
connected to hospitals, connected to payment systems.

Just tomorrow I am going to meet with members from across the country who 
are in very similar models to that. We estimate that about 20 percent of 
our members at the moment--maybe high teens getting to 20--have a health 
plan or have some sort of relationship to a health plan where they are 
starting to integrate payment and delivery.

So the more we see of that, the more we see coordinated, integrated systems 
of care emerging. And so we are supportive of that. The only problem is 
that that is not right for every market yet. It is very difficult to do on 
small population bases, for example. Very difficult to do if the payment 
isn't right in socioeconomically disadvantaged urban areas.

And so it is a concept that we are all very interested in and moving 
toward, I believe, but it is all a matter of markets and timing.

Mr. Kind. What are you seeing in the area of uncompensated care numbers 
right now? Obviously, there is some improvement in some States. But I hail 
from a State that has rejected the Medicaid expansion funds and has left us 
with a huge shortfall in that regard. But, overall, what have you been 
seeing?

Mr. Umbdenstock. It is much more favorable, as you might expect, in States 
that have chosen to expand Medicaid. Nationally, we believe that 
uncompensated care has dropped--or charity care has dropped about $7.5 
billion with the additional coverage, and about two-thirds of that, maybe 
about five in round numbers, is from Medicaid.

So we definitely continue to urge all States to take advantage of that 
option. And it works for the States. It works for communities and employers 
who have a backstop if people should lose insurance. And it is working and 
helping providers as well.

Mr. Kind. Finally--I know I am running out of time--but I would like to 
follow up with you in regards to one of your recommendations for 
improvement, the standardizing the merger and review process between the 
two Fed antitrust agencies. I think that is a huge area that is going to 
require more scrutiny by all parties involved. So I would like to follow up 
with you in the future with that.

Mr. Umbdenstock. We would be happy to. Big issue. Thank you, sir.

Mr. Kind. Thank you, Mr. Chairman.

Chairman Brady. Thank you.

Ms. Jenkins, you are recognized.

Ms. Jenkins. Thank you, Mr. Chairman.

Like many Americans, I am concerned about the future of the Medicare 
program. The current trajectory of Medicare shows a trust shortfall in 
2031, only 16 years from now. This impacts not just future beneficiaries, 
but many current beneficiaries as well.

Access to quality care is in jeopardy, and that is why this hearing really 
is so timely. Improvement of competition in Medicare has the potential to 
lead to lower prices, higher quality, and a more sustainable future for the 
program.

One area of Medicare that has already demonstrated these results is the 
Medicare Advantage program. And the latest numbers show that over 62,000 
Kansans enrolled in a Medicare Advantage plan last year. These private 
plans compete against each other to offer beneficiaries increased coverage 
options.

Particularly in rural areas, a Rural Policy Research Institute study shows 
that 216,000 more rural beneficiaries chose a Medicare Advantage plan 
between 2013 and 2014. This is despite the cuts to Medicare Advantage in 
the President's healthcare law and despite the shrinking rural population 
in America.

So, Dr. Antos, Representative Black already touched on a few of my 
questions. So maybe I will just pick up there. How do you explain this 
apparent discrepancy between the President's cuts to Medicare Advantage and 
the increased popularity of the program?

Mr. Antos. Well, I think it is a tribute to the poor performance of the 
fee-for-service program in Medicare. As I mentioned, part of the issue is 
that, once you get to know Medicare, you realize that it isn't the program 
you thought it was going to be. And I think this explains to a very large 
extent why there has been such an expansion of enrollment among the younger 
Medicare beneficiaries.

Now, it is the case that Medicare Advantage plans are much better organized 
as businesses than the various unconnected fee-for-service providers. And 
so one of the criticisms that is sometimes made is that, well, they are 
over-billing. But they are not over-billing.

They are, in fact, properly coding the maladies and the conditions of their 
customers. And they are not only properly coding that, but they are also 
fully incentivized to find ways to provide kind of 360-degree care rather 
than narrow focuses on hospital services or physician services or what have 
you.

Ms. Jenkins. Okay. Great.

Given the increased popularity of the Medicare Advantage particularly in 
rural America, what would you suggest that Congress do to spur this trend 
along?

Mr. Antos. Well, certainly one of the things that really should be done is 
even the sort of situation when people enter the Medicare program. When you 
turn 65, the default is fee-for-service Medicare. That is one of the 
reasons why you have so many people who then change after a couple years, 
change the default.

Another big, big factor that I think really gets at the rural issue is to 
change the basis of the bidding. Right now fee-for-service Medicare is 
treated as if it was a national program. Of course, it is not really a 
national program. It is different in every region. It is different in every 
locality. And, yet, there is a national standard, there is a national 
benchmark, and so on.

What really ought to happen is that we have full, fair bidding and, in 
rural areas, where cost conditions are vastly different than in urban 
areas, that the bids from Medicare Advantage plans are measured against the 
actual cost of Medicare providing services in those areas.

Ms. Jenkins. Okay. Thank you.

I yield back.

Chairman Brady. Thank you.

Dr. Price, you are recognized.

Mr. Price. Thank you, Mr. Chairman.

And I thank the panel. And I apologize for being late. And I am sorry if I 
repeat myself here.

I do want to focus in on the whole issue of competition in a particular 
area to start with, and that is the area of durable medical equipment.

You know, just because something says it is competitive doesn't necessarily 
mean it is competitive. And so it is important that you drill down and look 
at actually how programs run.

I would suggest, many of us would suggest, that the competitive bidding 
system for DME is neither competitive nor is it real bidding. And we have 
put forward a bipartisan solution to that that we call market purchase 
pricing that we think is superior.

But, Mr. Steedley, I want to have you reflect a little bit on the 
competitive bidding system in DME. What are your experiences? For those of 
us who were in health care--I was a physician for over 20 years taking care 
of patients--we oftentimes see a different example or different experience 
than what is relayed here in Washington.

So you and your peers who are trying to care for folks out there in the 
real world, what has competitive bidding meant to you all?

Mr. Steedley. Thank you, Mr. Price.

You know, Barnes Healthcare Services had the opportunity in round 2 to bid 
in Atlanta. And, surprisingly, we actually won the bid; yet, we declined 
that bid because the bid came in lower than our bid. And that is an 
important piece to hear here. 50 percent of winning bidders in competitive 
bidding actually bid less than the median price that is accepted.

It is about a standard of care--there are certain costs that are built into 
taking care of patients at home. And, specifically, if we just talk--if I 
narrow into the wheelchair example I just used, there is measuring these 
patients at home, there is working with the physical therapists, there is 
working with those physicians. It is making sure that these patients are in 
chairs that are appropriate.

And it is important to differentiate, to your point. I am not talking about 
just a broken hip or a sore knee that is going to need 2 or 3 weeks, 
sometimes, or 6 weeks of healing. Some of these patients are terminally 
ill. Some of these have ALS, muscular dystrophy, quadriplegic, and these 
folks require specialization with their chairs.

And so, for us, when we are looking at our cost structure and the necessity 
to take care of these patients, the things that they are going to need, the 
current system for us doesn't bring in enough revenue, quite frankly, to 
take care of these patients in the way that they deserve.

Mr. Price. So what I hear you saying is that there are patients out there 
that need services, require services. And the system that is being touted 
here in this town by so many at CMS as being an improvement, it is, in 
fact, harming individuals' access to care. Is that an accurate statement?

Mr. Steedley. And, specifically, I can tell you we take calls from 
patients, quite frankly, for winners in those areas where they have called 
because they can't get their wheelchairs repaired timely.

Some of these patients now, and I can supply a couple of these names for 
you later if you are interested, have decubitus sores, where they were put 
in inappropriate chairs with the wrong support structure for them.

What is going on is at this point, because the payment system is down so 
much, that providers are trying to find equipment that is under the cost. 
And that is not always appropriate for these patients.

Mr. Price. See, Mr. Chairman, this is the challenge that we have. It is 
that you have got folks who are winning supposed bids out here, but they 
don't have the expertise or the ability to carry out the care for those 
patients in that geographic area.

And I want to commend you, Mr. Steedley, for what you are doing. We are 
going to continue our work on the market pricing program. As I say, it was 
bipartisan last year. Last Congress, we had 180 cosponsors, 49 Democrats.

There is also a push to expand the payment rates for competitive bidding 
into noncompetitive bidding areas right now, and I know that that is a 
concern.

In fact, we had a letter that was signed by tens of individuals of the 
House that I ask unanimous consent to insert into the record to have OIG 
investigate exactly what the consequence of this would be.

[The information follows: The Honorable Tom Price Submission]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

Mr. Price. And the reason that that is important is that CMS uses claims 
data to determine whether or not folks get the kind of coverage or care 
that they need.

And, in fact, that is an inaccurate determiner of whether or not that 
patient is actually receiving the right care. So I am hopeful that the OIG 
will give us a report that actually reflects the sincere problems that are 
out there on the ground.

Thank you, Mr. Chairman. I yield back.

Chairman Brady. Dr. Price, thank you for bringing this idea forward.

Mr. Renacci.

Mr. Renacci. Thank you, Mr. Chairman.

I want to thank the witnesses. It is always interesting to come to these 
hearings and hear some of the concerns and issues. I, too, want to follow 
up with what Dr. Price talked about.

I am actually a member who had a DME company and went through competitive 
bidding before I came to Congress. I can tell you it was an interesting 
process because, as I thought I was doing a good job, I lost the 
competitive bid to another party.

I lost the bid to another party who then turned around and tried to sell me 
the bid back. And I know some of that cannot occur anymore with--
hopefully--Mr. Tiberi's bill, which requires securing a security bond.

And with competitive bidding, again, the name sounds right, and I heard one 
of my colleagues talk about it being a Republican issue. Hey, Republicans 
and Democrats, it doesn't matter whether it is a Republican idea or a 
Democrat idea. It is a bad idea if it is not working.

And what I saw in competitive bidding, it was driving good companies out 
and, at the same time, it was not giving clients the adequate equipment 
that was needed.

And that is, Mr. Steedley, one of the things I know that you said. It is 
interesting. There was a company in Ohio that actually came to me. They had 
won a bid for a certain number of canes at a certain price.

And it was also ruining their reputation because, although they provided 
the certain number of canes at the certain price, it appeared that people, 
because there weren't enough other competitive companies out there, were 
continuing to come to them. And they didn't want to provide any more canes 
at the price because it was not in their best interest.

Are you seeing some of those same instances in the business model that you 
are currently running?

Mr. Steedley. Yes, sir. And, to your point, the binding bid legislation is 
actually not going to go into effect for several more years. So that 
remains a little problematic.

To your point, there is a company in Orlando, Florida, that come to visit 
specifically--and I met with these folks. So I am talking from my personal 
experience here.

They won every single bid in round 2, all 90 MSAs in every product category 
in those bids. And to what you said a few minutes ago, their intention was 
to just resell those bids to desperate providers. It is still going on.

Mr. Renacci. Well, see, I wasn't even aware of that. And that is an issue. 
I mean, I had to live with it, and it became a process where other 
companies were making money and actually driving the cost down, causing 
providers to have to sell their product at less than actually a price they 
could afford to pay.

Do you see that also in the current situation where pricing mechanisms are 
far below cost of actually providing the service?

Mr. Steedley. Yes, sir. That continues. You know, if you look at even from 
the Association perspective, we are seeing a contraction now in the 
industry. Some of those folks are being bought by larger companies.

Just from a financial standpoint--and I think we are all businesspeople in 
the room--I can tell you those businesses are being bought sometimes for 
pennies on the dollar.

But, unfortunately, there are other providers that are going out of 
business because they did not win the bid. And, at some point, because they 
lost all that business in that area, they are gone and then the other 
providers that are left don't have enough left to sustain themselves 
anymore. So they are now going out of business.

What we are seeing, in essence--and competitive bidding is not the right 
word for this. What you are really seeing is a decimation of this industry. 
The lowest cost providers out there, the home care communities, are being 
taken apart slowly at this point.

And we talked a little about transparency. I said that in my opening 
statement earlier. We don't have good data from CMS that shows the 
correlation from the decrease in the part B spin here and what that 
translates into on the part A side.

I have spoken to patients that are telling me, because they can't get 
service, they are going to the emergency room or they are being admitted at 
some point for other problems subsequent to poor equipment or no equipment 
at all.

Mr. Renacci. I know you touched on this a little bit. But this practice 
does have--for me, it has some concerns about patients and the actual care 
they are getting.

I know that, when I operated in multiple cities in rural and urban areas 
prior to coming to Congress--health care, nursing home facilities--and I 
can tell you that it is always more costly and many times in those rural 
settings.

Just briefly, what are you seeing with patients? You touched on that, but I 
want to make sure we hit home on that. What is happening to those patients 
that aren't getting the proper equipment?

Mr. Steedley. You know, I can tell you--and I just saw this the week before 
last, I believe--what you are seeing is, people say, ``Well, there is no 
problem with these patients, no access issues. At some point, what is going 
on is some of these folks that would ordinarily have got a different piece 
of equipment now are getting equipment that is no longer the best for them.

For instance, the case I am referring to, the lady was an elderly lady that 
was walking around very ambulatory, COPD or CHF, whatever her issues were, 
but was carrying one of those great big, heavy e-tanks around with her. And 
when I talked to her about that, she has a closet full of them because the 
provider that won would not give her a smaller, lighter weight portable 
tank because the cost of that system was more expensive.

Mr. Renacci. Thank you very much.

Mr. Chairman, I yield back.

Chairman Brady. Thank you.

I would like to thank today's witnesses for their testimony today.

We are going to continue this discussion about competition within hospitals 
and community hospitals and physician-owned hospitals, as well as looking 
at are there better ways to create savings from a durable medical equipment 
bidding as well as high-quality service to seniors.

And before I finish, I can see Mr. McDermott is anxious to submit a 
document for the record.

Mr. McDermott.

Mr. McDermott. Thank you, Mr. Chairman.

For the record, I would like to submit a letter from Medicare Rights, which 
basically is in support of the competitive bidding process and ask 
unanimous consent.

Chairman Brady. Without objection.

[The information follows: The Honorable Jim McDermott Submission 2]

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Chairman Brady. Going forward, in continuing the discussions we had today, 
we will also be looking at issues of physician shortages, of disparities in 
rural health care within Medicare, as well as looking at improved programs 
on inpatient, outpatient and other hospital payment systems. So we will be 
encouraging input from both these witnesses as well as those in the 
audience today.

As a reminder, any member wishing to submit a question for the record will 
have 14 days to do so. If any members submit questions after the hearing, I 
would ask that the witnesses respond in writing in a timely manner.

With that, the committee is adjourned.

[Whereupon, at 11:51 a.m., the subcommittee was adjourned.]

[Submissions for the record follow:]



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