[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
STATE OF COMPETITION IN THE HEALTH CARE
MARKETPLACE: THE PATIENT PROTECTION
AND AFFORDABLE CARE ACT'S
IMPACT ON COMPETITION
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON
REGULATORY REFORM,
COMMERCIAL AND ANTITRUST LAW
OF THE
COMMITTEE ON THE JUDICIARY
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 10, 2015
__________
Serial No. 114-46
__________
Printed for the use of the Committee on the Judiciary
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://judiciary.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
96-053 PDF WASHINGTON : 2015
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
COMMITTEE ON THE JUDICIARY
BOB GOODLATTE, Virginia, Chairman
F. JAMES SENSENBRENNER, Jr., JOHN CONYERS, Jr., Michigan
Wisconsin JERROLD NADLER, New York
LAMAR S. SMITH, Texas ZOE LOFGREN, California
STEVE CHABOT, Ohio SHEILA JACKSON LEE, Texas
DARRELL E. ISSA, California STEVE COHEN, Tennessee
J. RANDY FORBES, Virginia HENRY C. ``HANK'' JOHNSON, Jr.,
STEVE KING, Iowa Georgia
TRENT FRANKS, Arizona PEDRO R. PIERLUISI, Puerto Rico
LOUIE GOHMERT, Texas JUDY CHU, California
JIM JORDAN, Ohio TED DEUTCH, Florida
TED POE, Texas LUIS V. GUTIERREZ, Illinois
JASON CHAFFETZ, Utah KAREN BASS, California
TOM MARINO, Pennsylvania CEDRIC RICHMOND, Louisiana
TREY GOWDY, South Carolina SUZAN DelBENE, Washington
RAUL LABRADOR, Idaho HAKEEM JEFFRIES, New York
BLAKE FARENTHOLD, Texas DAVID N. CICILLINE, Rhode Island
DOUG COLLINS, Georgia SCOTT PETERS, California
RON DeSANTIS, Florida
MIMI WALTERS, California
KEN BUCK, Colorado
JOHN RATCLIFFE, Texas
DAVE TROTT, Michigan
MIKE BISHOP, Michigan
Shelley Husband, Chief of Staff & General Counsel
Perry Apelbaum, Minority Staff Director & Chief Counsel
------
Subcommittee on Regulatory Reform, Commercial and Antitrust Law
TOM MARINO, Pennsylvania, Chairman
BLAKE FARENTHOLD, Texas, Vice-Chairman
DARRELL E. ISSA, California HENRY C. ``HANK'' JOHNSON, Jr.,
DOUG COLLINS, Georgia Georgia
MIMI WALTERS, California SUZAN DelBENE, Washington
JOHN RATCLIFFE, Texas HAKEEM JEFFRIES, New York
DAVE TROTT, Michigan DAVID N. CICILLINE, Rhode Island
MIKE BISHOP, Michigan SCOTT PETERS, California
Daniel Flores, Chief Counsel
C O N T E N T S
----------
SEPTEMBER 10, 2015
Page
OPENING STATEMENTS
The Honorable Tom Marino, a Representative in Congress from the
State of Pennsylvania, and Chairman, Subcommittee on Regulatory
Reform, Commercial and Antitrust Law........................... 1
The Honorable Henry C. ``Hank'' Johnson, Jr., a Representative in
Congress from the State of Georgia, and Ranking Member,
Subcommittee on Regulatory Reform, Commercial and Antitrust Law 2
The Honorable Bob Goodlatte, a Representative in Congress from
the State of Virginia, and Chairman, Committee on the Judiciary 11
WITNESSES
Thomas L. Greaney, Professor of Law, St. Louis University School
of Law
Oral Testimony................................................. 13
Prepared Statement............................................. 16
Richard J. Pollack, Executive Vice President, Advocacy and Public
Policy, American Hospital Association
Oral Testimony................................................. 31
Prepared Statement............................................. 33
Barbara L. McAneny, M.D., Member of the Board of Trustees,
American Medical Association
Oral Testimony................................................. 43
Prepared Statement............................................. 45
Daniel T. Durham, Executive Vice President, Strategic
Initiatives, America's Health Insurance Plans
Oral Testimony................................................. 65
Prepared Statement............................................. 67
Scott Gottlieb, M.D., Resident Fellow, American Enterprise
Institute
Oral Testimony................................................. 81
Prepared Statement............................................. 84
LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING
Prepared Statement of the Honorable John Conyers, Jr., a
Representative in Congress from the State of Michigan, and
Ranking Member, Committee on the Judiciary, submitted by the
Honorable Henry C. ``Hank'' Johnson, Jr., a Representative in
Congress from the State of Georgia, and Ranking Member,
Subcommittee on Regulatory Reform, Commercial and Antitrust Law 4
APPENDIX
Material Submitted for the Hearing Record
Letter submitted by the Honorable Tom Marino, a Representative in
Congress from the State of Pennsylvania, and Chairman,
Subcommittee on Regulatory Reform, Commercial and Antitrust Law 120
Response to Questions for the Record from Richard J. Pollack,
Executive Vice President, Advocacy and Public Policy, American
Hospital Association........................................... 123
Response to Questions for the Record from Barbara L. McAneny,
M.D., Member of the Board of Trustees, American Medical
Association.................................................... 161
Response to Questions for the Record from Daniel T. Durham,
Executive Vice President, Strategic Initiatives, America's
Health Insurance Plans......................................... 164
Question for the Record submitted to Scott Gottlieb, M.D.,
Resident Fellow, American Enterprise Institute................. 168
Response to Question for the Record from Scott Gottlieb, M.D.,
Resident Fellow, American Enterprise Institute................. 170
STATE OF COMPETITION IN THE HEALTH CARE MARKETPLACE: THE PATIENT
PROTECTION AND AFFORDABLE CARE ACT'S IMPACT ON COMPETITION
----------
THURSDAY, SEPTEMBER 10, 2015
House of Representatives,
Subcommittee on Regulatory Reform,
Commercial and Antitrust Law
Committee on the Judiciary,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:02 a.m., in
room 2141, Rayburn Office Building, the Honorable Tom Marino
(Chairman of the Subcommittee) presiding.
Present: Representatives Marino, Goodlatte, Collins,
Walters, Ratcliffe, Trott, Bishop, Johnson, Conyers, DelBene,
and Cicilline.
Staff present: (Majority) Anthony Grossi, Counsel; Andrea
Lindsey, Clerk; and (Minority) Slade Bond, Counsel.
Mr. Marino. The Subcommittee on Regulatory Reform,
Commercial and Antitrust Law will come to order. Without
objection, the Chair is authorized to declare recess of the
Committee at any time.
We welcome everyone to today's oversight hearing on ``The
State of Competition in the Health Care Marketplace: The
Patient Protection and Affordable Care Act's Impact on
Competition.''
I am going to recognize myself now for an opening
statement.
Today's hearing marks the beginning of a series of hearings
on competition in the health care marketplace. The first
hearing will undertake a broad examination of competition
within the hospital, insurance, and physician marketplaces.
Additionally, we will also focus on the impact that the Patient
Protection and Affordable Care Act, or ``Obamacare,'' has had
on competition within each of these sectors.
There is no doubt that there has been significant movement
in each of the hospital, insurer, and physician markets since
the enactment of Obamacare. Hospital mergers nearly doubled
between 2009 and 2013, the period surrounding the congressional
debate on Obamacare and immediately after its enactment. Four
of the five largest for-profit health insurance companies
recently announced their intent to merge, which will be the
subject of a separate Subcommittee hearing in the coming weeks.
Additionally, reports of physician practices either merging or
being purchased by hospitals has increased in recent years.
On top of all this activity, we are spending more on health
care than ever before, and that number is only expected to
grow. I trust that competition will put pressure on market
actors to deliver quality product at a reasonable price. I have
infinitely more confidence in the judgment of a competitive
marketplace over the judgment of government.
Obamacare is another government experiment attempting to
replace the will of the market with its own. An experiment
that, in my view, has gone horribly wrong. As Chairman of the
Subcommittee overseeing our antitrust laws in competition, I
believe we have a duty to ensure that the laws Congress pass
are encouraging competition and that the antitrust laws are
being enforced effectively. Today's hearing will help inform
Congress of the status of competition in the predominant health
care sectors, as well as add to the record of Obamacare's
impact on the state of competition in each of these sectors.
I look forward to hearing from our witnesses, and I yield
back the balance of my time, and I now recognize the Ranking
Member of the Subcommittee on Regulatory Reform, Commercial and
Antitrust Law, Mr. Hank Johnson of Georgia, for his opening
statement.
Mr. Johnson. Thank you, Mr. Chairman.
Today's hearing is the first in a series of hearings that
will examine the state of competition in the health care
marketplace. It is also the third hearing that this Committee
has held on this topic in as many years. But much has changed
since our last hearing in September of 2013.
Since the first open enrollment period began in October
2013, the Affordable Care Act has already expanded coverage,
savings and protections for millions of American consumers.
Since provisions of the Affordable Care Act have taken effect,
the law has resulted in the coverage of 16.4 million uninsured
people, dropping the uninsured rate by 35 percent, the lowest
in 50 years, and lowering the overall cost of health care for
both insured Americans and health care providers. It saved 9.4
million seniors more than $15 billion on prescription drugs, or
about $1,598 for every beneficiary, and it has dramatically
slowed the cost of health care spending, to the benefit of
taxpayers and the entire health care system.
The Department of Health and Human Services likewise
reported in July that the law has slowed the cost of health
care premiums as new competitors in local markets and price
competition intensifies. The Congressional Budget Office also
reported that these lower premium costs have lowered previous
cost estimates for the Affordable Care Act by about $142
billion, or 11 percent, while the Washington Post reports that
``the cost of the law has been falling for several years now
that analysts are beginning to assess the evidence of the law's
impact from its first full year of implementation.''
There is also ample evidence that the Affordable Care Act
is a reaction to, not a cause of, consolidation in the health
care marketplace. A unifying bipartisan theme of our hearings
on this topic is that waves of consolidation among health care
providers and insurers occurred long before the Affordable Care
Act. Whether due to lax antitrust enforcement or bad policy,
many local markets were highly consolidated before the
enactment of the Affordable Care Act in 2010. According to the
Department of Health and Human Services Report on Competition
in Health Insurance Marketplaces, competition has intensified
across the country as the number of health insurance issuers
have increased in most counties. As I have already noted, this
increased competition has had the effect of reducing premium
growth through an influx of new plans and increased pressure
for incumbent insurance issuers to moderate the cost of
premiums. Preserving and promoting this competition is
critical, and I encourage the antitrust enforcement agencies to
do so at every opportunity.
In closing, it is clear that now that we have put it to
work, the Affordable Care Act is saving lives and money. Rather
than demonizing the Administration and the law that has done so
much for so many, we would be ensuring that the progress we
have made in such a short time is not jeopardized by anti-
competitive behavior or consolidation. With that in mind and
notwithstanding the consistently partisan nature of discussions
concerning health care and the Affordable Care Act, I thank the
Chair for calling this hearing and I look forward to future
hearings on this subject. Few topics directly affect the lives
of American consumers as ensuring that health care markets are
delivering the best and most health care choices in every
county in America.
And with that, I would yield back. But let me say before I
yield back, I would like to offer into the record, without
objection, the statement of Ranking Member John Conyers.
Mr. Marino. So ordered, without objection.
[The prepared statement of Mr. Conyers follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
Mr. Johnson. I yield back.
Mr. Marino. The Chair recognizes the Chairman of the full
Judiciary Committee, Mr. Bob Goodlatte of Virginia, for his
opening statement.
Mr. Goodlatte. Thank you, Mr. Chairman.
Before we begin today's hearing, which marks the beginning
of a series of hearings on competition in the health care
marketplace, I think it would be helpful to clarify two points
of overriding concern.
First, health care is not provided in a true free market,
and has not been provided in a free market since at least the
onset of major government intervention in the market through
Medicare and Medicaid.
Second, health care as a service is unique in that nearly
every person in America will require some medical treatment
over the course of their lives. Health insurance is not like
fire insurance or car insurance, where there is a hope that one
will never have to use it. Medical costs inevitably occur and
hopefully insurance or some funds set aside for these costs
will be used when the time comes.
In the face of these facts--that the health care market is
not a fully free market and that Americans have no choice but
to participate in the market--it is essential that we preserve
as much competition and freedom in the overall health care
marketplace as we can.
We should strive to enact laws that foster competition so
that prices are checked, patients have choices, and the premium
quality of American health care can be maintained. Otherwise,
costs will go up, choices will narrow, and quality will be
diminished. That is simply the laws of economics at work.
In 2010, President Obama signed into law the Patient
Protection and Affordable Care Act, which I believe is
antithetical to competition. Rather than promoting free
markets, Obamacare put in place a regulatory structure that
stifled competition and instituted incentives for increased
market consolidation.
Since the enactment of Obamacare, I have been sounding the
alarm bells. The Judiciary Committee held hearings on Obamacare
and competition in each of the last two congressional sessions.
I am pleased that the Committee meets again to continue to
sound the siren and supplement the growing record of
Obamacare's anticompetitive results.
One of the principal tenets of economics is that
competition can lead to lower prices, enhanced product variety,
greater innovation, and downward pressure on costs. When
markets consolidate, there exists the potential for reduced
competition resulting in the contraction of the related
benefits.
Of course, consolidation does not always lead to a
reduction in competition. Market efficiencies can be obtained,
and the expansion of successful products can be achieved more
rapidly through transactions. However, when non-market and
government forces compel consolidation, those underlying forces
and their effects should be closely examined.
Accordingly, it is vitally important that antitrust laws
are properly and consistently enforced to prevent
anticompetitive consolidation and conduct, and that laws that
promote these activities are subject to strict and ongoing
scrutiny. Continuous and vigilant oversight, such as at today's
hearing, will help to ensure that health care markets operate
as freely and competitively as possible, in order to provide
consumers with premier and affordable health care.
I look forward to the testimony of our witnesses on the
state of competition in the predominant health care markets.
Thank you, Mr. Chairman. I yield back.
Mr. Marino. Thank you, Chairman Goodlatte.
Without objection, other Members' opening statements will
be made part of the record.
Now I will begin by swearing the witnesses in. Would you
please stand and raise your right hand, please?
Do you swear that the testimony you are about to give
before the Committee is the truth, the whole truth, and nothing
but the truth, so help you God?
Let the record reflect that all the witnesses have answered
in the affirmative.
Please be seated.
We have a distinguished group of witnesses here today that
I think are going to contribute a great deal to some of the
questions that we would like to have answered.
We will begin with Professor Thomas L. Greaney, who is a
Chester A. Myers Professor of Law and Co-Director of the Center
for Health Law Studies at the St. Louis University's School of
Law. Professor Greaney also is the author of Health Law, one of
the leading health care casebooks, as well as numerous articles
on the intersection of antitrust and health law that have been
published in, among other places, the New England Journal of
Medicine, the Antitrust Law Journal, the Journal of the
American Medical Association, and the Yale Journal of Health
Law and Policy.
Prior to joining the St. Louis University School of Law,
Professor Greaney served as the Assistant Chief in the
Antitrust Division of the Department of Justice. Mr. Greaney
received his B.A. magna cum laude from Wesleyan University and
his J.D. from Harvard Law School.
Welcome, professor.
Mr. Richard Pollack recently became the 11th President and
CEO of the American Hospital Association, known as AHA, on
September 1st, 2015. Mr. Pollack has been with the AHA for over
32 years, recently serving as the institution's Executive Vice
President for Advocacy and Public Policy, where he was
responsible for the development, implementation and management
of the Association's advocacy, representation and public
affairs activities.
Mr. Pollack started his professional career here on Capitol
Hill, serving as a legislative assistant to former Congressman
Dave Obey. Mr. Pollack earned his Bachelor's degree in
Political Science and Communications from the State University
of New York's College at Cortland, and his Master's degree in
Public Administration from American University.
Welcome, Mr. Pollack.
Dr. Barbara McAneny was re-elected on June 2014 to the
American Medical Association AMA Board of Trustees. Dr. McAneny
is a board-certified medical oncologist and hematologist from
Albuquerque, New Mexico, and has served in numerous leadership
roles at the AMA. Additionally, Dr. McAneny was appointed by
Health and Human Services Secretary Tommy Thompson to the
Practicing Physicians Advisory Council from 2002 to 2006.
Dr. McAneny graduated magna cum laude from the University
of Minnesota and with honors from the University of Iowa
College of Medicine.
Doctor, welcome.
Mr. Dan Durham is the Executive Vice President of Strategic
Initiatives at America's Health Insurance Plans, known as AHIP.
Mr. Durham has over 30 years of leadership experience with
major policy and regulatory issues, primarily in the health
care field. In addition to holding senior positions within
AHIP, Mr. Durham served in high-level policy positions in the
Federal Government, at the United States Department of Health
and Human Services, the Social Security Administration, and the
Office of Management and Budget.
Mr. Durham received his B.A. from the University of Notre
Dame and his Master's degree from Duke University.
Mr. Durham, welcome to you also.
Dr. Scott Gottlieb is a recent Fellow at American
Enterprise Institute and a practicing physician. Dr. Gottlieb
has served in various capacities at the Food and Drug
Administration, including as a Senior Advisor for Medical
Technology; Director of Medical Policy Development; and, most
recently, Deputy Commissioner for Medical and Scientific
Affairs, in addition to serving as a senior policy advisor at
the Centers for Medicare and Medicaid Services.
Dr. Gottlieb is also a prolific writer on health care
issues, and has been published in leading medical journals and
other well-respected periodicals.
Dr. Gottlieb received his B.A. in Economics from Wesleyan
University and his M.D. from Mount Sinai School of Medicine of
New York University.
Welcome, doctor.
Each of the written statements will be entered into the
record in its entirety, and I ask each of the witnesses to
summarize his or her testimony in 5 minutes or less. To help
you with the timing, you see the lights in front of you. The
lights will switch from green to yellow, indicating that you
have 1 minute to conclude your testimony. And when the light
turns red, it indicates that the witness' 5 minutes have
expired.
I do this, and I know that some of you are probably going
to do it. We are so intent on saying what we want to say or
reading our statements that we pay no attention to those
lights, and I will very politely just sort of raise the gavel
to get your attention to ask you to please summarize. So, thank
you.
With that, Mr. Greaney, would you like to make your opening
statement? Would you put your microphone on, sir?
TESTIMONY OF THOMAS L. GREANEY, PROFESSOR OF LAW,
ST. LOUIS UNIVERSITY SCHOOL OF LAW
Mr. Greaney. Thank you very much, Chairman Goodlatte,
Chairman Marino, and Ranking Member Johnson.
Mr. Marino. Could you pull it a little closer to you? It is
off to the side.
Mr. Greaney. I appreciate this opportunity to testify again
before this Committee.
Let me summarize my testimony with four key points.
First of all, the Affordable Care Act both depends upon and
promotes competition in health care markets. And secondly,
while there is no doubt that excessive concentration undermines
the competitive policies of the ACA, it is entirely erroneous
to claim that the ACA is somehow responsible for this
consolidation. Mergers to monopoly and oligopoly are efforts to
avoid or frustrate the Act.
Third, the recently announced health insurance mergers
threaten competition in a variety of product markets and bear
careful scrutiny. The only point I am going to make there is
that you should not be taken in by the argument that consumers
are somehow better off having big insurers confront big
hospitals. I call that the Sumo Wrestler theory.
And finally, my last point is that if state and Federal
legislators are concerned about competitiveness of health care
markets, as they should be, it is finally time to take a hard
look at the real problems that beset the health care market--
outdated regulations, anticompetitive practices that can be
corrected by procompetitive legislation, and payment incentives
that wrongly encourage consolidation. Those are your real
culprits, not the ACA.
Okay, let me begin with my first point. The ACA does not
regulate prices. It relies heavily on private-sector
competition, competition between providers and payers and
rivalry within each of those markets. Why do we need government
regulation to help competition? Well, let's remember what that
putative market, as we like to call it, looked like before
health reform. There was a dysfunctional market for individuals
and small groups; we had a non-system of service delivery, as
hospitals and physicians each operated in their own silos; and
we had payment systems that rewarded volume and not outcomes.
What has the ACA done to improve market competition? My
written testimony goes into a variety of areas, but most
importantly it put in place efficient markets for shopping and
bargaining in the individual and small-group market. Very
importantly, the exchanges set up mechanisms to shop and
compete. And remember that the ACA also put in rules that made
insurance products now comparable, understandable, and assure
basic levels of coverage. These are Economics 101 conditions
for better competition.
What do we have as a result? Well-functioning exchange
markets that have enabled over 10 million people to shop for
and find products.
The doomsday predictions about the exchanges--risk
selection would destroy the exchanges, policies would be
unaffordable, employer-sponsored markets would crumble--proved
to be wrong, wrong, and wrong.
As to the commercial market, the ACA also has had important
salutary effects. First and foremost, it forbid insurers to
engage in medical underwriting, going after preexisting
conditions. That sent a message to the insurance market that is
very important. I want to channel Bill Belichek here. It said
``do your job'' to insurers, develop health plans that control
costs and improve quality rather than chase risk. And widely
overlooked is what the ACA did with Medicare reform that is
still ongoing. Medicare payment reform emphasizing now value-
based purchasing, ACOs and lots of other things, shifted
delivery in a very important way, and we know that private
commercial markets follow what Medicare does.
So is everything copasetic? No. Unfortunately,
concentration is a big problem, but a little history is in
order. Much of that, much of the problematic concentration
preceded the ACA. The good news is that the DOJ and FTC are on
the job and have won a series of important victories that
should send a clear message about future consolidation.
I will just mention very briefly my point on insurance
sector consolidation since my time is running short. The
insurance market consolidation is problematic. It is going to
take an in-depth inquiry by the Department of Justice. But the
concept--and it is a fallacious one in my view--the idea that
somehow we are better off where we pit dominant insurers
against dominant hospitals, that is unsupported by the economic
evidence, both in theory and in practice. There are lots of
antitrust cases where we have seen large insurers and hospitals
confronting each other, and they find a way to either conspire
with each other, either hurting rivals or simply splitting the
spoils of their market power. Sometimes we find out that the
sumo wrestlers would rather shake hands than compete.
I listed a long list of ideas for a procompetitive agenda,
including things that would help de-concentrate markets. There
are a number of steps that could be taken. I commend Dr.
McAneny's testimony, which I think gives many of the ideas
which I support.
So I think those are the steps that would promote
competition and advance the goals of this Committee.
[Applause.]
[The prepared statement of Mr. Greaney follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
Mr. Marino. Thank you, Professor.
Mr. Pollack?
TESTIMONY OF RICHARD J. POLLACK, EXECUTIVE VICE PRESIDENT,
ADVOCACY AND PUBLIC POLICY, AMERICAN HOSPITAL ASSOCIATION
Mr. Pollack. Chairman Marino, Ranking Member Johnson, and
distinguished Members of the Committee, on behalf of our
Nation's hospitals, I appreciate your inviting me to be here
today.
The health care landscape is rapidly changing, and
hospitals are helping to lead the way forward. They are
focusing on improving the patient care experience, enhancing
quality, and lowering the cost of patient care. Many of the
market forces reshaping health care were in place long before
the passage of the Affordable Care Act, but the ACA has
accelerated that pace of change.
A major part of that change is the realignment in the
hospital field that I would like to discuss this morning. The
emphasis on wellness or population health has encouraged
collaboration among providers, along with the development of
coordinated care models. These new models are often value-, not
volume- or cost-based, which means that providers are at
financial risk if they don't achieve specified quality and cost
goals.
The Department of Health and Human Services has launched a
number of these programs, and by 2018 it expects to move half
of all Medicare payments to alternative models of reimbursement
that reward value. The Department has also recognized that
achieving these goals would require hospitals to make
fundamental changes in their day-to-day operations that improve
quality and reduce the cost of care.
The hospitals and health systems realigning and
transforming care means closely working with other providers to
make sure that patients and communities have convenient access
to care. That means coordinating with doctors and other
caregivers to deliver better patient-centered care; it means
hospitals are aligning with other hospitals to unify patient
information, better coordinate transitions and follow-up care,
and share financial risk, among other improvements; and it
means partnering to keep the doors of certain financially
failing hospitals open so that patients won't lose access to
the medical care they and their community rely on.
For example, a health system in Ohio acquired a small
community hospital in bankruptcy that saved 250 community jobs
and actually expanded access to care in that rural area, and
many small, stand-alone, and rural hospitals are particularly
in need of partners. Just the cost of acquiring and maintaining
electronic medical records, which can be as much as $50 million
for a midsize hospital, can tip the financial balance of these
organizations.
Outdated regulatory barriers continue to constrain the pace
of innovation, and despite repeated calls for the Federal
agencies to modernize these regulations, to date only one has
been changed. For example, we have repeatedly asked the Federal
Trade Commission, which oversees transactions in the hospital
field, for guidance on constructing clinical integration
arrangements that could in some instances take the place of
mergers. However, we have not received this guidance.
Now, despite these challenges, the results of hospital
realignment are promising. It is even impressive. The author of
a recent study in the Journal of the American Medical
Association used the term ``jaw-dropping'' to describe the
results, which found hospitalizations and costs going down for
patients. He observed that there has been tremendous focus on
making sure that our hospitals are safer and that treatments
are more timely and more effective. Moreover, he acknowledged
that the savings per patient did not come at the expense of
quality.
And let me highlight just one other fact, and that is that
hospital price growth is at historically low levels, less than
1 percent in 2015.
Now, while I understand that this hearing is not focused on
the recently announced health insurance acquisitions, I would
just like to briefly touch on that point. We have serious
concerns about two potential acquisitions and believe they
merit the greatest scrutiny from both the Department of
Justice's Antitrust Division as well as Congress.
Anthem's proposed acquisition of Cigna, and Aetna's
proposed acquisition of Humana, would eliminate two of the
largest national health insurance companies, leaving just three
dominant national providers of health insurance. That would
leave consumers with fewer and, no doubt, more expensive
options for coverage, and it would diminish the insurers'
willingness to be innovative partners with providers and
consumers to transform care.
In conclusion, I just want to say that America's hospitals
are woven into the fabric of our communities. Hospitals care
for patients when they are sick, and we work to keep
communities healthy. We have tried to lead the way and will
continue to try to lead the way to reshape the system, to
improve quality, to improve efficiency, and to make health care
more affordable for patients and families, and we certainly
look forward to working with the Committee on making sure that
consumers have access to high-quality, affordable care in their
communities.
Thank you.
[The prepared statement of Mr. Pollack follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
Mr. Marino. Thank you, Mr. Pollack.
Dr. McAneny?
TESTIMONY OF BARBARA L. McANENY, M.D., MEMBER OF THE BOARD OF
TRUSTEES, AMERICAN MEDICAL ASSOCIATION
Dr. McAneny. Thank you. Good morning. I am Dr. Barbara
McAneny. I am a cancer doctor practicing in New Mexico, and I
am immediate past chair of the American Medical Association.
Thank you for inviting us to participate in this oversight
hearing on competition in the health care marketplace.
Physicians want to participate in a health care delivery
system that allows us to deliver high-quality and efficient
care to our patients. We believe that competition between and
among health care providers, facilities and insurers is an
excellent prescription for achieving that goal.
The Affordable Care Act, which includes provisions that are
designed to stimulate competitive forces in segments of the
health care market, is a disruptive force whose impact is still
being revealed. New payment and delivery models focusing on
quality and efficiency can foster competition by encouraging
innovation. Physician leadership in these new models is
critical both to protecting patients' interests and driving
down costs.
Indeed, preserving the ability of physicians to participate
in alternative payment models, including small or specialty or
rural practices, is essential because it ensures patient
choice, preserves the doctor-patient relationship, and provides
better competition in health care markets. Therefore, we
recommend reassessing and removing legal barriers that inhibit
physician engagement.
Specifically, we strongly support the FTC and DOJ efforts
to clarify the application of antitrust laws and urge
additional guidance to encourage the development of physician-
guided, innovative delivery models. Currently, broad
prohibitions under the Federal fraud and abuse laws discourage
physicians from adopting innovative incentive programs that
could kick-start competition. We therefore urge Congress and
the Administration to strengthen and expand program integrity
exemptions for physicians participating in alternative delivery
and payment models.
Ultimately, physicians should be able to maintain
independent practices and participate in innovative care
models. Anticompetitive hospital markets may undermine the
incentive of hospitals to compete based on quality, potentially
laying the groundwork for suboptimal care. Lifting the ban on
new physician-owned hospitals, which have developed an enviable
track record on quality and cost, offers one way to inject new
competition into hospital markets.
Similarly, we believe that competition, not consolidation,
is the right prescription for health insurer markets.
Competition can lower premiums, enhance patient care, and spur
innovative ways to improve quality while lowering costs. Our
annual study of commercial health insurance markets shows that
70 percent are already highly concentrated. We believe that
there must be a rigorous review of proposed mergers to
determine their effects on competition and their consequences
for patient care.
In 2010, the Department of Justice found that the proposed
Blue Cross merger in Michigan would have resulted in ``the
ability to control physician reimbursement rates in a manner
that could harm the quality of health care delivered to
consumers.'' The same analysis should be applied to pending
mergers.
In practice, the concentration of market power among a
handful of nationwide insurers impacts physicians' ability to
facilitate individualized care. Doctors are left with no
recourse to advocate for our patients, and innovation is
stifled. Market dominance does not produce patient benefits
when physicians are squeezed and networks are narrowed.
Patients should be able to select their doctors based on
quality and service, and doctors should be free to get patients
what they need and deserve. This is a stark reminder of what is
at stake: the health and safety of American patients.
We are at a critical decision point on health insurance
mergers because once the handful of national players is further
reduced, there is simply no going back. Post-merger remedies
are likely to be both ineffective and highly disruptive. Thus,
we believe that the time for heightened scrutiny and careful
consideration is now, before proposed mergers take effect and
result in a fait accompli wherein patients and physician
practices are permanently harmed.
Competition plays a major role in enabling patients to
access the high-quality care they deserve at a reasonable cost.
We thank the Subcommittee for your continued efforts on this
issue, and we look forward to working with you to improve
health care competition. Thank you.
[The prepared statement of Dr. McAneny follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
Mr. Marino. Thank you, Dr. McAneny.
Mr. Durham?
TESTIMONY OF DANIEL T. DURHAM, EXECUTIVE VICE PRESIDENT,
STRATEGIC INITIATIVES, AMERICA'S HEALTH INSURANCE PLANS
Mr. Durham. Good morning, Subcommittee Chairman Marino,
Chairman Goodlatte, Ranking Member Johnson, and Members of the
Subcommittee. I am Dan Durham, Executive Vice President at
America's Health Insurance Plans, and I appreciate this
opportunity to testify on issues regarding competition in the
health care system.
A competitive health care system is the best way to achieve
innovative, high-quality, affordable health care. Competition
among health plans occurs at the local level, and the diversity
of AHIP's membership, which includes local, regional, and
national plans, reflects the many choices available to
consumers.
Innovation in payment and delivery has resulted in a broad
range of options available in the marketplace as health plans
continually work, in collaboration with providers, to improve
the value of their products for consumers. Our written
testimony highlights initiatives that our members have
pioneered to promote quality and affordability, as well as
consumer tools that promote patient-centered care.
Regarding competition in the marketplace, the Department of
Health and Human Services reports that an average of 40 plan
options are available per county in 2015. That is up from 30
last year. And McKinsey reports a 26 percent increase in the
number of issuers competing on exchanges. Competition within
local markets is evolving, with a variety of high-value
products, from patient-centered medical homes to bundled
payments to accountable care models. The range of collaborative
products that drive value is vast, and health plans tailor
these products to help meet the specific needs of local patient
populations.
As has been reported, there is merger activity in the
health insurance industry. While I can't speak to the potential
outcomes of these reviews, it is important to understand the
broad framework that the antitrust agencies use to evaluate
whether a particular transaction is procompetitive or
anticompetitive, and the evolving nature of the market for
health coverage.
Assessing the impact of proposed mergers should start with
a clear understanding that many mergers and acquisitions are
beneficial to consumers. They facilitate new, high-value
products and efficiencies that reduce cost. The Department of
Justice has indicated, ``The primary benefit of mergers to the
economy is their potential to generate significant
efficiencies, and thus enhance the merged firm's ability and
incentives to compete, which may result in lower prices,
improved quality, enhanced service, or new products.'' The DOJ,
along with 50 state attorneys general and insurance
commissioners play an important role in reviewing proposed
mergers and determining their potential impacts. This includes
a thorough evaluation of a large body of data and other
evidence to determine whether a merger would harm consumers by
adversely impacting competition in specific products and
specific geographic areas.
Notably, there is no single national market for health
coverage. Health plans negotiate with providers in local
markets and offer particular types of products that differ
widely from one another. The agencies also consider the nature
of the market itself and whether it is undergoing changes that
are relevant to its analysis. For example, the highly regulated
nature of health insurance markets is relevant to an analysis
of the potential competitive effects of transactions. This
highly regulated market we face distinguishes health insurance
from other less regulated markets.
The bottom line is that consolidation should be looked at
on a case-by-case basis and it is problematic only when a
transaction leads to anticompetitive effects such as an
increase in cost resulting from harmful consolidation in
provider markets.
There is substantial evidence in peer-reviewed research
that shows a significant share of health care cost increases
are driven by dominant providers charging higher prices. The
Robert Wood Johnson Foundation study found that increases in
hospital market concentration lead to increases in the price of
hospital care, and that when hospitals merge in already
concentrated markets, the price increase can be dramatic, often
exceeding 20 percent. This study further cautions that
physician-hospital consolidation has not led to either improved
quality or reduced costs. Other studies that we have detailed
in our written testimony show that anticompetitive
consolidation in provider markets is resulting in higher health
care costs for consumers and employers and government programs.
Thank you again for this opportunity to testify. AHIP and
our members look forward to continuing to work with the
Subcommittee and other stakeholders to improve patient access
to high-quality, affordable health care.
[The prepared statement of Mr. Durham follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Marino. Thank you, Mr. Durham.
Dr. Gottlieb?
TESTIMONY OF SCOTT GOTTLIEB, M.D., RESIDENT FELLOW, AMERICAN
ENTERPRISE INSTITUTE
Dr. Gottlieb. Thank you, Mr. Chairman and Mr. Ranking
Member, for the opportunity to testify. My name is Scott
Gottlieb. I am a physician and Resident Fellow at the American
Enterprise Institute.
The health care sector is undergoing a secular
consolidation as payers and providers assume an historic level
of acquisition and mergers. These trends were underway prior to
implementation of the Affordable Care Act, but there is no
question that the ACA hastened them.
The consolidation of physicians at the local level should
be a particular concern. In the end, most health care is local.
Once an institution has monopolized the providers in its
market, it renders market-based reforms hard to achieve and
reduces the ability of competition to be used as a tool for
improving quality and reducing costs.
More importantly, the new arrangements that are being
forged, where doctors become part of large delivery systems,
usually with a hospital at its hub, reduces productivity.
Compelling economies of scale are not apparent in a physician
practice marketplace. This has been borne out by many studies
that examine the question, some of which I review in my written
statement for this hearing. There is a lot of evidence that as
doctors transition to becoming salaried employees of hospitals
and health systems, their individual productivity in terms of
metrics such as volume and intensity of care delivered also
generally declines.
Looking at this in view of our broader fiscal challenges
when it comes to health care, the only way that we are going to
solve some of the challenges facing the entitlement programs
like Medicare is to get more health care for every dollar of
GDP that we spend on it. To these ends, the last thing we ought
to be doing is adopting structures that reduce productivity.
I know there will be some discussion today of new
technology, and particularly drugs, as factors driving
increases in the cost of medical care, and I want to just
comment briefly on that. However one interprets the data on
drug costs, it is widely agreed that many new technologies
improve productivity by improving outcomes or obviating costly
alternatives.
Take oncology care. Although very costly, total spending on
oncology care as a percentage of our $2.7 trillion national
health care budget has been constant over the last 20 years. It
is just less than 5 percent of total health care spending. It
comes out to about .8 percent of GDP. But the mix of
expenditure has changed dramatically over time. Far less money
is being spent on services like hospitalizations and far more
on outpatient medicines. Cancer treatments that used to make
patients very sick and require costly hospitalizations have
been replaced with targeted drugs that can allow patients to be
treated at home.
So the proportion of spending on inpatient care admissions
fell from 64 percent of total cancer spending in 1987 to 27
percent by 2005, according to studies. Here is what happened.
Transferring cancer care to the outpatient setting produced
substantial savings. It is cheaper to deliver care outside the
hospital. This is how technology improves productivity and
lowers costs, which brings me back to the consolidation
underway in the market for health care services.
This consolidation not only reduces productivity and in
turn increases costs, it also reduces patient access. This is
especially troubling when it comes to rural markets where there
is a lower density of doctors and patients can find it harder
to get care at a site near their homes. It is important to
remember that the scope of the consolidation that we are seeing
in health care is not a response to market factors. Rather, it
is a deliberate function of policy choices. The ACA envisions
doctors practicing in large integrated health systems, often
with a hospital at its hub. The idea is that these newly
consolidated entities will be big enough to take capitated risk
and invest in the kinds of technologies that it is believed
will lead to better coordination in medical care. The ACA's mix
of policies seeks to hasten these outcomes.
The relationships that doctor practices are forging with
their acquiring entities are far stickier than past
arrangements. Moreover, for doctors, the opportunity to unwind
these business engagements and go back to their old
configurations are much more narrow. The economics behind these
arrangements also raises some more fundamental questions. For
one thing, these constructs were, in part, a response to
criticism of a fee-for-service approach to payment, which is
widely presumed to give doctors a financial incentive to
prescribe more care. As the analysis commonly goes, under a
fee-for-service arrangement, doctors are paid more when they do
more things and not necessarily when they improve outcomes. But
in reaction to these concerns, have we merely traded one flawed
set of financial incentives for another? After all, if the
financial incentives work in one direction, they have to work
in the opposite direction. If doctors will prescribe too much
care when they are paid to do more, as critics of the fee-for-
service medicine system maintain, won't these same inducements
work in reverse? Won't doctors prescribe too little care when
they are paid to do less?
This also raises another key question, and this one is
clinical. Are patients better off on the margin when they are
prescribed a little more care than they need or a little less?
The body of literature doesn't fully resolve this question.
Since all health care is local, and the lack of competition
will soon make it much harder to implement market-based reforms
in health care, the resulting monopolies will make more
regulation the most obvious solution to the inevitable cost and
quality problems. To change these outcomes, I believe that
Congress needs to reform the ACA to remove the pervasive biases
in the ACA that favor health system ownership of medical
practices. At a time when the urge to merge doctors into health
systems and turn physicians into salaried roles, there is a
private market counter-effort to create new models that have
physicians practicing in smaller units. Many aspects of medical
practice are not responsive to scale, and where scale does
help, many of the characteristics of health care that benefit
from integration can be achieved without consolidation but by
better use of technology.
A legislative proposal to improve health care quality that
manages cost would support local competition between providers
and choice for patients. We need to improve productivity and
preserve entrepreneurship, autonomy, and local competition that
have long been the hallmarks of American medical progress.
Thank you.
[The prepared statement of Dr. Gottlieb follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
__________
Mr. Marino. Thank you, Dr. Gottlieb.
Members on the dais will now begin their 5 minutes of
questioning, and I recognize myself for my 5 minutes.
Mr. Pollack, I would like to begin with you, sir. There
have been a number of reports of hospitals purchasing physician
practices. In some cases, patients enter the same building and
see the same doctor after the purchase, but the Medicare
reimbursement rate for the service is significantly higher. In
some instances, Obamacare increased these pricing disparities.
Are Medicare reimbursement rates driving purchases of
physician practices, and do you think that will impact
Medicare's solvency?
Mr. Pollack. I think, Mr. Chairman, there are two issues
here. One is the issue of physicians wanting to be part of
teams and wanting to be part of group practices that deliver
care in a coordinated way, and very often they are part of the
hospital entity. That is certainly a trend that we are seeing.
When physicians do become part of the hospital entity and they
deliver services within the hospital entity, there are
requirements that have to be met that they are part of that
facility, as opposed to providing service in their own office
or in a different site.
Hospital costs for those physicians are legitimately
higher, and the Medicare rate does, in fact, reflect a higher
amount. That is legitimate, in our view, because the regulatory
requirements for practice in that setting are very different
than what the requirements are in a physician office or an
ambulatory care center. The patients we take care of in that
setting are anyone who walks through the door, Medicare or
Medicaid. We are open 24 hours, 7 days a week. The patients
that are taken care of in those hospital-based physician
clinics tend to be sicker, and we have studies that we are
happy to submit for the record that show they are poorer and
more economically challenged. They suffer from a more difficult
set of circumstances. So it is, in fact, more expensive to take
care of patients in those types of settings.
Mr. Marino. Thank you.
Dr. McAneny, would you like to respond to my question?
Dr. McAneny. Yes. Thank you very much, Mr. Chairman. I take
care of cancer patients in a very poor community in New Mexico
which ranks at the lowest for income. While the American
Medical Association supports the right of physicians to choose
employment, we focus on the word ``choose.'' We don't believe
that competition should force physicians to select employment
over self-employment or other options.
I do disagree with the statement that we are unable to take
care of sicker patients in the outpatient arena. In our
practice, if I sold to the hospital tomorrow and I saw the same
patient and did the same services, you are absolutely correct,
my services would be reimbursed at a higher level if I were
hospital-based than physician fee schedule. But we do take care
of very ill patients, and we manage to keep them in the
outpatient arena.
The regulatory burden that physicians have is one of the
impediments to physician practices. The ability to be able to
comply with all the regulatory requirements is one of the
barriers that has driven younger physicians in particular to
wanting to join hospitals in hopes that someone else will take
care of all that and just let me see my patients.
Mr. Marino. Thank you.
Dr. Gottlieb, I have a specific question for you. In your
testimony, you stated that there has been a net loss of
insurers since the enactment of Obamacare. You also discuss co-
op insurance plans that have been subsidized under Obamacare.
Can you discuss the success rate of the co-op insurance plans
and how the declining number of insurers will affect
competition in the insurer marketplace? You have about 56
seconds.
Dr. Gottlieb. I am referring mostly to the commercial
marketplace. There has been no new net commercial insurance
company formation since the enactment of Obamacare, actually
since 2008. So whatever new plans we have seen, new carriers
enter the market, we have seen offsetting losses. And actually,
we have seen a loss of new carriers. We have seen new plans
enter the market, but they have all been existing carriers that
have decided to offer plans on the exchanges. They are not new
carriers. So I don't think that is very robust competition. It
is an indication that investors aren't allocating capital to
start new health plans, I think because of the regulatory
impediments and the high cost of getting into the market.
As far as the co-ops and the provider-sponsored plans,
particularly the hospital-sponsored plans, I think the
Administration envisions that picking up the slack and
providing competition. But the co-ops are all--I think almost
all under water, and one has already declared bankruptcy, and I
am not very optimistic that a lot of the provider-sponsored
health plans are going to survive. We have done this in the
past, and it has been demonstrated that hospitals don't manage
risk well. There is a reason why insurance companies exist.
Mr. Marino. Thank you.
My time has expired.
The Chair recognizes the Ranking Member, Mr. Johnson.
Mr. Johnson. Thank you, Mr. Chairman.
Dr. Gottlieb, do you disagree with all of the studies that
have proven that the cost of health care insurance premiums,
the increases in the cost of insurance premiums has gone down
since the onset of the Affordable Care Act?
Dr. Gottlieb. What I see is that----
Mr. Johnson. Do you agree or disagree?
Dr. Gottlieb. I disagree with the premise because what I am
seeing is that costs are being shifted to consumers. So the
cost of providing coverage for employers, which is what the
Administration often cites, has in fact been growing less
quickly than in the past.
Mr. Johnson. My question has to do with the premium growth,
the cost of premiums, the growth in the cost of premiums.
Dr. Gottlieb. Right. So the cost that would----
Mr. Johnson. Not shifting of cost to consumers. I am just
talking about the cost of health care premiums and the rise in
the cost of health care premiums. Do you agree that the price
increases have moderated since the passage of the Affordable
Care Act?
Dr. Gottlieb. I disagree because the cost to consumers has
gone up.
Mr. Johnson. All right. Thank you. You just refuse to
answer that question.
Well, let me ask you this. Do you----
Mr. Marino. Just a minute. I am going to give the witness
30 seconds to respond to that.
Mr. Johnson. No, no. From whose time, Mr. Chairman?
Mr. Marino. From your time. You have to let the witness----
Mr. Johnson. No, no, no, no.
Mr. Marino. You must let the witness answer the question.
Mr. Johnson. Mr. Chairman, the witness has not answered the
question.
Mr. Marino. Dr. Gottlieb, please respond if you would like
to respond.
Mr. Johnson. I have a problem with parliamentary order.
Parliamentary inquiry, Mr. Chairman.
Mr. Marino. Yes?
Mr. Johnson. Who controls the time during my questioning of
my witnesses?
Mr. Marino. I do.
Mr. Gottlieb, answer the question.
Mr. Johnson. All right. Well, I am going to take exception.
Mr. Marino. Exception noted.
Dr. Gottlieb, you may go ahead and answer the question.
Mr. Johnson. In fact, I am just going to--if you won't----
Mr. Marino. No, you have to give the witness an opportunity
to answer the question.
Mr. Johnson. Mr. Chairman, when I ask a question and the
witness refuses to answer the question----
Mr. Marino. You didn't give him an opportunity to answer
the question. You kept cutting him off.
Mr. Johnson. The witness refused to answer the question,
and it is my prerogative, Mr. Chairman, as the questioner, to--
--
Mr. Marino. You still have your time, you still have your
time.
Mr. Johnson. My time is running because I am responding to
your interruption of my questions.
Mr. Marino. You continue to ask your questions, and we will
give him 30 seconds when you are----
Mr. Johnson. Mr. Chairman, you started at 4 minutes and 20
seconds--I had 4 minutes and 20 seconds----
Mr. Marino. Go ahead.
Mr. Johnson [continuing]. When you interrupted me to try to
give this witness an opportunity to answer my question in the
way that he wanted to answer it.
Mr. Marino. You have the extra time. Go ahead again with
your questions.
Mr. Johnson. Okay. All right.
Now, Dr. Gottlieb, I asked you a question, do you agree or
disagree with the studies that have shown that the rise in
premium costs has been moderated since the passage of the
Affordable Care Act, and you went into a discussion about
shifting of costs to consumers. That is not my question. I will
give you one last chance to answer my question, and I think you
understand my question. Do you agree or disagree with those
studies?
Dr. Gottlieb. I disagree with those studies because I think
they are flawed.
Mr. Johnson. All right. Thank you. All right.
Now, Dr. Gottlieb, do you agree that Congress should repeal
the McCarran-Ferguson Act antitrust exemptions for insurance
companies?
Dr. Gottlieb. No, I do not.
Mr. Johnson. All right. Thank you.
Dr. McAneny, I hope I pronounced that correctly. In a
speech in June of 2015, FTC Commissioner Julie Brill stated
that while the antitrust agencies are watchful of
anticompetitive behavior, not one accountable care organization
has been challenged for anticompetitive conduct by the
antitrust agencies. What is your response to this approach to
provider collaborations in the health care marketplace?
Dr. McAneny. I think the antitrust laws are very confusing
to people, with or without an affordable care organization, to
try to create an organization that allows us to collaborate as
physicians, take economic risk together, and to do clinical
integration. And I can't speak as a physician since I am not a
lawyer to what the FTC and DOJ are doing with that, but we feel
that if we could release some of those barriers and make those
laws much more clear so that physicians could understand them
and stay within the confines of the law but still be able to
collaborate together, we wouldn't have to become employees or
consolidate the industry in order to create a lot of new
mechanisms that could deliver better care at a lower cost.
Mr. Johnson. Thank you. In your written testimony you argue
that Medicare and Medicare Advantage are distinct product
markets. Why is Medicare not an adequate substitute for
Medicare Advantage, and what effect would consolidation in the
Medicare Advantage market have on physicians and seniors?
Dr. McAneny. Thank you, sir, for that question. The AMA has
found that very few patients will switch back and forth from
Medicare Advantage programs to plain fee-for-service Medicare,
in part because of the concerns of being able to pay the 20
percent co-pay with fee-for-service Medicare. The Medicare
Advantage programs have been given extra money to be able to
provide better benefits, and patients respond to that.
What we find is that when those patients consolidate into
fewer and fewer Medicare Advantage plans, that if the benefits
are not what the patient wants, if a physician, for example, is
not on the panel of that Medicare Advantage program, that they
have a distinct disadvantage in being able to get care and they
are often forced to pick between their primary care doctor, who
is on one, and their specialist is on another, and they need
both of us. So we look at the managed care Medicare Advantage
market as being distinct from fee-for-service Medicare for
those reasons.
Mr. Johnson. All right. Thank you.
Mr. Greaney, in their testimony, both Mr. Pollack and Dr.
Gottlieb observed that consolidation in the health care
marketplace was hastened by the ACA. What is your response to
that?
Mr. Greaney. I think that is a bit misleading. Surely the
Affordable Care Act encourages providers to get together, to
consolidate, to form efficient delivery systems, and that is
certainly true. But nothing in the ACA encourages consolidation
to monopolies and oligopolies. In fact, just to give you an
example, your doctor probably tells you a glass of wine with
dinner every night is probably a good thing, but he would
counsel against two bottles of wine, and I think that is what
we are talking about here. We are talking about consolidation
that is excessive.
As I have said in my testimony, the Affordable Care Act is
premised on having competitive units at the delivery level and
at the insurance level so that the ACA relies on competition
and relies on healthy enforcement of the antitrust laws. If you
look to the string of victories the FTC has achieved, both in
hospital markets and in challenging physician mergers, it is
doing its job. So to that extent, blaming the ACA for
consolidation is misleading because you would be hard pressed
to find a health care economist or policy person who thought
what was needed was anything but the fragmentation that we have
had heretofore.
Mr. Johnson. Thank you, and I yield back.
Mr. Marino. The Chair recognizes the Chairman of the full
Committee, Congressman Goodlatte.
Mr. Goodlatte. Thank you, Mr. Chairman.
Dr. Gottlieb, I think you wanted to explain your answer of
trends with regard to insurance premiums, and I think you
should be afforded that opportunity, so I will give that to you
now.
Dr. Gottlieb. Thank you, Congressman. What we have seen in
the market and what the Administration often talks about is the
cost of coverage, of providing coverage for employers to their
employees and premium growth, and it is true that premium
growth, at least in the recent years, has moderated, although
we are seeing it accelerate quite dramatically.
But what has happened is we have seen a very dramatic shift
of cost to consumers. We have seen the advent of very narrow
plans, closed drug formularies, closed networks, exclusive
provider organizations, and all of that has served to shift
costs onto consumers. I think that that is a big component----
Mr. Goodlatte. Things that aren't covered by the insurance,
in other words?
Dr. Gottlieb. Exactly.
Mr. Goodlatte. So the opposite of what is purported to be
the benefit of Obamacare?
Dr. Gottlieb. Well, closed drug formularies in particular
is a real new phenomenon in the market. The only place where we
had seen closed drug formularies prior to implementation of the
Affordable Care Act was in Medicare Advantage. But Medicare
Advantage had the protected classes which made sure that the
formularies were robust.
What is happening in the Affordable Care Act in the
exchange-based plans is there are closed drug formularies where
if the drug isn't on the plan's formulary, you are completely
out-of-pocket and what you spend doesn't count against your
deductible.
Mr. Goodlatte. I need to take my time for other things. So
what you are saying is that whether or not insurance premiums
are moderating, that doesn't necessarily mean that the overall
cost to the consumer and overall cost to society----
Dr. Gottlieb. Exactly.
Mr. Goodlatte [continuing]. The overall cost to taxpayers
has moderated.
Dr. Gottlieb. It has gone up quite a bit to the consumer.
Mr. Goodlatte. Right. Thank you.
Dr. McAneny, I may come back to Dr. Gottlieb if I have
time, but he said that health system ownership of medical
practices is an undesirable trend. You said that you wanted to
make sure that they had choice. In a moment I will go to Mr.
Pollack and give him an opportunity to respond as well. But one
of the things that I see and one of the things I hear from my
physicians is that they are actually in competition with the
employees who are at the hospital, and it is very difficult to
compete with them when there are such disparate reimbursement
rates that take place in the hospital compared to what the
physician may get in their private practice. What is your
observation about that?
Dr. McAneny. Well, Mr. Chairman, I think you summarized it
very well, that it is very difficult for individual physicians
to be able to compete with hospital-based physicians because
they have the leverage that we as individuals lack to be able
to negotiate with insurance companies. We find that the
regulatory burden is still there in the independent market and
that hospitals are able to purchase a lot of the same supplies
and everything else that we need to purchase at a lower price
or a subsidized price.
Mr. Goodlatte. Mr. Pollack, I take your point with regard
to the cost of operating a hospital, but I also am concerned
that if we are trying to promote competition and there is only
one hospital in a community, and that hospital has people
providing services in this area, how do the private
practitioners successfully compete with the hospital
practitioners, if you will, in that kind of marketplace, and
what are the trends there? I see a lot of consolidation. I
think Dr. McAneny said it is already at 70 percent, perhaps, of
physicians going in to work at hospitals. Where do you get the
competition if they all go into the hospital and nobody is out
there providing that competition?
Mr. Pollack. I think some of the competition is among
hospital systems, and I think what we have to remember here is
that we have a new way of paying for a lot of care in terms of
different mechanisms that require payment for taking care of
people.
Mr. Goodlatte. What if there is only one hospital in the
community?
Mr. Pollack. By the way, you made an eloquent point at the
very beginning, Mr. Chairman, about how health care is a unique
kind of market.
Mr. Goodlatte. I agree with that.
Mr. Pollack. There are 13----
Mr. Goodlatte. But I am still not going to let you off the
hook with that. We still have to find ways to compete.
Mr. Pollack. No, no, your point is very well taken. There
are 1,300 critical access hospitals in this country in areas in
which there really is not competition. There are another 500 or
so sole community providers or rural referral centers. So
inherently, it is hard to say that competition plays out in a
very even----
Mr. Goodlatte. Competition amongst hospitals is an
important issue, and we are going to get to that as a part of
this series of hearings that we are going to hold. But right
now I want to talk about competition between doctors working in
the hospital and doctors who are working outside the hospital.
How do we promote that? How do we assure that we continue to
have competition from physicians who want to practice on their
own; or, from a societal standpoint, from an economic
standpoint, is it important that they be outside the system and
practice on their own?
Mr. Pollack. And I think that pluralistic approach still
exists today. But I think what is important to recognize is
that there are a lot of physicians that want to be in practices
that are group practices, whether they are on their own or
whether they are employed arrangements. There are a lot of
physicians in the next generation that are coming out of
medical school that actually want to be a part of these groups
because they don't want to take calls 24/7 and they want to be
part of these teams.
Mr. Goodlatte. Mr. Chairman, if I might, I would like to
let Dr. Gottlieb answer this same question that I just asked
Mr. Pollack.
Mr. Marino. Without objection.
Dr. Gottlieb. What was the question?
Mr. Goodlatte. The question is how do we assure continued
competition in communities that have only one hospital system
when the fact of the matter is more and more physicians go to
work in the hospital and take up that competition?
Dr. Gottlieb. I think we don't, and I practice in one such
community. I think when the hospital monopolizes most of the
local physicians, it is very hard to have provider-based
competition. I do believe that provisions in the Affordable
Care Act have skewed the market in this direction, quite
deliberately so. I think it is part of a broader political
philosophy that I think, to date, hasn't been successful.
Mr. Goodlatte. Thank you, Mr. Chairman.
Mr. Marino. The Chair now recognizes the Ranking Member of
the full Judiciary Committee, Congressman Conyers from
Michigan.
Mr. Conyers. Thank you, Mr. Chairman.
I welcome the witnesses, apologize for my late arrival.
I would like to start off with Professor Greaney by asking
him what he has heard or observed here today that you think we
ought to be most cautious about in terms of this analysis
between competing aspects of providers for the Affordable Care
Act.
Mr. Greaney. Thank you, Mr. Chairman. I think several of
the things that have been mentioned today----
Mr. Conyers. Pull that mic a little closer.
Mr. Greaney. Several of the things that have been brought
up today I think are absolutely valid criticisms of the current
state of the law. I think the disparate payments between site
of payment really makes no sense. MedPac has put out studies
showing that those payments should be adjusted appropriately.
That is the kind of change where I think Congress can step in
and correct preexisting law, law that preexisted the ACA, and
take steps.
Chairman Conyers has been talking for many years about the
McCarran-Ferguson Act. You heard Dr. McAneny's testimony about
changing the fraud and abuse laws to permit and encourage
greater cooperation short of mergers. There are many of those
steps that can be undertaken, and I think Congress should
devote its attention to those things because we have a lot of
old law that is like barnacles on the hull here. There is old
law that is dragging competition down, but they preceded the
ACA, and Congress could and should step up to the plate and
deal with them.
Mr. Conyers. Thank you.
I wanted to yield, if he needs time, to my friend from
Georgia, Mr. Johnson.
Mr. Johnson. Thank you, Mr. Chairman. I will go back to Dr.
McAneny.
You mentioned the narrowing of physician networks, which
happens when insurance companies consolidate. Could you tell us
a little bit more about that issue?
Dr. McAneny. Thank you very much, Mr. Johnson, for that
question. That is one of our major concerns. When a patient who
has, in my field of cancer, a specific need, say a genomics
test that says a certain drug is indicated, I have to be able
to go to my insurance company and convince them to provide that
medication or that service or that referral. The more
consolidated the industry becomes, the further away it is from
my individual patient, the harder it is for me to weave through
the regulatory areas of the insurance company to be able to get
to somebody who can approve that drug for that patient, and it
often takes months.
The more burdens that----
Mr. Johnson. And, by the way, that is not the regulatory
apparatus of the government. You are talking about the
regulatory apparatus of the insurance companies.
Dr. McAneny. Exactly, sir.
Mr. Johnson. All right. Proceed.
Dr. McAneny. Yes. It gets very difficult for me to be able
to advocate appropriately for my patients. When the insurance
company is small and local and they need me in their network,
then they will listen to me when I try to get something for a
patient. If I go to a national network or I am obviously always
advocating for a patient, I become a disruptive physician and I
am less inclined to be included in that network because I spend
more money and I am a thorn in the side of insurance companies
who don't want to buy those expensive drugs and processes that
Dr. Gottlieb was talking about.
So it is very intimidating to physicians. If you know in
your practice that you can't do without a given payer, they
know that they don't really have to pay attention to what you
are requesting because you can't afford to leave.
Mr. Johnson. And consolidation aggravates this situation.
Dr. McAneny. It will make it far worse. Yes, sir.
Mr. Johnson. All right. Well, let me ask Professor Greaney,
contrary to reports that costs have gone up overall for
consumers since the passage of the Affordable Care Act, a
shifting of, say, premium increases to higher deductibles and
co-pays and that kind of thing, what is your response to that,
sir?
Mr. Greaney. We have seen a number of studies where
competition has lowered premiums, has lowered costs. The
exchanges are a particularly good example where it has
occurred, has had a very beneficial effect on cost. The
individual markets experienced much better cost experiences,
and I think the message here is that competition works.
Mr. Johnson. Yes, 9.4 million seniors have saved more than
$15 billion on prescription drugs since the passage of the
Affordable Care Act, an average of $1,598 per senior.
Mr. Greaney. Yes.
Mr. Marino. You can finish, sir. The gentleman's time has
expired, but you can finish your point.
Mr. Greaney. Well, I was just going to mention that one
important driver of cost is whether we get new entry into
markets, and there is a particularly interesting example in
Arkansas. When it expanded Medicaid, Arkansas said let's have
the private option, let's have private insurers cover the new
Medicaid beneficiaries. What happened there? Not only did the
new beneficiaries get covered, but it increased competition in
the marketplace in Arkansas, so everybody benefitted, including
the private market. It went from two competitors to six. So
private competition can be generated, and I think states that
haven't expanded Medicaid are shooting themselves in the foot
in the private market as well.
Mr. Conyers. Chairman Marino?
Mr. Marino. Yes, sir?
Mr. Conyers. Could I ask unanimous consent for one question
additional?
Mr. Marino. Yes, sir, without objection.
Mr. Conyers. I thank you so much.
My last question is to Professor Greaney again, and it is
about the implementation of the health insurance exchanges
under the Affordable Care Act. Has it promoted competition, in
your view?
Mr. Greaney. Oh, most certainly. I think we have seen a lot
of markets where there has been new entry and there has been a
shakeup of the markets. But there are still plenty of markets
where we haven't had much competition, new entry in exchanges,
and that is why Congress is rightly concerned about the
insurance mergers, because we want new entry. But if we have
gone from five down to three, the most likely new entrants are
going to disappear. So that is a concern on the horizon.
Mr. Conyers. Thank you, Mr. Chairman.
Mr. Marino. The Chair now recognizes the Congresswoman from
California, Ms. Walters.
Ms. Walters. Thank you, Mr. Chairman.
I want to direct the question to Mr. Durham, and then give
Mr. Pollack an opportunity to respond.
Mr. Durham, your testimony raises concerns about hospital
consolidations. The testimony cites an analysis that claims,
``Hospitals and acquisitions increased 44 percent between 2010
and 2014, with a total of 442 transactions occurring during
this timeframe.'' Surely not all of these mergers have an
anticompetitive effect, and how do we differentiate between a
consolidation that increases competition and one that decreases
competition?
Mr. Durham. A very good question, Congresswoman. I believe
that is really a detailed analysis that the Department of
Justice conducts. They look at data that is not publicly
available and examine it at the local market. It is critical
that this analysis be done in specific geographic areas to
really determine the potential impact on competition.
As I mentioned in my testimony and oral statement, DOJ sees
that there are circumstances where mergers can create
efficiencies and enhance competition. So it really depends on
what they are seeing in the local geographic market.
We are all about driving value, moving away from the
antiquated fee-for-service model that pays for volume and
providing value for patients, lower cost, and higher-quality
care. And these mergers can certainly make that happen,
particularly when two companies have different areas of
expertise. One may have expertise and may have done a lot in
chronic care management, while another has done more in value
payment models in collaboration with providers. Bringing those
two together can bring higher value to patients, and that is
what we are focused on in terms of bending this cost curve.
Ms. Walters. Thank you.
Mr. Pollack?
Mr. Pollack. Thank you very much for that question, I
appreciate it. Mr. Durham's testimony has a litany of studies
that talk about how consolidation increases prices. I think a
lot of them are old. They are old data. They are incomplete.
For example, there is one study that is mentioned in the
testimony that looks at 12 states, but they say that they can
only find a relationship in three out of the 12 states. The
three states that they look at--Ohio, Georgia, and Missouri--
have a lot of critical access hospitals, rural referral
centers, and sole community providers, which we said inherently
are a different situation.
The newer studies that we have seen from JAMA show that, in
fact, we have reduced costs. We have seen other studies that
show that our price growth is at historic lows, and we have
studies that I would be glad to submit to the record that do
not show a correlation between consolidation and price
increases.
The last and very important point is that we also did a
study that I would submit for the record by the Center for
Health Transformation, and it looked at hospital deals, if you
will, between 2007 and 2013. There were 607 in that period.
That represents only 12 percent of our field. Of the 607 that
occurred, all but 22 resulted in at least five hospitals still
remaining after those consolidations. And of the 22 where there
were less than five, if you go through the stories of each of
those 22, some were to prevent a bankrupt hospital from going
out of business entirely, and many were to reconfigure
hospitals so they can exist to be an access point in
communities that wouldn't have access to care.
So I think in the hospital world, our arrangements are
focused on a different objective, which is to move to the
future in terms of rationalizing the system and finding ways to
preserve access where many just wouldn't exist if we didn't
have these arrangements. Thank you.
Ms. Walters. I yield back.
Mr. Marino. Thank you.
The Chair now recognizes the congressman from Georgia, Mr.
Collins.
Mr. Collins. Thank you, Mr. Chairman.
Mr. Greaney and Dr. Gottlieb, I have a question. I will
frame the question and I would like, Mr. Greaney, if you would
start; and, Dr. Gottlieb, if you would weigh in on this as
well.
One, I want to thank the Chairman for holding this series
of hearings that we are going to be having looking at these
issues and on similar topics, but I also want to focus a little
bit today on one because I want to encourage that there be a
hearing on this issue in particular, the effects of PBMs on
competition in the health care market and how Obamacare may
have affected the competition in that area.
This summer the FTC approved CVS' acquisition of Omnicare
without conducting a significant investigation into the
combination of the largest long-term care pharmacy with the
largest Part D PBM. The FTC's lack of action ties into other
concerns I have heard from my constituents about the conduct of
PBMs and their effect on competition.
Independent community pharmacists play a vital role in
Northeast Georgia, where I am from, a rural community, and
across the Nation, but they are being crippled many times by
burdensome regulations, and also the often, at times, abusive
PBM practices. My constituents and I share a concern that the
way Obamacare treats the PBMs will further harm independent
community pharmacists.
To that end, Mr. Greaney and Dr. Gottlieb, I would like to
know, in your opinion, what can be done to ensure independent
pharmacies and PBMs can compete on a level playing field? And
in this post-Obamacare environment, has Obamacare really
affected that? And do you feel like, aside from congressional
action, in the PBM space, could the FTC be doing more in this
area of PBMs and independent pharmacies, especially in the
health care chain?
So, Mr. Greaney, I will start with you.
Mr. Greaney. Well, surely I agree, Congressman, that the
PBMs are like other intermediaries in health care. They play an
important role in containing costs and doing the bargaining.
But if their size and their market structure is concentrated,
we face the same problems we face in other industries. And I
think, particularly in PBMs, there was the controversial
decision of the FTC to allow the Express Scripts-Medco merger
years ago----
Mr. Johnson. Excuse me, sir. Can you pull the mic up? Thank
you.
Mr. Greaney. Sure. There was some question about the FTC's
decision to let that merger go forward. At the time, the FTC
was comforted by the fact that there would be new entry and
smaller participants would generate more competition. The FTC
has done retrospectives of its own decisions, and this might be
a good time for it to do so, to look back and say how has that
worked out. To the extent that their prior prediction has
proven untrue, and I don't know that it has but I have heard
talk that it has, maybe it would be time for a retrospective to
see how the market is operating.
Mr. Collins. Dr. Gottlieb?
Dr. Gottlieb. I am less concerned, to be honest about it,
about the vertical integration of PBMs trying to buy
acquisitions outside their core space than the horizontal
acquisitions that would increase their market concentration.
The reality is we have a concentrated market of PBMs, and the
Express-Medco merger would concern me more than the Omnicare
acquisition because it is more of a vertical integration. What
is happening is the PBMs are trying to sort of buy their way
out of their current market to try to capture more margin from
other market segments.
I think that this would all be less concerning if it was
easier for new PBMs to get started and existing PBMs that are
small to continue to grow by trying to offer focused services
and differentiate themselves in the marketplace. Quite frankly,
I think the health plan consolidation will make it harder for
smaller PBMs to continue to grow and will potentially give more
market share to some of the existing large PBMs.
Mr. Collins. One of the things right there that concerns me
is there is a PBM market there, and we understand that, but my
problem is concerning our independent pharmacies and others who
are outside this who would provide a service in communities in
the health care chain that are basically, because of many times
the practices, small or large, are being worked out.
I wasn't going to do this but, Dr. McAneny, do you all have
anything to add on that, especially from--because I have heard
from physicians as well who struggle with their patients to get
drugs filled in a certain area because of restrictions,
especially in my area, a rural area.
Dr. McAneny. I would agree with you as another person from
a rural area, sir. What we have found in practice is that the
PBMs add another barrier because of their large consolidated
structure that makes it hard for us to get patients what we
want, and it has driven a lot of independent pharmacies out of
business, and those were the pharmacies where, when somebody
needs something at midnight, you can get the pharmacist to
provide the drug. When it is a large consolidated company
living a thousand miles away, they are not going to open a
store to get patients something in the middle of the night.
Mr. Collins. I am glad I am not one of the only ones that
has actually been ringing this bell.
This panel is great and our time is limited. Mr. Durham, I
think we have had a chance to talk about this, how we deal with
this in isolation. I appreciate you being here and the
challenges of rural health care in a market in which
consolidation is really not an aspect because you have a
dominant player and you have a lot of smaller players due to
many things. Obamacare, frankly, is one of them. They are
struggling right now in many markets.
So again, Chairman, great hearing. I think this is
something we need to continue. Again, my folks a little bit
more on that issue in the whole health care chain, along with
our hospitals, because it has been effective there as well.
With that, I yield back.
Mr. Marino. Thank you.
The Chair now recognizes the congressman from Texas, Mr.
Ratcliffe.
Mr. Ratcliffe. Thank you, Mr. Chairman.
You know, during my time in Congress, already I have had to
fight to protect the 700,000 Texans that I represent from the
perversely named Patient Protection and Affordable Care Act
because, let me assure you, the stories that I get from my
constituents certainly confirm that the law does not protect
them and that it is certainly not affordable. Time permitting,
I could relate to you hundreds and hundreds and hundreds of
examples like constituents of mine in Paris, Texas, a business
owner who has seen his monthly cost go up $300 and his
deductible go up $3,000; or another constituent in Gilmore,
Texas who has seen his deductible go up over $7,000 this year.
And now the news is even worse because we are told that the
cost of insurance plans on healthcare.gov in Texas are expected
to increase by another 25 percent next year. Does that sound
affordable to anyone? I don't think so. It certainly doesn't
seem that way to my constituents because survey after survey
show that 80 percent of them are opposed to Obamacare and want
to see me help get rid of it.
And it is not just individuals. It is hospitals. The impact
on hospitals in my district has been, frankly, gruesome. I have
had hospitals in Gilmore and Linden and Mt. Vernon and
Clarksville close in just the last 2 years alone. How do my
constituents who live in those rural areas get access to life-
saving care and treatment that they need? How is this improving
access to my constituents?
The simple truth is that it is not, that Obamacare has
reduced access, it has increased the cost of health care, and
it has lowered the quality of health care in my district. So I
appreciate, Mr. Chairman, you having this hearing so we can
learn from these witnesses on how we can keep insurance
affordable, hospitals accessible, and health care competitive
under this terrible law.
So let me turn and start with you, Dr. Gottlieb. Do you
believe that the heavy regulatory burden under this law is
driving solo and small group practices out of the health care
market?
Dr. Gottlieb. Well, I absolutely do. I think the ACA
provisions are biased in favor of consolidation of physicians
into large systems. I think the arbitrage that we talked about
today between the Medicare billing system, the inpatient-
outpatient billing system is certainly one. But also if you
look at the payment reforms, they are all structured around the
idea of doctors practicing in integrated delivery systems, but
they are biased in favor of a hospital owning that delivery
system. For example, there is a need for physical
infrastructure of the IT system. The anti-Stark provisions
don't apply unless doctors are part of those new arrangements.
I think there is a way to try to come up with policies that
give an equal footing to doctors practicing independently but
still practicing in an integrated way, but not requiring them
to sell their practices.
The other thing we need to keep in mind is that the law
also increases medical practice costs quite substantially at
the same time that physician reimbursement is being held flat
under Medicare and probably declining commercially. So doctors
are seeing their costs go up year over year, and they are
seeing their revenues stay stagnant or decline. That is also
forcing them into these arrangements.
Mr. Ratcliffe. So, Dr. Gottlieb, what impact will this have
on competition?
Dr. Gottlieb. My view is--and I practice in a market that
has a lot of doctors, but I believe in my market competition is
declining because a handful of health systems are monopolizing
the local providers.
I think the bigger question before this Committee is also
the issue of productivity. In these arrangements, there is no
good data demonstrating that productivity actually improves
among providers inside these arrangements and that medical
practice itself benefits from scale. There are a lot of studies
demonstrating the opposite. I am sure you could find one or two
studies that demonstrate the counterpoint, but there is a body
of literature now showing that productivity goes down, and that
should worry us.
Mr. Ratcliffe. Thank you, Dr. Gottlieb.
Mr. Durham, can you comment on Obamacare's impact on access
to mental health services and what is the insurance industry
doing about it?
Mr. Durham. Certainly, Congressman, I would be happy to
talk about that. Our industry has long supported the Mental
Health Parity Act, and health plans have been committed to
implementing parity requirements to ensure that patients have
access to high-quality, evidence-based treatments and care at
affordable prices.
Now, there is strong enforcement of parity laws, and health
plan benefit and coverage options related to mental health
services must be approved by state and Federal regulators.
Health plan coverage decisions for mental health and substance
abuse follow evidence-based guidelines and recommendations from
leading medical and behavioral health specialists, and our
plans are reviewing new evidence every day to make sure
patients have access to safe and effective treatments.
There is still more work to be done here to address the
wide variation in clinical practice and the cost of health care
that pose serious barriers to patient access. We are committed
to improving the value of care for all patients, particularly
those that are suffering from mental problems.
Mr. Ratcliffe. Thank you, Mr. Durham.
I see my time has expired. Mr. Chairman, I will yield back.
Mr. Marino. Thank you.
Seeing no other Members to ask questions, this concludes
today's hearing.
I want to thank all the witnesses for attending and for
being present. You all contributed to answering questions that
are important to us. Without objection, all Members will have 5
legislative days to submit additional written questions for the
witnesses or additional materials for the record.
This hearing is adjourned.
[Whereupon, at 11:29 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Material Submitted for the Hearing Record
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Response to Questions for the Record from Daniel T. Durham, Executive
Vice President, Strategic Initiatives, America's Health Insurance Plans
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Question for the Record submitted to Scott Gottlieb, M.D.,
Resident Fellow, American Enterprise Institute
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Response to Question for the Record from Scott Gottlieb, M.D.,
Resident Fellow, American Enterprise Institute