[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]




             EXAMINING THE EXTENSION OF SPECIAL NEEDS PLANS

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 26, 2017

                               __________

                           Serial No. 115-50










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      Printed for the use of the Committee on Energy and Commerce
                        energycommerce.house.gov
                                   ______
		 
                     U.S. GOVERNMENT PUBLISHING OFFICE 
		 
27-071 PDF                WASHINGTON : 2018                 




















                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman

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

                         Subcommittee on Health

                       MICHAEL C. BURGESS, Texas
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    ELIOT L. ENGEL, New York
FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
TIM MURPHY, Pennsylvania             DORIS O. MATSUI, California
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                     Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)

                                  (ii)





























                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     1
    Prepared statement...........................................     2
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     3
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, prepared statement.....................................    62
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, prepared statement........................    62

                               Witnesses

Chris Wing, Chief Executive Officer, SCAN Health Plan............     4
    Prepared statement...........................................     7
G. Lawrence Atkins, Ph.D., Executive Director, National MLISS 
  Health Plan Association........................................    11
    Prepared statement...........................................    13
Melanie Bella, Independent Consultant and Former Director, 
  Medicare-Medicaid Coordination Office, Centers for Medicare and 
  Medicaid Services..............................................    25
    Prepared statement...........................................    27

                           Submitted Material

Discussion Draft, H.R. ___, the Special Needs Plans 
  Reauthorization Act of 2017....................................    63
Article of June 29, 2017, ``Fixing the 5 Percent,'' by Karen 
  Weintraub and Rachel Zimmerman, The Atlantic, submitted by Mr. 
  Green..........................................................    88
Joint statement of SCAN Health Plan and Avalere Health, April 2, 
  2012, submitted by Mr. Burgess.................................    99
Letter of July 26, 2017, from Joseph White, Interim President and 
  CEO, Molina Healthcare, to Mr. Burgess and Mr. Green, submitted 
  by Mr. Burgess.................................................   102
Memo of March 30, 2012, from Dianne Munevar and Edward Drozd, 
  Avalere Health, to Peter Begans, SVP Public & Government 
  Affairs, SCAN Health Plan, submitted by Mr. Burgess............   103
Slide presentation, ``Dual Eligible Population Analysis for SCAN 
  Health Plan: Hospitalizations and Readmissions,'' Avalere 
  Health, March 2012, submitted by Mr. Burgess...................   111
Statement of the Bipartisan Policy Center, July 26, 2017, 
  submitted by Mr. Burgess.......................................   135
Letter of July 26, 2017, from Mary R. Grealy, President, 
  Healthcare Leadership Council, to Mr. Burgess, submitted by Mr. 
  Burgess........................................................   138
Letter of March 28, 2017, from Christian L. Soura, President, and 
  Judy Mohr Peterson, Vice President, National Association of 
  Medical Directors, to the Honorable Orrin Hatch, et al., 
  submitted by Mr. Burgess.......................................   140
Letter of July 20, 2017, from AIDS Healthcare Foundation, et al., 
  to Mr. Walden, et al., submitted by Mr. Burgess................   145
Statement of America's Health Insurance Plans, July 26, 2017, 
  submitted by Mr. Burgess.......................................   147
Letter of July 24, 2017, from Margaret A. Murray, President and 
  Chief Executive Officer, Association for Community Affiliated 
  Plans, to Mr. Walden and Mr. Pallone, submitted by Mr. Burgess.   152
Letter of July 25, 2017, from John G. Lovelace, President, 
  Government Programs and Individual Advantage, UPMC Health Plan, 
  to Mr. Burgess, et al., submitted by Mr. Burgess...............   155
Editorial of February 7, 1997, ``Making the Budget Bearable,'' 
  New York Times, submitted by Mr. Burgess.......................   157
Excerpt, Congressional Record--Senate, December 22, 1995, pages 
  S19184 to S19185,submitted by Mr. Burgess......................   158

 
             EXAMINING THE EXTENSION OF SPECIAL NEEDS PLANS

                              ----------                              


                        WEDNESDAY, JULY 26, 2017

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:15 a.m., in 
Room 2322, Rayburn House Office Building, Hon. Michael C. 
Burgess (chairman of the subcommittee) presiding.
    Members present: Representatives Burgess, Barton, Shimkus, 
Murphy, Blackburn, Lance, Griffith, Bilirakis, Long, Bucshon, 
Brooks, Mullin, Hudson, Collins, Carter, Green, Schakowsky, 
Butterfield, Matsui, Castor, Schrader, Kennedy, Cardenas, 
Eshoo, DeGette, and Pallone (ex officio).
    Also present: Representative Costello.
    Staff present: Paul Edattel, Chief Counsel, Health; Jay 
Gulshen, Legislative Clerk, Health; Katie McKeough, Press 
Assistant; Jennifer Sherman, Press Secretary; Josh Trent, 
Deputy Chief Counsel, Health; Jeff Carroll, Minority Staff 
Director; Rachel Pryor, Minority Health Policy Advisor; 
Samantha Satchell, Minority Policy Analyst; Andrew Souvall, 
Minority Director of Communications, Member Services, and 
Outreach; and C.J. Young, Minority Press Secretary.
    Mr. Burgess. Very well. I will ask all of our guests and 
Members to take their seats. The Subcommittee on Health will 
now come to order. The Chair recognizes himself 5 minutes for 
an opening statement.

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

    Today the committee moves forward with its work in regular 
order to examine extending and improving the Medicare Advantage 
Special Needs Plans. Special Needs Plans enjoy bipartisan 
support because of their successful record in providing 
comprehensive coordinated care to two million Medicare 
beneficiaries.
    This committee is especially interested in understanding 
how we can help improve Special Needs Plans for dual eligibles, 
since the majority of Special Needs Plans
    enrollees are dually eligible beneficiaries who are 
enrolled in both Medicare and Medicaid. Dual-eligible 
beneficiaries often have multiple chronic conditions, physical 
disabilities, and cognitive impairments. Yet, too often, these 
very beneficiaries are forced to navigate two Government 
programs with benefit structures, rules, and incentives that 
are often less than simple or intuitive.
    Today, we embark on our process to try to not only extend 
the Special Needs Plans, but improve the tools that States and 
plans have to help these beneficiaries. So in addition to 
hearing from our three experts before us, we also invite 
stakeholders' feedback on a bipartisan discussion draft 
recently released. The goal is simple. We want detailed 
feedback from stakeholders on the policies and specific 
language in this draft. We all share the goal of helping 
improve health outcomes, enhance quality, and improve the 
patient experience for Special Needs Plans enrollees who are 
some of the most vulnerable, high-need beneficiaries in 
Medicare.
    As a starting place, the discussion draft includes a number 
of provisions including reauthorizing the Institutional Special 
Needs Plans permanently, and extends the dual-eligible Special 
Needs Plans for 5 years. It streamlines Medicare and Medicaid 
benefits through one process so it is easier for duals to 
navigate their benefits. It improves access to supplemental 
benefits for patients with chronic illnesses through the 
inclusion of a bipartisan proposal supported by various 
members, including the gentleman from New Jersey, Mr. Lance. It 
enhances quality by directing HHS actions and holds us 
accountable for results, by requiring a number of studies so 
Congress receives appropriate feedback on policy changes.
    I hope members will thoughtfully engage in today's 
discussion, examine the policies carefully, and provide 
feedback to committee staff as we move forward.
    Thank you to each of our witnesses. We certainly look 
forward to hearing from each of you this morning.
    [The prepared statement of Mr. Burgess follows:]

             Prepared statement of Hon. Michael C. Burgess

    The subcommittee will come to order.
    The chairman will recognize himself for an opening 
statement.
    Today the committee moves forward with its work in regular 
order to examine extending and improving Medicare Advantage 
Special Needs Plans (SNPs). SNPs enjoy bipartisan support 
because of their successful record in providing comprehensive, 
coordinated care to about 2 million Medicare beneficiaries.
    This committee is especially interested in understanding 
how we can help improve SNPs for the dual eligibles--since the 
majority of SNP enrollees are dually eligible beneficiaries who 
are enrolled in both Medicare and Medicaid. Duals often have 
multiple chronic conditions, physical disabilities, and 
cognitive impairments such as dementia, developmental 
disabilities, and mental illness. Yet, too often, these very 
beneficiaries are forced to navigate two Government programs 
with benefit structures, rules, and incentives that are often 
less than simple and intuitive.
    Today, we embark on our process to try to not only extend 
SNPs, but improve the tools that States and plans have to help 
these beneficiaries. So in addition to hearing from our three 
expert witnesses before us, but we want to invite stakeholder's 
feedback on a bipartisan discussion draft we released. Our goal 
is simple: we want detailed feedback from stakeholders on the 
policies and specific language in this bill. We all share the 
goal of helping improve health outcomes, enhance quality, and 
improve the patient experience for SNP enrollees who are some 
of the most vulnerable, high-need beneficiaries in Medicare. As 
a starting place, this discussion draft includes a number of 
provisions, including:
     Reauthorizes Institutional SNPs permanently and 
extends D-SNPs and C-SNPS for 5 years;
     Streamlines Medicare and Medicaid benefits through 
one process so it is easier for duals to navigate their 
benefits;
     Improves access to supplemental benefits for 
patients with chronic illnesses through the inclusion of a 
bipartisan proposal supported by various members, including Mr. 
Lance;
     Enhances quality by directing HHS actions;
     Holds us accountable for results, by requiring a 
number of studies so Congress receives appropriate feedback on 
policy changes.
    I hope Members will thoughtfully engage in today's 
discussion, examine the policies carefully, and provide 
feedback to committee staff as we move forward.
    Thank you to each of our witnesses. We look forward to 
hearing from each of you.

    Mr. Burgess. I would yield to the gentleman from Kentucky, 
but he is not here. Let me yield back my time, and I will yield 
to the gentleman from Texas, the ranking member of the 
subcommittee, Mr. Green, 5 minutes for an opening statement, 
please.

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

    Mr. Green. Thank you, Mr. Chairman, and thanks to our 
witnesses for being here this morning. We are here to discuss 
the extension of the Special Needs Plans that serve some of our 
most vulnerable and highest need Medicare beneficiaries. The 
Medicare, Prescription Drug, Improvement and Modernization Act 
of 2003 established a new Medicare Advantage coordinated care 
plan, options specifically for individuals with special needs. 
This type of MA plans known as Special Needs Plans, or SNPs, 
are authorized to target enrollment to one or more types of 
individuals with distinct healthcare needs. Specifically, 
institutional SNPs, or I-SNPs, are largely enrolled 
beneficiaries who live in nursing homes; dual-eligible SNPs or 
D-SNPs, enrolled beneficiaries who are eligible for both 
Medicare and Medicaid; and Chronic Condition SNPs, or C-SNPs, 
enroll beneficiaries with certain severe and disabling chronic 
conditions like end-stage renal disease.
    Since the enactment of the Affordable Care Act, all new and 
expanded D-SNP plans are required to have contracts with the 
State Medicaid agencies to coordinate and deliver benefits and 
the ACA created a subset of D-SNPs known as fully integrated, 
dual-eligible, FIDE SNPs.
    Mr. Chairman, we have to keep up with all these short-term 
things.
    More than 2 million Americans are enrolled in 600 SNPs 
nationwide. There is a great amount of variety across SNPs and 
how they work in each State. Since the ACA, SNPs have been 
extended four times, more recently in the Medicare Access and 
CHP Reauthorization Act or MACRA in 2015. Authorization of the 
program is currently set to expire at the end of the calendar 
year. Discussions about SNP reauthorization has largely focused 
on duration of the authorization, with a growing number of 
stakeholders advocating for permanent authorization.
    Today, I look forward to learning more about the advantage 
of long-term or permanent authorization of SNPs and I am also 
interested in how we can address challenges to integrating 
benefits and providing high-quality care for complex patients 
with health and socio-economic needs. The SNP extension is an 
opportunity to complement other efforts in Medicaid to 
integrate the delivery of benefits and improve care 
coordination and quality.
    Finally, I would like to acknowledge the debate going on 
now in the Senate and actions the House took earlier this year 
will cast a shadow on the total discussion. The American Health 
Care Act and the Better Care Reconciliation Act both devastate 
Medicaid, ultimately cutting funding by 35 percent. Medicaid 
cuts will harm the ability of States to integrate in SNPs and 
other long-term services and support offering. Cuts in Medicaid 
will undermine these successes and harm our most frail 
citizens.
    While Medicare provides critical benefits, Medicaid wraps 
around that coverage and fills in the gaps. I hope my 
colleagues will abandon the pursuit to return to meaningful 
bipartisan work to improve our health system, like improving 
and extending SNPs.
    Thank you, Mr. Chairman. I look forward to today's 
discussion, and if anybody on my side wants my last minute and 
50 seconds? No. I yield back, Mr. Chairman.
    Mr. Burgess. Will the gentleman yield?
    Mr. Green. Sure.
    Mr. Burgess. So I have been contemplating introducing a 
bill that would modify or perhaps prohibit TLAs of the future. 
Three-letter acronyms. Does anyone else on the majority----
    Mr. Green. I would be glad to co-sponsor it.
    Mr. Burgess. Does anyone else on the majority side seek 
time for an opening statement? Anyone else on the minority side 
seek time?
    The Chair apparently concludes with opening statements. The 
Chair would like to remind Members, pursuant to committee 
rules, all Members' opening statements will be made part of the 
record.
    We do thank our witnesses for being here today, taking time 
to testify before the subcommittee. Each witness will have the 
opportunity to give an opening statement, followed by a round 
of questions from Members.
    This morning, we will hear from Mr. Chris Wing, the CEO of 
SCAN Health Plan; Dr. Larry Atkins, President, National MLTSS 
Health Plan Association; and Ms. Melanie Bella, who has been to 
this committee before, I believe, consultant and former 
Director of the Federal Coordinated Health Care Office, Centers 
for Medicare and Medicaid Services.
    We appreciate all of you being here this morning. Mr. Wing, 
you are now recognized for 5 minutes to give an opening 
statement, please.

 STATEMENT OF CHRIS WING, CHIEF EXECUTIVE OFFICER, SCAN HEALTH 
 PLAN; G. LAWRENCE ATKINS, PH.D., EXECUTIVE DIRECTOR, NATIONAL 
 MLTSS HEALTH PLAN ASSOCIATION; AND MELANIE BELLA, INDEPENDENT 
CONSULTANT AND FORMER DIRECTOR, MEDICARE-MEDICAID COORDINATION 
       OFFICE, CENTERS FOR MEDICARE AND MEDICAID SERVICES

                    STATEMENT OF CHRIS WING

    Mr. Wing. Chairman Burgess, Ranking Member Green, and 
members of the subcommittee, thank you very much for the 
opportunity to testify today.
    When it comes to SNPs, SCAN covers the waterfront. We are 
the only fully integrated dual-eligible SNP in California. We 
have an Institutional SNP in California. We also have three 
chronic illness Special Needs Plans in California.
    Like patient advocates, SCAN supports permanence for all 
SNPs. SCAN does come at the subject from a special vantage 
point. SCAN was a Social HMO for 22 years before the 
demonstration project evolved into SNPs. We have seen over 3 
decades how tailoring care to meet the special needs of seniors 
with complex conditions is the right approach. The care is 
better for the beneficiaries and the cost is less.
    Let me give you one example. Several years ago, SCAN asked 
the research firm Avalere Health to compare SCAN's dual-
eligible population in California to fee-for-service duals. 
Using the CMS' five percent sample, Avalere found 5,500 fee-
for-service duals in California who had similar risk 
characteristics as our 5,500 duals. We tracked them for over 2 
years. We called it a Doppleganger study.
    What did it find? Hospital admissions were 14 percent less 
for the SCAN population. And re-admissions were 25 percent 
less. Not only did the extra care provided by SCAN provide 
better care for the beneficiary by eliminating hospitalizations 
and re-hospitalizations, but it saved the Government a 
significant amount of money.
    It is clear that duals, who are the system's most in need 
and most expensive group of patients, are significantly helped 
by fully integrated D-SNPs. That is why SCAN supports 
permanency for D-SNPs.
    We also strongly support moving all D-SNPs on an expedited 
schedule toward full integration.
    C-SNPs have also succeeded in giving patients better care 
through added benefits and specialized networks. We think C-
SNPs have also earned permanency.
    We are happy that the committee is proposing to make I-SNPs 
permanent as well. However, let me point out one flaw with the 
current I-SNP structure.
    SCAN runs an Institutional SNP in California, meaning that 
we strive to keep our nursing home eligible beneficiaries in 
their own homes in the community and not in the nursing home. 
However, our plan has shrunk dramatically because we are not 
allowed by law to give beneficiaries the home and community-
based services they need to stay in the community and lead 
independent lives. To get those long-term services and 
supports, they have to spend down their assets and go on 
Medicaid and being dually eligible.
    To rectify that, we strongly urge the committee to consider 
including bipartisan legislation introduced in the last 
Congress by Representatives Leonard Lance and Kurt Schrader, 
here on Energy and Commerce, as well as Representatives Linda 
Sanchez and Pat Meehan on Ways and means. It would create a 
demonstration project to target a limited amount of Medicare 
funding toward frail individuals who are in the cusp of 
spending down their income and becoming dually eligible. It 
would allow them to receive home and community-based services, 
which is now allowed today. This demonstration would allow 
these individuals to stay in their homes, where they and their 
families want them to stay, preserving their dignity and 
comfort and would be a first step towards cost savings and 
entitlement reform.
    Finally, we want to strongly support the provision in your 
bill which grants increased flexibility to all plans, not just 
SNPs, to use supplemental benefits for nonmedical services.
    We appreciate you folks very much. Thank you.
    [The prepared statement of Mr. Wing follows:]
  
  
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    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. Dr. Atkins, you are recognized for 5 minutes for 
an opening statement.

                STATEMENT OF G. LAWRENCE ATKINS

    Dr. Atkins. Thank you, Mr. Chairman. Chairman Burgess, 
Ranking Member Green, and members of the subcommittee, thank 
you for the opportunity to testify on reauthorizing the Special 
Needs Plans.
    My name is Larry Atkins and I am the Executive Director of 
the National MLTSS Health Plan Association which I am sure the 
chairman will be happy to know does not fit into a three-letter 
acronym. Association members are the managed care plans that 
contract with States to manage long-term services and supports. 
Member plans are in 18 of the 22 States that have MLTSS and 
enroll nearly a million members in MLTSS plans and 175,000 in 
duals demo MMPS, the Medicare-Medicaid Plans.
    Managing LTSS focuses on helping individuals with 
functional needs and their families, attain their goals by 
obtaining the assistance they need either in institutions or in 
their homes and communities. We partner with our States to 
achieve shared objectives of rebalancing from institutions 
toward more home and community-based settings and integrating 
beneficiaries in the community and managing Medicare 
expenditures.
    SNPs, in particular, SNP for dual eligibles, the D-SNPs, 
improve our success with dual eligibles through opportunities 
to engage in fully integrated programs where we can bring 
Medicare's medical benefits together with the MLTSS benefits 
that we provide to provide a fully integrated and coordinated 
care for the individual.
    We fully support SNP reauthorization and urge the committee 
to consider a permanent reauthorization at this time. The cycle 
of repeated reauthorizations since 2003 has created uncertainty 
about the future of SNPs that deters plan investment and 
beneficiary enrollment in SNPs.
    D-SNPs, in particular, are a critical building block for 
integrating plans.
    Why is integration so important? Managing care for people 
with the most complex care needs is the key to controlling 
healthcare spending overall. Only six percent of Medicare 
beneficiaries use LTSS. They account for 43 percent of the 
spending, much of it medical in Medicaid.
    Providing better support in the home and community can 
prevent the failures that trigger unnecessary and expensive 
hospitalizations and institutional admissions that make up a 
lot of our healthcare spending. To do that, plans need to be 
able to manage both medical and nonmedical resources to 
communicate and share information between care managers and 
LTSS and medical providers and to capture savings on the 
medical side that can support the necessary services on the 
LTSS side.
    For duals, this means combining Medicare and Medicaid and 
right now, only a small proportion of duals are actually in 
integrated plans.
    We need an aggressive effort to expand integrated plan 
availability and enrollment. A barrier to integration is the 
difficulty of aligning Medicare and Medicaid coverage, that is, 
enrolling an individual in the same organization's Medicare and 
Medicaid plan. Most States auto-enroll Medicaid participants in 
their Medicaid managed care plan. On the Medicare side, 
beneficiaries choose. And in the SNP program, it allows for 
monthly decisions about election of plans' coverage. And they 
often remain in traditional Medicare or in another 
organization's Medicare plan which limits the MLTSS plan's 
ability to manage and coordinate care and share information 
among provides.
    The fully integrated dual SNP, the D-SNP, the FIDE SNP, and 
the MMPs, put the two plans together and offer them to 
beneficiaries as a single package. Only a handful of States 
have opted for either of these models to date. The problem is 
they use voluntary enrollment or passive enrollment with an opt 
out, either of those two approaches, which is actually acting 
to keep integrated models from reaching a large share of the 
duals' population.
    We urge the committee to permanently authorize SNPs. We 
support the effort to expand FIDE SNPs in more integrated 
approaches and we recommend that the Congress allow States to 
require duals that are in an MLTSS plan to be enrolled in an 
aligned MA plan.
    For the future, we propose adopting a common legislative 
and regulatory framework for plans that integrate Medicare and 
Medicaid to try to get around some of the alphabet soup that we 
have. To this end, we support creating a unified appeals and 
grievance process for integrated plans. We also support 
expanding the authority of the Medicare and Medicaid 
Coordination Office to encompass oversight of all integrated 
plans.
    Finally, we thank the committee for moving quickly on SNP 
reauthorization. SNPs alone though cannot drive the expansion 
of coverage under integrated plans. We look forward to 
continuing to work with the committee on strategies to bring 
the benefits of fully integrated plans to a larger portion of 
the population in need of LTSS. Thank you.
    [The prepared statement of Dr. Atkins follows:]
  
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    Mr. Burgess. The Chair thanks the gentleman. Ms. Bella, you 
are recognized for 5 minutes, please, for an opening statement.

                   STATEMENT OF MELANIE BELLA

    Ms. Bella. Chairman Burgess, Ranking Member Green, members 
of the committee, thank you for having me this morning. My name 
is Melanie Bella. My background is in Medicaid and duals. I 
have been fortunate to serve as a Medicaid Director and more 
recently ran the Office of Duals within CMS.
    Today, as you know, there are a little over 11 million 
people who are eligible for Medicare and Medicaid. We spend 
about $350 billion annually on their care. The majority of 
those individuals are not in programs that integrate their 
Medicare and Medicaid. However, there are promising models that 
bring those two programs together.
    Three such models are the Special Needs Plans that we are 
talking about today; Medicare-Medicaid Demonstration Plans, and 
the PACE program. Of note, PACE is the only permanent program. 
This means that for all of our 11 million dual eligibles, we 
have 1 option that is permanent to integrated clinically and 
financially the Medicaid and Medicare programs.
    We need to do more. We have an opportunity to do more and 
one such opportunity is before you today with the permanent 
authorization of Special Needs Plans. My remarks today will 
focus on the dual-eligible plan specifically.
    There is three things I want to kind of plant in your mind 
today. Number one, is that this takes investment. This is an 
active choice to make an investment of time and resources, and 
there is an opportunity cost to choosing this path that is 
pretty complicated over others. It is much easier to make 
investments in things when they are stable. So authorizing 
this, giving permanency to this program, allows States, plans, 
and even beneficiaries who are choosing to be in these programs 
the assurance they need that they are not going to worry every 
few years, that the program might be going away.
    The second is that full integration is really difficult. 
There is no doubt that the bar should be high and that if we 
want to have Special Needs Plans and dual-eligible Special 
Needs Plans, we should have an expectation that there is full 
integration of Medicaid and Medicare. But what that means is 
that we have to help State Medicare agencies get their long-
term supportive services and behavioral health services into 
managed and integrated products so we can pair those together. 
So what we should be doing is continuing to break down any 
barriers that stand in the way of doing that.
    In my written testimony, I have included examples of areas 
where the Duals Office within CMS could be given authority to 
break down many of those barriers, largely administrative, that 
make it really difficult for States and plans to bring those 
two worlds together.
    Lastly, we have to talk about States. States have to be our 
full partners in this. They are already resource constrained, 
and so they need incentives and capacity to be able to do these 
things. They also need tools to ensure that if we have these 
aligned programs that people are actually in them. So today, 
there are a few States where you have fully aligned programs, 
where Medicaid and Medicare are available, say if I am the 
dual-eligible beneficiary. But large numbers of people aren't 
in those plans. And so there are tools that we could be using 
to help facilitate those choices. One example where CMS could 
be very helpful just today would be to lift the moratorium on 
something called seamless conversion which is something that 
allows States and plans to ensure that people are getting their 
services from the same entity.
    So to reiterate an earlier point, States are in the same 
bucket of wanting assurance that this program is going to be 
stable and it is not going away which is another reason in 
support of permanency for these programs.
    In closing, this is I think my favorite subject in the 
world, so I would like to thank the committee for taking it on. 
This is a really important step. There are many more we could 
take, but the opportunities here really are ones that lend 
themselves very well to, I think, areas where we could have 
bipartisan agreement, so I appreciate the opportunity very 
much.
    [The prepared statement of Ms. Bella follows:]
  
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    Mr. Burgess. The Chair thanks the gentlelady. The Chair 
thanks all of the witnesses for your testimony. We will move 
into the Members' questions portion of the hearing. I want to 
begin by recognizing the gentleman from Illinois, 5 minutes for 
questions, please.
    Mr. Shimkus. Thank you, Mr. Chairman, and welcome. This is 
an interesting topic.
    And Ms. Bella, you mentioned, I have listened to all of the 
testimony, but my first question was going to be on seamless 
conversion which you talk about, but I was going to direct to 
Dr. Atkins and then Ms. Bella, you can follow up.
    The question is on the seamless conversion, can you tell us 
how this helps ensure coordinated care for beneficiaries and 
whether you think or not, I know Ms. Bella thinks this is 
something we should address or will be involved in the 
legislative fix.
    Dr. Atkins. The seamless conversion operates on the 
Medicaid side that States can move beneficiaries because the 
beneficiaries are automatically enrolled in Medicaid managed 
care plans in most States. States can reassign them to a 
different plan, but it aligns with a D-SNP.
    Arizona, for example, has had a pretty aggressive program 
to realign their Medicaid beneficiaries with their D-SNP 
coverage. The problem is that they can still move, the 
beneficiaries can still change their coverage on a monthly 
basis on the Medicare side. So the fact that as long as there 
is this complete flexibility and freedom of choice on the 
Medicare side, it is very difficult to achieve full alignment.
    Mr. Shimkus. So, and I can ask anyone, so is this something 
that you think we should try to address legislatively and fix 
on the Medicare side?
    Dr. Atkins. Yes.
    Mr. Wing. Yes.
    Mr. Shimkus. Ms. Bella?
    Ms. Bella. Yes.
    Mr. Shimkus. OK, good. Let me go to, I think Mr. Wing and 
Dr. Atkins again, and of course, Ms. Bella, if you want to 
chime in. So the Medicaid CHP Payment and Access Commission, 
because I don't like these acronyms, especially, can you 
imagine somebody listening to these opening statements and not 
knowing what any of these terms are? They would be thinking we 
are talking in a foreign language.
    The Medicaid CHP Payment and Access Commission noted that 
dual eligibles may often be enrolled in up to three health 
plans, a SNP, a Medicaid plan, and a limited benefit plan such 
as behavioral health or long-term services and supports. While 
we know how that has evolved, I think that the discussion here 
is that integrated care should be integrated care. And it is 
kind of silly financially to have to go through, for the 
individual consumer very confusing.
    Can you speak to the degree to which the committee's draft 
legislation addresses this issue of the possibility of three 
different plans and whether there are additional steps the 
committee should take?
    Mr. Wing. We believe in full integration. And we still have 
a lot of work to do. SCAN has been dealing with dual eligibles 
for 40 years, as I mentioned. One of the areas, and you 
mentioned one, is behavioral health. Thirty years ago, the 
industry made a mistake about separating the medical component 
of care from the medical component of care and we now have 
pilots, especially if we have permanence, it makes a lot of 
sense. We are not a not-for-profit, but we have to be diligent 
with our capital deployment. But we now have a pilot in 
anticipation of either a 5-year permanence and we have a pilot 
in Riverside where we are actually coordinating bringing a 
telephonic Skype-based telemedicine that is focused exclusively 
on behavioral health. So from SCAN's perspective, we need to 
integrate this so it is totally seamlessly integrated for the 
beneficiaries, for the State and for the plan.
    Mr. Shimkus. Dr. Atkins?
    Dr. Atkins. I think the legislation helps. It creates much 
more of a push toward FIDE SNPs which is really the only full-
integrated approach. And then you know, I think the challenge 
is that in many States you don't have the managed LTSS or you 
don't have managed behavioral health to be able to integrate 
with the D-SNP. So you can't get everybody into a FIDE SNP if 
you don't have the managed LTSS and behavioral health.
    And then I think you spoke to the issue of a managed 
Medicaid plan, just generally, and then often these separate 
MLTSS or behavioral health plans, but I think if the States can 
be moving more directly to integrating on the Medicaid side, 
then I think the challenge comes down to trying to find a way 
to get that alignment to happen on the Medicare side.
     Mr. Shimkus. Ms. Bella, do you want to add anything to 
this?
    Ms. Bella. I would say it is an important incremental step. 
It is taking us one step further. It is still not getting us to 
a point where we have one program fully integrated without all 
the incentives, but to do that, we have a lot of enrollment and 
other financing issues to tackle. So it is an important step. 
It is not the end game.
    Mr. Shimkus. Thank you very much. I yield back, Mr. 
Chairman.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from Texas, 
Mr. Green, 5 minutes for questions, please.
    Mr. Green. Thank you, Mr. Chairman. Ms. Bella, you noted 
that the clinical and financial integration are both critical 
to actually achieving true coordination between Medicare and 
Medicaid. As part of your testimony, you also highlighted that 
even in States where fully aligned plans are offered, sometimes 
beneficiaries do not enroll in these plans. You mentioned 
specifically that improved enrollment processes and enhanced 
outreach to promote aligned plans could address some of these 
issues.
    Ms. Bella, can you provide an example of what you mean by 
improved enrollment processes?
    Ms. Bella. Sure. I think part of the challenge is these are 
difficult programs to explain to people who are eligible for 
them. And we make it more difficult with having a different set 
of requirements for Medicaid and a different set of 
requirements for Medicare that complicate.
    We also have different processes for reviewing and 
approving those materials, so the end result is to talk to real 
people. The information isn't as clear as it could be. So it is 
sort of one set of things around materials and processes. It is 
another set of things around and this is probably more detailed 
than we have time to go into today, but the Medicaid program 
looks at people one way and has one set of eligibility rules, 
and the Medicare rules look at that exact same person a 
different way. And so we have conflicts in terms of how people 
are enrolled, how long they are enrolled, when and how often 
they can make enrollment choices and all of those things just 
they create problems for people and they really just erode a 
continuity of care and being able to keep people in a plan.
    Mr. Green. Do you have any examples of how we can improve 
that outreach?
    Ms. Bella. Yes, there are examples. There are examples of 
how you can coordinate member materials, so requirements on the 
Medicare-Medicaid side around summary benefits, annual notice 
of coverage. So some of that is being tested in the 
demonstration States and in Minnesota right now, tested well.
    There are examples of how you can have joint review of 
those materials. What was just discussed about seamless 
conversion, allowing that to proceed, lifting the moratorium on 
that would be important. So I would be happy to present some 
more explicit examples outside of the hearing, but there are 
definitely concrete things, many of which are being tested 
today.
    Mr. Green. If you would give that to us so we could include 
it in the record, I would appreciate it.
    Ms. Bella. Sure.
    Mr. Green. Thank you, Ms. Bella. Finally, there are certain 
States that Congress should look to as models that have been 
very innovative and promoted integration between Medicare and 
Medicaid. Do any of the panelists have thoughts on certain 
States that we might look at, whether it be Minnesota or 
someone else?
    Dr. Atkins. Well, there is certainly, you know, there are 
the States that started first with full integration. 
Massachusetts, Minnesota, Wisconsin were the early States. And 
Massachusetts is another State to look at for their FIDE SNP. 
They have a senior care options program for the seniors, and 
they are in the duals demonstration for the under-65 
population.
    But I think a lot of the States now who have gone either to 
adopt MMPs or have pushed more on integration, there are a lot 
of States out there that I think coming at it from very 
different perspectives have done a great deal in this space. 
The ones that are now sponsoring FIDE SNPs are an example.
    Mr. Green. Ms. Bella, I have another question. It seems 
like there is a menu of options available to dual-eligible and 
chronically ill beneficiaries. I think we need a basic review 
of the system of care as it stands for these beneficiaries so 
that we better understand how the pieces fall together.
    What are the options a dually eligible or chronically ill 
beneficiary is available to them in any given State? For the 
record, what is a D-SNP, a FIDE SNP, and what is a duals demo 
and the PACE program and how do all these different care 
options fit together.
    Ms. Bella. Are you asking what each of them is for the 
record?
    Mr. Green. Yes, for seeing how they all fit together.
    Ms. Bella. I think of it as sort of menu of integration. So 
you start with sort of--your goal is to get to full 
integration, which means Medicare-Medicaid benefits are 
delivered by one entity, and they have financial integration, 
too. So the financial alignment duals demonstrations integrate 
the services, the payment. One entity gets a set amount of 
money every month to provide that care.
    One step down from that are the FIDE SNPs, the fully 
integrated, dual-eligible SNPs. so they have a contract with 
Medicare as a Special Needs Plans. They have a contract with a 
Medicaid agency for long-term care and behavioral health. They 
manage those two separate contracts. They get two separate 
funding streams, but they are still responsible for everything, 
just not quite as integrated as the Medicare-Medicaid Demo 
Plan.
    One step down from that is a regular dual-eligible SNP, so 
they have contract with Medicare as a SNP. They may or may not 
have a contract with Medicaid and so they are not quite as 
integrated as the FIDE SNP, because they are not managing the 
long-term care and the behavioral health benefit.
    And then one step down from that would be a regular MA plan 
because there are many duals that are in regular MA plans. They 
have no relationship to Medicaid at all.
    And I erred by saying PACE should be over here beyond the 
MMP plan, because PACE is completely clinically and financially 
integrated with both Medicaid and Medicare.
    Mr. Green. Thank you.
    Dr. Atkins. Is it all right if I comment on that? I think 
PACE has a lot of features that would be beneficial for other 
integrated plans and the other thing is that the MMPs have a 
three-way contract between the State, the Federal Government, 
and the plan. And that actually is the plans have reported, and 
I think the State and Federal Government feel the same way, 
that that has enhanced the level of communication that goes on 
between the three entities and it is really moved to a much 
higher level of coordination. So I think the three-way contract 
is another interesting piece.
    But we advocate for eventually a single kind of overarching 
design for integrated plans and to try to allow these different 
modalities, but to bring them in under a kind of a common 
architecture because I think they are really are there because 
that is the way they have evolved. They are not there because 
that is the way that makes the most sense.
    Mr. Green. Thank you. Thank you, Mr. Chairman. I appreciate 
the information as we look at this legislation.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from 
Pennsylvania, Mr. Murphy, 5 minutes for questions, please.
    Mr. Murphy. Thank you, Mr. Chairman. This just sounds like 
one of the biggest Rube Goldberg messes the Government could 
come up with. So let me try and peel back a little bit here.
    Mr. Wing, I was fascinated by what you talked about with 
some of these patients through telemedicine. I am assuming you 
have some sort of telepsychiatry consult. We know that people 
who have a chronic illness or acute illness doubles their risk 
for mood disorder, depression. When that is untreated, it 
increases their costs.
    Who does that, the work that you talked about in your plan, 
who actually does those teleconsults?
    Mr. Wing. Actually, right now we have a pilot. I am under a 
nondisclosure agreement, but we have a pilot.
    Mr. Murphy. I don't mean what the group does, I mean is it 
a psychiatrist, psychologist, social worker?
    Mr. Wing. Well, actually, it is everything above. I can 
discuss the intervention.
    Mr. Murphy. Briefly.
    Mr. Wing. I came from a physician group that did a really 
good job, DaVita Medical Group. But diagnosing opioid abuse, 
substance abuse, and depression is easier said than done. So in 
this modality, the primary care physician is given an iPad and 
when he even suspects that there is opioid abuse, substance 
abuse, or bipolar disease, put the patient in a private exam 
room, give them an iPad that is connected to Skype to a 
specialized geriatric nurse practitioner. She is the one that 
does the better assessment and then she can then connect the 
patient through telehealth through a national network in 
behavioral health.
    Mr. Murphy. Let me ask a couple of things that would make 
it even worse. Are you aware that even in that, that primary 
care physician because of a regulation put forth in the Nixon 
administration, if that person is already in treatment or 
receiving methadone or Suboxone, that doctor may not have 
access to the records and therefore may prescribe an opioid for 
his pain or the treatment, they don't even know that person is 
in treatment because of this thing called the 42 CFR Part 2. 
Are you aware of that?
    Mr. Wing. Yes.
    Mr. Murphy. It is another mess that we have to fix. Plus, 
we also have a strange thing that even those psychologists may 
do the work, they have to bill through the psychiatrist and so 
which adds administrative costs and takes the psychiatrist away 
from their work. So it is another expense that we add to the 
system. So let us continue to build on Rube Goldberg.
    And in this, too, I want to ask all of you, if you are 
aware, too, what we find is that a true coordinated care model 
is the physician can really understand we have a complex case. 
You have a person, dual eligible, so they already are having 
multiple problems. And we even know, when you have got the flu 
it is hard to manage your flu. But when you are dealing with a 
chronic illness and perhaps mental illness on top of that, 
behavior and physical medicine have to be integrated together, 
but that requires a lot of work. But even in that context, I 
want to make sure I understand, because my understanding is 
Medicare doesn't pay for these services that are needed. For 
example, responding to a patient's phone call about a symptom 
or problem may not be paid for; or communications between the 
primary care physician and specialists to coordinate a care 
isn't paid for. Communicating between community physicians and 
emergency room isn't paid for or providing proactive telephone 
outreach to high-risk patients to say we want to make sure we 
see how you are doing, be aware of these symptoms, etcetera, 
how is your medication going, not paid for. Spending time with 
a patient in shared decision making to map out a game plan for 
them isn't paid for. Hiring nurses or another staff member to 
do education, patient education on medication, treatments, 
anything else isn't paid for. Providing palliative care isn't 
paid for. And even such things as getting the patient to the 
doctor's office. I have heard of one program in Miami that 
actually does this. They actually bring the patients to the 
doctor's office and deliver medication and guess what? Patient 
compliance goes way up.
    So is it your understanding, too, or am I getting this 
right, in a coordinated care plan with these very, very 
difficult cases, these things aren't paid for, but we know that 
those things save money.
    Dr. Atkins. Can I comment on that? I think this is a 
critical issue because Medicare actually is much more 
restrictive about what can be covered and not covered than 
Medicaid is. Medicaid is more flexible, but neither one of them 
is particularly flexible. And when you put the two together, 
you still have to deal with limitations on coverage, coverage 
restrictions and things that are built in the statute.
    So what we would advocate for is that as we go toward these 
more integrated models, that in the context of an integrated 
system where you are fully capitating across all of these 
services and supports, behavioral health, long-term services 
and supports and the medical, that you give the plans the 
flexibility to be able to provide the services that make the 
most sense in the case that they are dealing with, 
understanding that they are financially at risk for the overall 
cost of care for that patient. But if they see the possibility 
of providing a service, whether it is a counseling service or 
whether it is an inhome service that would help to reduce the 
medical costs on the medical side, they have the opportunity to 
do that.
    Mr. Murphy. So this goes back to eliminating Rube Goldberg 
and saying if we empower the physicians to work closely with 
the patient and make some determines what they need and work 
more directly with that, and have a system of payment that is 
designed to cover that patient, let the medical practice decide 
what is best, we can actually save a lot of money and it is 
quite frankly, I believe more compassionate and works toward 
better healthcare.
    Dr. Atkins. And I would urge you to include the fact that 
it is just not medical because for a lot of these people, the 
more significant services for them really are the services and 
supports that help to reduce medical expenditures.
    Mr. Murphy. Yes, I add to that also psychological 
behavioral services. Thank you very much. Mr. Chairman, I yield 
back.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair recognizes the gentlelady from Florida, 
Ms. Castor, 5 minutes for questions, please.
    Ms. Castor. Well, thank you very much for calling this 
hearing, Mr. Chairman. And thank you to our witnesses for your 
expertise here.
    You all, based upon your testimony you say that not enough 
dual eligibles are enrolled in the Special Needs Plans, 
correct? And you have made recommendations to improve that, 
remove barriers, work with States to improve the enrollment 
there.
    Do you all agree that as we move in this direction, the 
Government could see substantial cost savings?
    Mr. Wing. This is Chris Wing. The answer is yes. In our 
fully integrated D-SNP, we actually have two products. We have 
more of an ambulatory program for the aged, blind, and disabled 
dual eligible. It is called Connections.
    We have another program in California. These members have 
to meet the California standards for being certified for 
nursing home eligible. In our program, for the seniors that in 
that Connections at home, all of them nursing home certifiable, 
we keep 96 percent of them, 96 percent in the community and 
outside of nursing homes. And if you do the math, this isn't a 
DRG where it is $12,000 or $14,000. This could be a 7-year 
length of stay and $4,000 or $5,000 a month. The savings to the 
system are very, very profound, coupled with a better quality 
of life, better quality of care for beneficiaries.
    Ms. Castor. And I am going to ask you a little bit more 
about that, but do you all agree?
    Dr. Atkins. Yes, if I could just reinforce that. HHS 
released a study this spring of the MSHIL program in Minnesota 
which is a fully integrated program and it was a comparison of 
the people who were in the MSHIL program to people who were 
just in MLTSS alone without the integration with Medicare. They 
found a very substantial reduction. I don't know the figure on 
top of my head, but there is a very substantial reduction that 
is possible.
    Ms. Castor. And Ms. Bella, do you agree? And then how do we 
keep track? What measures are in place? How do we keep track of 
cost savings over time so we are investing where we need to 
invest?
    Ms. Bella. Well, I do agree there is cost savings, but they 
are not immediate and they accrue more immediately on the 
Medicare side for things like hospitalization, readmissions, 
better prescription drug management. It takes more time to see 
on the Medicare side and that is part of the problem is that we 
have a mismatch between when the savings happen and how the 
payers benefit. And so that is why you haven't seen as much 
take up of some of these so that is one of the things we need 
to address. We track that by looking at outcomes, the hard 
utilization outcomes that are measurable around key utilization 
areas that are driving costs, around all the inpatient buckets. 
And then on the Medicaid side it services all the long term 
care and how much of that can be moved into home and community-
based settings and how are we seeing those shifts. So there is 
ways of tracking.
    Ms. Castor. And that is the responsibility of CMS?
    Ms. Bella. It needs to be the responsibility of CMS and the 
States, but also MedPAC and MACPAC also play an important role 
because they can bridge those data together and help do some of 
the academic pieces of that that the governments aren't 
necessarily staffed to do.
    Ms. Castor. So we are really struggling with the escalating 
cost of prescription drugs all across the board and all kinds 
of insurers. Is this a way where we can realize cost savings as 
well for prescription drugs paid by the Government under Part D 
and Medicaid and how would that work?
    Ms. Bella. Certainly, prescription drugs is an area that 
when the two programs aren't talking to each other, the costs 
can go up because there is no coordination, there is no one 
managing the meds, and there are all of those things. So the 
integrated program where you have one entity responsible who is 
seeing everything that that person is getting, yes, they have 
an opportunity to improve the medication management and 
presumably drive costs down.
    Ms. Castor. Are there incentives in place to do so?
    Ms. Bella. The health plans have incentives. I mean the 
health plans are fully capitated have incentives to make sure 
that the dollars are being used wisely. Those incentives don't 
always flow back to the States and the Federal Government, and 
so again, there is sometimes mismatches in where investments 
are being made and where savings are being recouped, but the 
health plans have incentives across the board when they have 
responsibility for both pots.
    Ms. Castor. Did you want to comment on that, too?
    Mr. Wing. The answer is that we have the risk. We are going 
to work with our providers to profile aberrant prescribing 
patterns and also try and work with the patient to make sure we 
understand what their desires are, what their goals are, we 
meet their desires so they will be more compliant.
    Dr. Atkins. There is also, I think, an issue of medication 
adherence which is that very often we have spent a lot of money 
in this country on prescriptions that people either don't take 
or don't take properly and they really don't have the effect 
that they need to have. So one of the advantages of an 
integrated program is that there is a lot of emphasis on 
medications.
    Ms. Castor. And there has also been increased recognition 
of the importance of social determinants, things like social 
supports and an individual's physical environment and that is 
how we can help create positive outcomes and cost savings and 
this is something that Medicaid has worked on for a while and I 
am glad to see Medicare learning from Medicaid here.
    Mr. Wing, SCAN, I understand, has been very innovative in 
its thinking about social determinants of health and how 
nontraditional services and interventions can help. Tell us a 
little bit more about that.
    Mr. Wing. You know, we were founded to focus on complex 
seniors especially dually eligible. And it is amazing what 
small things can really make a profound difference.
    I came from DaVita Medical Group, and doctors do a great 
job, but oftentimes they don't know what is going on in the 
home. So we have a program where we put social workers and care 
navigators into the home to take stock, do an HRA, but take 
stock as far as the whole social determinants of health, and 
report back to the doctor. We don't only provide the 
transportation back to the doctor which often is a barrier for 
dually eligible, but oftentimes we have a care navigator go 
with a patient and make sure the doctor knows the social 
determinants and everything else that is going on in the home.
    One case--if I can--about 2 years ago, we videotaped a 
member who was socially isolated, living by himself, a Latino 
gentleman. He already had Parkinson's, but he had glaucoma. Our 
community health navigator, not a high cost, in the home 
identified--the member was doing the best he can to put the eye 
drops in, but couldn't do it. A $12 wrist guard, a $12 wrist 
guard. The doctor thought the member was doing his best, but 
did not know he couldn't do it. A $12 wrist guard, all of a 
sudden this patient now can slow the delay of the glaucoma and 
fast forward in 5 years, if he had gone blind, had Parkinson's, 
if he showed up in ER, he is going to get admitted. But that is 
not the worst outcome.
    The worst outcome is when he was about to be discharged. He 
is not going to be discharged back to the community. He is 
going to go to custodial care the rest of his life. So these 
social determinants probably predict anywhere between 20 to 80 
percent of health outcomes. And when you are totally integrated 
like SCAN is for a fully integrated D-SNP, we have all the 
incentives to work with the doctors, but also make sure we are 
in the home and we know everything that is going on with that 
patient, their care givers, and their family situation.
    Ms. Castor. Thank you.
    Mr. Burgess. The gentlelady's time has expired. The Chair 
recognizes the gentleman from New Jersey, Mr. Lance, 5 minutes 
for questions, please.
    Mr. Lance. Thank you, Mr. Chairman. As the chairman 
indicated, I am one of the sponsors in the bill that would 
enable expanded supplemental benefits to meet the needs of the 
chronically ill, Medicare Advantage enrollees.
    I want to work with the entire panel on this issue. New 
Jersey has struggled with behavioral health and substance abuse 
issues. Dual eligibles who are in the program, we have in New 
Jersey, try to address the whole person, both physical and 
mental health.
    In the panel's opinion, does this kind of dual payment 
integration foster clinical integration?
    Mr. Wing. Again, the answer is yes. You know, for our 
Medicare Advantage plan, not for our SNPs, we are prohibited 
from offering nonhealth type of services. Let us take the 
individual who needed a $12 wrist guard, boy, would that make a 
difference in somebody who is in a Medicare Advantage 
population? Yes.
    We all know about the hip fractures for seniors often lead 
to bad outcomes, whether it is nursing home care, institutional 
care, but if we could provide solid grips in the bathrooms, by 
the toilets, that would make a profound difference. But right 
now, Medicare Advantage plans cannot offer, by law, Medicare 
benefits to a Medicare Advantage only audience.
    Mr. Lance. Well, thank you. And I want to continue to work 
with the panel on this and other issues because I think this is 
an incredibly important area and I commend those on the other 
side of the aisle, including Congressman Schrader, who is 
working with me on this issue and it is to be continued.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentleman from 
California, Mr. Cardenas, 5 minutes for questions, please.
    Mr. Cardenas. Thank you, Mr. Chairman, Mr. Ranking Member. 
I would to thank you for holding today's hearing and allowing 
the committee to shine a light on a program that is helping to 
improve the lives of so many medically vulnerable Americans.
    Too often in these discussions, we lose track of the real-
world effects of our decisions. The conversation today is not 
about some obscure policy provision. It is about real people 
with real needs.
    One of those real people lives in my district. Let us just 
call her Cassandra. Cassandra is 73 years old and has several 
chronic conditions including congestive heart failure, 
diabetes, and hypertension. For anyone unfamiliar with diabetes 
testing, a blood glucose test, or an A1C score above 8 is 
considered uncontrolled. This can lead to range of negative 
health effects including amputations, kidney failure, and loss 
of vision.
    Before joining the Special Needs Plans, Cassandra had an 
A1C reading of 12. This is dangerously high. This, along with 
her other poorly controlled conditions, led to at least seven 
hospitalizations over the course of just 1 year. Cassandra 
joined an SNP in 2014 and today her A1C level is just 7.6. 
Cassandra has also only been to the ER once since her 
enrollment and has only been hospitalized for one scheduled 
surgery. Cassandra's care is coordinated by her care team and 
she has regular meetings with her primary care provider and 
nutritionalist to keep her conditions under control.
    For the first time, Cassandra is getting healthier as she 
gets older, and her quality of life is much, much better.
    Cassandra is just one example of the millions of people 
benefitting from these specialized plans. We owe it to these 
patients to provide the certainty that these plans will be 
there for them in the future and that is why I believe it is so 
important to reauthorize them permanently to make them more 
effective and more efficient. Bottom line, better quality of 
care.
    One of the many populations that are treated through 
Special Needs Plans and are end-stage renal disease, otherwise 
known ESRD patients, so I have a question for Mr. Wing. 21st 
Century Cures took the first steps in developing ESRD specific 
quality measures for ESRD C-SNPs. As you know, not all quality 
measures are applicable to such a specialized patient 
population due to the uniqueness of the ESRD patient population 
and the type of specialized care they receive.
    So Mr. Wing, do you believe ESRD C-SNPs could better 
measure the quality of care provided if more specialized 
measures were developed?
    Mr. Wing. The answer is yes. And actually we have an ESRD 
Special Needs Plans in Riverside with DaVita Medical-- 
actually, DaVita, the parent. And it is amazing here. Not just 
we have the quality metrics. We can always improve quality 
metrics. We think the stars measures have fundamental changed 
the conversation between health plans' providers because there 
is the economic incentives now. We always think there is 
improvement. Well, boy, when you talk to the nephrologists, 
when you talk to the patients, when you talk to the nurses 
about the care that dialysis patients get, ESRD Special Needs 
Plans, the savings are there, but again, the beneficiary 
satisfaction, the patient satisfaction is there as well. So the 
answer is we do applaud the current measures, but we can always 
improve upon them.
    Mr. Cardenas. Mr. Wing, I have been listening to your 
answers today and I really appreciate you sharing your 
expertise with us. But one of the things that seems to be the 
common thread in all of this that you have been explaining and 
that is the communication between human beings. I mean we have 
all been incredibly impressed with the technology and the 
advances and the efficiencies of being able to be more accurate 
when it comes to seeing what is really going on with a patient 
down to the molecular level, but at the same time it seems like 
every single one of your answers seems to point toward we need 
to make sure that our human beings are actually able to 
communicate with each other and share information and that 
seems to be the driving factor to having much, much better 
results. Would you agree?
    Mr. Wing. I would agree. Hopefully, I am not a one-trick 
pony, but I think there is two tricks, integration and risk-
bearing entities will always strive to innovate for better 
care, better quality and better financial outcomes. But I am 
always amazed, when we put people into patients' or 
beneficiaries' homes to find out what is going on, the doctors, 
as good as they are, as committed to quality as they are, they 
don't know what is going on in the home. We have to have eyes 
and ears in the home to translate to the doctors. So 
communication and risk-bearing entities I think are a large 
part of the solution for this type of population.
    Mr. Cardenas. And unfortunately, in this modern world, the 
human element seems to be in so many systems that want to get 
eliminated. This one we have to be very careful to understand 
how important that that human touch is. Thank you so much. I 
yield back.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair recognizes the gentleman from Missouri, 
Mr. Billy Long, for 5 minutes for questions, please.
    Mr. Long. Thank you, Mr. Chairman. And Dr. Atkins, in your 
testimony you discussed fully integrated, dual-eligible Special 
Needs Plans. The uptake by States has been slow and enrollment 
has been relatively low, yet you state Congress should commit 
to advancing models that can fully integrate Medicare and 
Medicaid benefits.
    There is a concern that if we move too quickly, we are 
trying to force rather than facilitate integration. How do you 
respond to this concern?
    Dr. Atkins. Well, you know, the difficulty with the uptake 
has been just that we have a lot of States that don't have 
managed MLTSS and behavioral health. So trying to integrate, 
and you can't really do a FIDE SNP if you don't have 
integration--managed care on both sides. So that is one of the 
challenges.
    And then, you know, I think the enrollment issue has been a 
substantial challenge in both the MMP program and the FIDE SNP 
program. It is either voluntary enrollment that people 
voluntarily choose to enroll as beneficiaries in the combined 
plan or in the case of MMP, there has been passive enrollment 
with an opt-out and so people find themselves in the plans, 
don't really know quite how they got there and often are 
persuaded either by their physician or by an LTSS provider to 
opt-out of the plan without really understanding what the 
choice has been.
    So I think the challenge has been to address these 
questions about enrollment because what we find is that when 
people do enroll in these plans, the level of satisfaction goes 
ways up. So in the disability community, for example, in the 
younger disability community, there has been some resistance to 
going into managed care. So there has been some resistance to 
going into these integrated plans, but a lot of that is built 
on a lack of understanding about what is going on in these 
plans. And when beneficiaries get in, they report they are much 
more satisfied with this experience. So I think it is going to 
be a lot of education.
    I think in many cases, the MMPs were launched in the State 
without adequately communicating in advance what these plans 
were. And then when you look at the beneficiaries who get 
assigned to these plans, often these are very hard to reach 
beneficiaries and when they get into an MMP, it is the first 
time anybody has ever shown up and had contact with them about 
what is going on with their healthcare or what are their 
services and supports. And so it has been very difficult to 
kind of get to everybody and get the information out there, but 
I think that we need to have some strategies around how do we 
get more people to enroll in these plans.
    Mr. Long. All that being said and talking about enrollment, 
could this lead to fewer comprehensive plans being offered?
    Dr. Atkins. I am sorry, I didn't understand the question.
    Mr. Long. I said could this lead to fewer comprehensive 
plans being offered, forcing rather than facilitating?
    Dr. Atkins. If we go to a FIDE SNP, for example? I mean I 
think a FIDE SNP is incredibly----
    Mr. Long. Trying to move too quickly, is that going to----
    Dr. Atkins. Oh, if we go too quickly, are we scaring people 
away? Well, I think in each State where these products get 
launched, the State has to do the work initially. It may take a 
year or more to work with all of the groups that are affected.
    Just as an example, in Kansas when they brought managed 
LTSS to the IDD population, intellectually and developmentally 
disabled population, which has been carved out of most of these 
in many States, at first blush, there was a lot of resistance 
because the State had not communicated what was going on to the 
population. The plans had to spend the first year just 
communicating with the advocacy groups, working with the 
service delivery system that was there, getting them to 
understand what was going on before they actually started to 
launch services and enroll people. So those are the things that 
just have to happen because there is so much lack of 
understanding.
    Mr. Long. I have got one more question, it is again for 
you, Dr. Atkins. You also state in your testimony that 
facilitating full integration will only be possible initially 
in States that enroll dual beneficiaries in Medicaid managed 
plans, yet enrolling dual eligibles in managed care requires a 
waiver, and the process of retaining a waiver can often be 
long, challenging, and uncertain.
    How can we, as a committee, facilitate integration, while 
not relying on States to get waives from CMS?
    Dr. Atkins. Do you want to answer that?
    Ms. Bella. Depending, there are ways that States can have 
their beneficiaries in managed care. They don't require--they 
are not 115 waiver process. They can do it through a State plan 
process. And so, depending on the path the State takes, there 
are more or less complex ways of doing that.
    If you are asking are there ways that we could make it 
easier for States who want to do integrated programs----
    Mr. Long. Right, as a committee, how can we assess?
    Ms. Bella. Yes, there are ways to do that. They are 
somewhat State-specific, depending on how the States structure 
their program, but there are always ways that we can simplify 
and making these two programs work better together.
    Mr. Long. OK.
    Dr. Atkins. But I will say that there is a very strong 
movement in this country right now toward managed LTSS. We have 
got three more States coming in this year. We have a number of 
States lined up starting the process for next year and beyond. 
And so we have expanded the number of States already that are 
involved in MLTSS and that movement is pretty strong because it 
is really to the States' advantage in trying to manage these 
costs to do these managed care contracts because they can 
really get their arms around trying to figure out how to keep 
the population that has been in institutions or is headed 
toward institutions really stabilized in the community.
    Mr. Long. Thank you. Mr. Chairman, I have no time left, but 
if I did, I would yield it back.
    Mr. Burgess. The Chair appreciates the gentleman's offer. 
The Chair recognizes the gentlelady from Colorado, Ms. DeGette, 
5 minutes for questions, please.
    Ms. DeGette. Thank you very much, Mr. Chairman. I want to 
thank Chairman Walden and Ranking Member Pallone for having 
this hearing on SNPs, and you, too.
    I am really happy that the SNP Reauthorization Act includes 
this bill that I have been working on with Representatives 
Lance and Kennedy and also our colleagues on Ways and Means, 
Congressman Meehan and Congresswoman Sewell.
    What this bill does, H.R. 3044, it expands supplemental 
benefits for chronically ill Medicare Advantage enrolless. What 
it does, under the bill, both traditional Medicare Advantage 
plans and SNPs, would be able to offer individualized benefits 
that meet the specific healthcare needs of chronically ill 
enrollees. And I know you have all been talking about this 
today.
    Supplemental benefits could include services that are not 
traditionally covered by health plans like meal delivery, as 
long as there is a reasonable expectation that such services 
will maintain or improve health. For example, somebody 
mentioned today that the new flexibility would allow plans to 
purchase air conditioning for COPD or asthma patients who 
couldn't otherwise afford it. Now even though that is not a 
traditional healthcare service, such a change in a patient's 
living environment could have huge health benefits. I think 
that this common-sense legislation will lead to better health 
outcomes and improve quality of life, including in my own 
State, 273,000 seniors.
    And I just really want to thank the committee on a 
bipartisan basis for including our bill in this broader bill 
that we are considering today. And so I hope we can continue to 
work in a bipartisan basis to reauthorize the SNP program and 
include this common-sense bill that we have.
    Mr. Wing, I was really struck by your testimony about the 
gentleman who had Parkinson's and glaucoma and how all you 
needed to get was a wrist band for him so he could put his eye 
drops in. This is true with so many seniors and what we end up 
doing, and part of it is because Congress doesn't really know 
how to look at budgeting for prevention and management. And it 
is very frustrating for our constituents. This is something 
that Chairman Burgess and I have actually been working on for a 
long time, trying to figure out how to incentivize prevention 
through the budget process, rather than just paying for more 
and more emergency services and whatever.
    And so, I am just wondering, I know in your testimony, you 
said you strongly support provisions in the SNP Reauthorization 
Act that grant increased flexibility to use supplemental 
benefits of nonmedical services. Do you have some other 
examples that you can share with the committee today?
    Mr. Wing. Sure. Thank you for the question. I mentioned 
that the fall often necessitates a hip fracture and a hip 
fracture necessitates not only a hospital admission, but 
oftentimes long-term facility admission. Oftentimes, if you 
have just grips in the toilet, the shower, and solid flooring 
in the kitchen, solid flooring in the bathroom, you can negate 
the fall that precipitated the hip, and again, knowing what is 
going on in the home.
    Oftentimes, a doctor is going to look for medical 
solutions, but oftentimes there is a social solution. Maybe a 
little bit of inhome support, a low-level person coming in and 
helping with food, with bathing, with activities of daily 
living for a member that is in a straight MA plan. We prevent 
them from having an ER visit, a hospital visit, and since we 
are at risk for the Medicare benefits want to give us the 
flexibility to prevent that and provide better care for the 
beneficiary and reduce costs for the system.
    Ms. DeGette. Doctor, I see you nodding your head. Did you 
want to add to that?
    Dr. Atkins. I think it is a very important move forward and 
given this flexibility in MA. Because we have to keep in mind 
that the only benefits we provide on long-term services and 
supports in this country are under Medicaid. And so we are 
serving a very small portion of the population that has fairly 
substantial LTSS needs. The more we can do to create more 
flexibility in the Medicare Advantage program in cases where 
the services that we are going to authorize the plans to 
provide actually help reduce the overall costs of the plan 
anyway.
    Ms. DeGette. Right.
    Dr. Atkins. So it is really improving outcomes and reducing 
costs. I think that is really important to try to explore as 
much of that as possible. And I know you are familiar with the 
Bipartisan Policy Commission. In fact, Council's report 
recently about other ways to do that.
    Ms. DeGette. Thank you. Thank you very much. I yield back.
     Ms. Blackburn [presiding]. The gentlelady yields back. Mr. 
Carter, you are recognized 5 minutes.
    Mr. Carter. Well, thank you all for being here, certainly 
an important subject.
    I want to start off with something that is bothering me. I 
get the SNPs. I get the Institutional in I-SNPs. I was a 
consultant pharmacist in a long term care setting for over 25 
years. And I can understand and see how they work. And I can 
see the benefit of that. I can see the chronic, the C-SNPs. I 
can see the benefit there. I have witnessed that through my 
practice in retail pharmacy. I have seen how they are 
beneficiary.
    What I struggle with and I have always struggled with is 
the dual eligible. Explain to me why we have to have dual 
eligible? Explain to my why we can't introduce legislation that 
says you have to be one or the other. You are not going to be 
both. I mean just simplify it for me.
    Dr. Atkins. Well, one of the critical things is that 
Medicare doesn't really cover anything but medical expenses and 
for many of the people we are talking about who have very 
complex care needs, being able to address their nonmedical 
needs can have more impact on their overall health than the 
cost of care for them than spending the money on the medical 
side. So Medicare is limited in its capacity to serve this 
population completely.
    For those people who are in Medicaid and have the long-term 
services and supports covered in the Medicaid program, they 
have those services available to them. Where you have dual 
coverage----
    Mr. Carter. Then why don't you just let them be Medicaid? 
Say you are going to be Medicaid. You are not going to be 
Medicare.
    Ms. Bella. In 1965, the then Congress created two programs 
with two separate titles. These folks qualify under both title. 
So the only way to get rid of it is to have a new title that 
encompasses the medical----
    Mr. Carter. OK, I want to introduce a new title, and it is 
going to be you are one or the other. Just explain to me. I 
just struggle. I have always struggled with it.
    Ms. Bella. The challenge with this population is they, 
right now, they are eligible to get their medical needs met 
through Medicare and their long-term supports and behavioral 
health and wrap-around services met through Medicaid. So you 
can't really put them in one or the other because they--right 
now, the system gives them both. And so if you want to make a 
choice, then you have to make them ineligible for one or the 
other because today, they are eligible for both and they need 
both types of services, medical and nonmedical.
    Are they delivered in the right way? No. Is it efficient to 
have them delivered this way? No. Do we need a new title? Yes. 
Are these things that we are talking about today, are they 
important steps? They are, if we can align incentives which is 
part of what we are talking about today to put things together, 
give the money to one entity and start to fix some of these 
problems that have kept having accountability.
    Mr. Carter. Is that what your PACE program is?
    Dr. Atkins. Yes, that is what PACE is.
    Mr. Carter. So that is the answer I am looking for here. Is 
we need PACE.
    Dr. Atkins. Well, PACE needs to be----
    Ms. Bella. They are two separate titles.
    Mr. Carter. So we are just going to create another title.
    Dr. Atkins. The only thing I would suggest, I think there 
should be a category of integrated plans and they should have 
their own statutory and structure and regulatory structure. But 
to get away from having two sources of money coming into these 
programs, one from the Federal Government and one from the 
combination Federal and State government, the Federal 
Government would have to be willing to essentially take the 
Medicare money for these people and give it to the States to 
serve that population.
    Mr. Carter. And what would be wrong with that?
    Dr. Atkins. Nothing.
    Mr. Carter. Listen, the source remains the same.
    Dr. Atkins. Right.
    Mr. Carter. Whether it is Medicare or Medicaid, guess where 
it is coming from originally. It is coming from here, whether 
it is administered through the State.
    Dr. Atkins. Right. In the MMP program we have a three-way 
contract with the Federal Government and the State and the plan 
all work together. If the Congress so chose, they could take 
that Medicare money and just essentially hand it to the States 
and let them run the contract, if that was what people wanted 
to do. But that would be a major shift from where we are today.
    Mr. Carter. I can't imagine. I just have struggled with 
this for many years to understand this, why we can't simplify 
to it where you are on one or the other. And I get it. I know 
that people who are eligible for Medicare who are lower incomes 
need that safety net program to help them because there are 
services that are not covered, but still, I don't understand 
why and maybe I need to understand the PACE program. I have got 
20 seconds left. Can you tell me how it is going to benefit and 
how it would help with this?
    Ms. Bella. Both PACE and what he is referring to as the 
MMP, which is Medicare-Medicaid Plan, give an entity the 
payment for both Medicaid and Medicare services. There is one 
contract. So you are not kind of fighting two different 
regulators. You attempt to align the administrative 
requirement. So they are the closest things we have to sort of 
having it be seamless that there is really two programs behind 
it. So they are the models that you would use if you were 
trying to get away from having two separate programs that are 
constantly at odds with each other.
    Mr. Carter. OK. My time is up. I yield back. Thank you.
    Mr. Burgess [presiding]. The Chair thanks the gentleman. 
The gentleman yields back. The Chair recognizes the gentleman 
from Oregon, Mr. Schrader, 5 minutes for questions, please.
    Mr. Schrader. Thank you very much, Mr. Chairman. I 
appreciate that. Dual eligibles is really the absolute gold 
standard by which I think healthcare delivery in this country 
will be judged if we are going to make improvements. They are 
the most expensive population, require the most attention, to 
my good colleague's comments earlier, the fact that we have got 
two different programs dealing with a complex population with 
many needs is confounding.
    I would take a slightly different approach. I like what I 
was hearing from Mr. Atkins about, you know, starting over, an 
integrated model with overarching rubric that the States could 
play into that combined the better aspects with one set of 
criteria, not two, with Medicaid having one set of eligibility 
requirements and Medicare having another. It seems like the 
time has come with the SNP programs, the MMP programs, come up 
with some sort of way that we could have a common standard by 
which the monies get delivered to one spot, however much money 
that is, and then the States again, under some overarching 
rubric, come up with a better way, more efficient, more 
coordinated way that would be maybe up front a little costly, 
but over the long haul yield measurable, better outcome results 
that would decrease the cost for these very difficult patients 
going forward.
    That would be fun to work on. I think based on the 
testimony I have heard so far, I think you would find a lot of 
willing participants, both sides of the aisle, across the 
political spectrum to do that.
    Currently, the money that comes into these MMPs or the SNP, 
the dual SNP programs, is it the--I am a little ignorant here 
also in terms of how the money flows. Is it always a case that 
the full Medicaid payment and the full Medicare payment come 
into these programs and are utilized by whatever program 
delivery system is there, Mr. Atkins?
    Dr. Atkins. Well, yes, I would defer to my colleague who 
actually ran the program to be a little bit better informed on 
how the mechanics work. But go ahead.
    Ms. Bella. Sure. The Medicare-Medicaid rate, the Medicare-
Medicaid Plans, the Federal Government and the States set the 
rate, and they give Medicare and Medicaid money to the plan, 
and it encompasses the full set of Medicare and Medicaid 
benefits.
    In the arrangements where you have Medicare managed care 
and a SNP or a FIDE SNP, it varies by State. In the most 
integrated products, the same plan is getting capitated amount 
for all the Medicaid benefits and Medicare benefits?
    Mr. Schrader. So how does the overall amount of dollars 
compare to the two separate payments that are out there?
    Ms. Bella. In the MMP products, the two payers, we took 
those factors into account and assumed benefits of coordination 
and reduced duplication and took cost savings off the top of 
that.
    Mr. Schrader. I think that has a lot of appeal to members 
on both sides of the aisle. Instead of having two big payments 
that add up to X plus, we have one that adds upto X or X minus 
because of that coordinated care. I think you a lot of willing 
participation.
    Dr. Atkins. Yes, and one of the other issues is just when 
you are dealing with a very frail or a population with a lot of 
very complex care needs is the risk adjustment that goes into 
the payment to make sure that it adequately reflects the social 
factors that are binding on these populations as well.
    Mr. Schrader. And risks gaming the system a little bit, not 
that anyone would do that, but everyone then would be 
compensated for the degree of risk that they are incurring 
given the complex needs of their particular people going 
forward.
    I guess the other point I would make that Mr. Wing touched 
on a little bit is that there is a very fantastic bill out 
there that Mr. Lance and myself have to keep people from 
falling into, hopefully, the dual-eligible situation, i.e., 
making sure low income Medicare patients can access some of the 
advantages of this integrated approach and I would hope that 
there is an opportunity as we go forward to include this type 
thing. Again, we are thinking of cost savings rather than 
having someone have to spend themselves down into Medicaid to 
be able to take advantage of the dual-eligible MMPs or PACE or 
whatever the program is. We could start giving some of these 
inhome, community-based services earlier on and save a ton of 
money from having to pay for these very same people on a more 
institutionalized or more expensive setting going forward.
    So I would hope the Chair and ranking member would look 
forward to working with us on this, maybe going forward and see 
if we can't continue to improve a very good system that seems 
to be developing here. With that, I yield back.
    Mr. Burgess. The Chair thanks the gentleman. The gentleman 
yields back. The Chair recognizes the gentleman from North 
Carolina, Mr. Hudson, 5 minutes for questions, please.
    Mr. Hudson. I thank the chairman and thank you, panel, for 
being here today. It is very helpful helping us grapple with 
this very complex issue. You have touched on this in your 
testimony a little bit, but I have a question, sort of about 
the deadlines and time frames under our discussion draft. Do 
you think these time frames and deadlines for integrating 
benefits and providing services is realistic to States that 
need more time? I just ask if anybody has a comment on that.
    Dr. Atkins. I think the way it is structured for States 
that haven't been able to do managed care on the LTSS and 
behavioral health side, there is a way to get around that and 
kind of be able to do it even with a fee-for-service kind of 
structure in place there. So I think that is an important 
carve-out because a lot of States aren't yet in the position to 
be able to have aligned Medicare and Medicaid managed care 
plans.
    But I think the time frames, as far as what I have seen, in 
the legislation seem reasonable.
    Mr. Wing. SCAN also believes that the movement to full 
integration for the D-SNPs is mission critical. Unless we have 
integration, there is no hope for savings, long-term savings, 
keeping people out of nursing homes for the State which is a 
big burden for the State. So I think it is 2021 and legislation 
and we support that. We think if there is a FIDE SNP at any 
stage, there is a lot of FIDE SNPs like SCAN in the United 
States, we think a 4-year time frame is very, very doable and 
essential.
    Mr. Hudson. Great. I appreciate that. Dr. Atkins, in your 
testimony, you know, what we have also heard from the GAO that 
there are not standardized measures for long-term services and 
supports that have been widely adopted or broadly used. 
However, it sounds like your association has initiated an 
effort to adopt quality measures that can meet the State 
requirements or yet not burdensome for plans. This sounds great 
to me, but I am wondering if you could tell me more about when 
you think the association will have more to report to us. 
Obviously, the more data points we have to deal with, the 
better.
    Dr. Atkins. Thank you for that question. I will say that we 
have adopted a quality framework which is a list of the 
indicators that we would feel we were able to report in a 
reasonable time frame. We will hay to put all of this into 
effect, all the companies who participate will agree to put all 
of this into effect.
    These are measures that we did not create. These are 
measures that have gone through the NQF process or are being 
developed by Mathematica for CMS or are generally out there in 
the home and community based consumer survey.
    So there are existing measures that we believe that we can 
actually produce now out of our databases. So the process we 
are going through right now is to do what is called 
specification. We are actually digging down into each of our 
plans to see where the data is going to come from and how 
consistent we can get it to be across all of these.
    Our purpose is not to do it unilaterally by ourselves, but 
to work with our States to encourage the States to essentially 
accept these measures that we would report as measures that are 
used in overseeing the quality, integrating with the quality 
reporting systems that they are going to have in place because 
it is a State function to report this.
    Mr. Hudson. Right. I think that is critical for being able 
to determine the impact on the beneficiaries.
    Dr. Atkins. We would be glad to come back and talk to you 
in a couple of months with some much more detail about where we 
are with it.
    Mr. Hudson. I think it would be great, Mr. Chairman. I hope 
we can encourage that and I will yield back the balance of my 
time if anybody else would like to use it. Thank you.
    Mr. Burgess. The gentleman yields back. The Chair thanks 
the gentleman. The Chair recognizes the gentlelady from 
California, Ms. Eshoo, 5 minutes for questions, please.
    Ms. Eshoo. Thank you, Mr. Chairman for holding this hearing 
and to the witnesses, thank you for your wonderful testimony. 
You bring enormous expertise to the hearing room and we all 
appreciate it.
    I am fascinated by the question of our colleague from 
Georgia about why does it have to be this way? Do we need a new 
title? Why do we have part of Medicare? Why is it in Medicaid? 
And I can't help but think of the President saying ``Whoever 
knew that healthcare could be so complicated.'' So we are 
dealing with the complications here and these hearings are 
targeted to specific areas, but they also broaden and deepen 
our understanding of the system that we have and how we want to 
improve it and what is important to do.
    What stands out to me today is how important Medicaid is, I 
mean how essential it is. And so the broader context in terms 
of what we are dealing with, whether some of us like it and 
some of us don't like it is that the House passed a bill that 
fundamentally restructures the Medicaid program by implementing 
per capita caps and block grants and the Senate is debating a 
lot of things, but we know that Medicaid is on the chopping 
block.
     Now this discussion about reauthorizing, I think we should 
reauthorize. I think that we need to make some changes and you 
have brought some very good ideas to the table, but the reality 
is that I think anyway, Medicaid is hanging by a thread. I 
think it is hanging by a thread. Forget the ACA. Medicaid 
itself as an entitlement is hanging by a thread.
    So my question, I guess I will start with Ms. Bella, is 
what would that do to dual eligibles? I mean it is my 
understanding that 70 percent of the SNP plans have dual 
eligibles in them, so can you talk about what if there is, in 
fact, an implementation of per capita caps or block grants in 
the Medicaid program, how does that affect what we are talking 
about today? We are talking about improving it, but the larger 
picture is that it is up to a 35 percent gouge of Medicaid 
itself.
    Ms. Bella. So I guess a couple of things. One, we are 
talking about improving it and improving it means we can put a 
full kind of cadre of Medicaid-funded services along with the 
medical piece.
    Ms. Eshoo. I understand what those are. I worked on this 
years ago when I was a county supervisor for the dual 
eligibles. And we developed a capitated plan in the county.
    You know what? I took care of my parents and they were 
blessed with a long life. And I know what is needed in the 
home. They are better off at home if, in fact, you can bring 
the kinds of services that they--the particular services that 
they need. So while they weren't enrolled in Medicaid, they 
were Medicare beneficiaries, they had the beneficiary of their 
daughter, too. But in terms of the care, I understand it.
    Ms. Bella. Right, so those services----
    Ms. Eshoo. And the care for each one of them was unique.
    Ms. Bella. Right, those are the services that are at risk 
with a per capita or some sort of Medicaid block grant. And it 
is those services that are keeping people in these integrated 
programs out of the hospital and out of other places.
    Ms. Eshoo. See, thank you for saying that. I hope everyone 
is listening to this. Because we are dealing with frail, 
elderly people that are far more vulnerable. I have always 
thought--I remember saying to the doctor when he said I think 
we need to take your father to the hospital and I said well, 
what are they going to do at Stanford Hospital that I can't do 
here at home for him? He said, you know, you have got a good 
point. So we kept him at home and in three and a half days, he 
was much better. But I think that in some ways we have got our 
heads in the sand here, because we are talking about how to do 
this, what it is, reauthorizing and meanwhile in the larger 
bubble, there is a wrecking ball that is going up against 
Medicaid. So we have got some choices here and I think we need 
to tell the truth about what is going on which is so 
frustrating to me. I am glad we are having the hearing, but you 
know what, we are pretending that everything is all right. And 
it is not because what is at hand is going to take a wrecking 
ball to what these people have come here to testify about. 
Thank you, and I will yield back.
    Mr. Burgess. The gentlelady's time has expired. The Chair 
recognizes the gentlelady from Indiana, Mrs. Brooks, 5 minutes 
for questions, please.
    Mrs. Brooks. Thank you, Mr. Chairman, and I, too, thank you 
for providing your expertise to all of us.
    I have heard a lot of discussion today about the need for 
more integration coordination, but one policy area I know there 
is often typically a lot of bipartisan interest in is the issue 
of telehealth and it is something that--I represent a district 
that is urban, suburban, but very rural as well. I know that 
one school in a smaller community of Elwood, Indiana, has begun 
some telehealth with the school nurse and I know that this is 
something that I think could have tremendous benefits to 
citizens throughout the country.
    So I am interested in each of you commenting on the policy 
idea that many Medicare Advantage plans have expressed an 
interest in, and that is to allow Medicare Advantage plans to 
offer telehealth as part of their bid, so they don't have to 
use rebate dollars to provide it. They have an incentive to be 
efficient in their bids and this flexibility could be 
particularly helpful with the frail, disabled, or homebound 
beneficiaries and beneficiaries in rural areas that I just 
discussed.
    So I wondered if you could please share with us, if you 
think it would be useful to give special needs plans this 
authority, at least for the next 5 years, and to see how this 
tool could boost the health outcomes for patients and what each 
of your thoughts are on telehealth and these types of plans.
    Mr. Wing?
    Mr. Wing. I will start. I mentioned earlier that we have a 
pilot of behavioral health telehealth which we think is mission 
critical. And when you are dealing with the fully integrated D-
SNPs, we are talking about a very vulnerable population and a 
lot of them, as you mentioned, are homebound. And so we need to 
figure out how do we bring the delivery system into their home?
    In telehealth, the technology is there. The funding isn't, 
but the technology is there. And we are using it for 
telehealth, but for truly homebound members who don't have the 
financial wherewithal to go to a doctor, don't have the 
transportation to go to the doctor. They either have cognitive 
impairment or other reasons why they can't go to the doctor. We 
need to bring the delivery system there.
    Now you can bring doctors to the home, but that is a very 
expensive proposition. Telehealth seems to hold the hope of 
bringing medical physicians, psychologists, psychiatrists, and 
other providers into the home at a fraction of the cost in real 
time. And oftentimes, these frail duals, they can't wait 15 
days to get in to see a specialist. They need to see them now. 
So we are very supportive.
    Mrs. Brooks. Any particular reason why you are only focused 
on behavioral health?
    Mr. Wing. No. We are a small company. We happen to find 
this company out of Nashville and know that behavioral health, 
opioids is a really big issue of the senior population in 
aggregate. When you take the duals, it is a very pressing 
issue. I think 48 percent of our dually eligible have a 
clinical diagnosis of depression, 48 percent. When you see 
those numbers, you have to do something about it. And we can't 
bring a psychiatrist, a psychologist in a home. First of all, 
we don't even know the diagnosis yet. So we think telehealth is 
the right modality for behavioral health, but probably for a 
lot of other type of specialties.
    Mrs. Brooks. Thank you. Dr. Atkins?
    Dr. Atkins. I think Mr. Wing spoke earlier about the 
importance of eyes and ears in connecting the medical and 
nonmedical parts of the delivery system and that is critical. I 
think that we have to explore a lot of technology solutions 
that are going to enable us to be better connected in people in 
their homes who have these very complex care needs. Telehealth 
certainly is going to be a major part of that.
    Mrs. Brooks. Ms. Bella, do you see any impediments to us 
advancing telehealth in Medicare Advantage plans?
    Dr. Atkins. No, especially if it is part of a broader push 
to recognize supplemental benefits generally that plans could 
be given more flexibility around when they are taking the 
financial risk.
    Mrs. Brooks. Actually, building on that issue regarding 
supplemental benefits, could you give us examples of 
supplemental benefit plans, benefits that plans provide and how 
they improve patient outcomes, other supplemental benefits?
    Ms. Bella. Sure, I think--Chris, do you want to answer?
    Mr. Wing. Well, again, if you take the FIDE SNP where we 
can provide these Medicaid type of benefits, you know, I 
mentioned I wrist card, solid flooring in the bathroom, solid 
flooring in the kitchen, guard rails in the toilet area and the 
shower that prevent the fall, a home- and community-based 
services, having a home health aide to help with bathing, 
cooking to prevent nursing home viable people being placed in 
custodial care. It is really being able for a Medicare 
Advantage plan to offer Medicaid-like benefits to prevent the 
reason for necessity for acute admission or even more 
importantly, going into long-term custodial care where they are 
never going to come back from. These are really demonstrated 
long time demonstrated benefits that really curtail costs, but 
they radically improve the quality of life for beneficiaries.
    Mrs. Brooks. Thank you. Thank you for those examples. I 
yield back.
    Mr. Burgess. The Chair thanks the gentlelady. The 
gentlelady yield back. The Chair recognizes the gentlelady from 
California, Ms. Matsui, 5 minutes for questions, please.
    Ms. Matsui. Thank you, Mr. Chairman, and I want to thank 
the panelists here today. We are learning an awful lot and 
realize that there is so much more to learn here.
    I have got to say that the future of special needs plans is 
so very important as we move forward because since their 
creation I guess in 2003, we have seen success in managing 
complex populations across Medicare and Medicaid, such as those 
dually eligible for programs and seniors with chronic 
conditions like diabetes and dementia and so forth.
    But as we see the increase in population and look to see 
the quality of care that the individuals have gotten, I think 
it is important because sometimes it is not as successful and 
we really need to be very clear as we move towards full 
integration in Medicare and Medicaid options for the 
chronically ill and dual-eligible beneficiaries. The protection 
of beneficiary rights and the quality of care that 
beneficiaries receive should be the first consideration when 
evaluating any policy change. To that end, I think one of the 
most important things that could impact a beneficiary's 
experience is a unified appeals and grievance process.
    Now I know that for many individuals, it can be 
overwhelming to understand how to appeal, doubly so if you are 
a person who happens to have both Medicare and Medicaid 
benefits.
    All of our witnesses have highlighted the importance of a 
consistent and understandable appeals process for our 
beneficiaries, but I would like to dig a little deeper into 
this.
    Mr. Wing, can you discuss how appeals and grievances work 
in the FIDE SNP, and how this is different from other types of 
SNPs?
    Mr. Wing. Well, I will talk about one of the solutions is 
we do suffer from the different rules for Medicare and 
Medicaid. We have to deal with that. I think Melanie Bella has 
been talking about that for years. It is very complex. It is 
confusing for the members, for the family, for the doctors and 
that confusion leaves people to go, I am not going to join.
    Ms. Matsui. Right.
    Mr. Wing. At SCAN, we have what we call for our fully 
integrated D-SNPs, we have basically concierge care. We want 
these people to stay with us, but when they are having a 
problem with an appeal or a referral or anything, we want them 
to have a one-on-one relationship with somebody in our call 
center that is not a bank. So everyone of our fully integrated 
D-SNP members have what we call a PAL, personal assistant line, 
where they develop a unique relationship with someone at our 
call center. If they have got a problem with coordinating 
appeals and grievances we are there for them. If they have got 
a problem with the delivery system, we are there for them. If 
they have got a problem with how we deliver care or home health 
aide services at home, we are there for them. And that is 
mission essential. These people, they have got a lot of special 
needs, complex needs. They need the system to come alongside 
them as opposed to them coming along aside the system.
    Ms. Matsui. OK. Ms. Bella, can you talk about this issue 
from the perspective of your former role as Director of 
Medicare and Medicaid Coordination Office? What barriers did 
you encounter?
    Ms. Bella. In the grievances and appeals specifically?
    Ms. Matsui. Yes.
    Ms. Bella. There are some legislative barriers and then 
there are some administrative barriers and so part of the--the 
language that is in the House bill will go a long way toward 
fixing, so in the Medicare-Medicaid programs there are 
different requirements about time frames, for example, and what 
level you have to go to, for example.
    And so in CMS, in the demonstrations, we were able to 
integrate some of those things, but we just couldn't go quite 
far enough and we were still doing it under demonstration 
authority. Again, the language that you are considering today 
makes a huge step forward and then there are some 
administrative pieces where we can continue to wrap around 
that. That would streamline it even better and make it both 
protective of the beneficiary, but also make it easier for all 
parties to operate under.
    Ms. Matsui. OK. Thank you. Dr. Atkins, even with your 
associations, why diversity in membership? It seems like this 
is an important recommendation that has been agreed upon. Can 
you discuss why unified appeals are so important from the 
beneficiary perspective?
    Dr. Atkins. Well, certainly. I mean one of the more 
confusing aspects of the system is the different routes and 
different time frames and things that are involved in appeals 
and grievance under the different programs. So I think it is 
critical that we work toward getting a single set of uniform 
set of rules.
    We would, of course, love to see a common architecture in 
the program, a common architecture for integrated plans that 
would address a lot of these kinds of issues.
    Ms. Matsui. Right, right. I think it is really important as 
we talked about the unification of--and I think it is very, 
very difficult, as we know, in Medicaid and Medicare. But there 
is aspects here that I think I could see having some sort of 
unifying aspect of it where people aren't as confused as to 
what to do as we move forward. I see my time is gone. I yield 
back the balance.
    Mr. Burgess. The gentlelady yields back. The Chair thanks 
the gentlelady. The Chair observes that the Chair has actually 
delayed his time for questions to the end. We also have been 
joined by Mr. Costello, who is not on the subcommittee, but I 
believe the gentleman would like to seek time for questions. Is 
that correct?
    Mr. Costello. Yes, thank you, Mr. Chairman.
    Mr. Burgess. I will recognize the gentleman for 5 minutes 
for his questions.
    Mr. Costello. As a follow-up, to a line of inquiry that 
Mrs. Brooks had to you, Mr. Wing, could you share with me the 
certain types of specialty providers, be they medical or 
nonmedical, that you see most likely to begin or most likely to 
have the capacity to offer telehealth services?
    Mr. Wing. I thought you were going to go a different 
direction. I appreciate the question.
    Mr. Costello. You can take another direction.
    Mr. Wing. I thought you were going to ask me what is the 
specialty or type of provider that is going to make the most 
profound difference in the future.
    Mr. Costello. That was going to be my next piece of it.
    Mr. Wing. I like that question. I think it is going to be 
community health navigators. These people are $14 or $15 an 
hour, but going into the people's home, assessing what is going 
on with the social determinants. This is a low-cost, high-
impact intervention. We would like to flood the market, 
especially for those who are nursing home certifiable, and make 
sure we are identifying the social determinants of health 
quickly, make sure the doctor knows. But I see no greater 
innovation. I don't think this is a medical problem that 
requires medical intervention. This is a social problem that 
requires a social solution and I think having an army, if you 
will, covering fully integrated D-SNPs or seniors who have 
Chronic Special Needs Plans, I think is going to be one of the 
most pronounced interventions, the most impactful interventions 
to improving quality and reducing costs that we are going to 
see over the next 5 to 10 years.
    Mr. Costello. Thank you. Ms. Bella, your testimony comments 
on how there are things that CMS and States can do to improve 
the coordination of benefits and delivery of services for dual 
eligibles, including those with disabilities. You know that 
State Medicaid manuals should move toward capitation of their 
LTSS and behavioral health benefits.
    You also said though that they need assurance that if they 
go down this path, the future of D-SNPs is not uncertain. So to 
confirm, you are effectively saying that a longer extension 
would allow more planning and investment in infrastructure and 
policies that would better serve individuals with disabilities? 
Is that correct and could you expound upon that a little bit?
    Ms. Bella. Sure. I am actually saying that permanency would 
go the furthest because these have been sort of in limbo since 
2003, meaning every few years people are wondering do we have 
to come back and argue for their case. And so Pennsylvania is a 
great example. Your State just spent several years putting 
together a managed LTSS program. They put in their Community 
HealthChoices Program. They have required all those 
participants to be D-SNPs. Tremendous amount of work. 
Tremendous amount of progress. And we want them to keep 
investing in that with already limited resources. They can't 
feel like it is at risk of going away. So if we want to get 
States to continue building these programs, they need the 
assurance of knowing that this program is permanent and stable.
    Mr. Costello. Thank you.
    Dr. Atkins. Could I add one thing to that which is that the 
MMP program, which is the demonstration program, has a time 
limit on it and we have a lot of people enrolled very 
successfully in MMP programs. It would be helpful for those 
people to know where they go when that demonstration ends.
    Mr. Costello. Thank you for your thoughts and thank you, 
Mr. Chairman.
    Mr. Burgess. Does the gentleman yield back?
    Mr. Costello. I do.
    Mr. Burgess. The Chair thanks the gentleman. The Chair 
recognizes himself for the balance of the time. Just checking 
to see if you are paying attention. Ms. Matsui, apparently not.
    First off, thank you all for the very intriguing discussion 
this morning.
    Mr. Wing, let me just start with, you mentioned right at 
the end here of this, something that I have thought for a long 
time, which is--you even used the term--``concierge medicine.'' 
Yes, navigators are important. Yes, the home health aides are 
important. But you can have all the fingers in the world, but 
if you don't have a palm, it doesn't do you any good.
    So I remember having this discussion with Dr. Berwick when 
he was CMS Director, many, many years ago, that when I voiced 
some of the same frustration that the gentleman from Georgia 
voiced this morning about not understanding why we have these 
programs that are sometimes difficult to comprehend and 
navigate, why there wasn't just one place and that, to me, 
would have been that position of the concierge or direct 
primary care or whatever you want to call the model.
    So I was grateful to hear you mention that this morning. I 
do think that that is a direction that this subcommittee should 
explore. I have felt that for a long time.
    And Ms. Bella, even the agency that you used to head up 
when we look at the enabling language in the Affordable Care 
Act, the establishment of a Federal coordinated healthcare 
office, that was the goal. And when I talked to Dr. Berwick and 
I said why don't we do a concierge doctor for these poor folks 
and actually take care of them, his answer was we are going to 
set up a new Federal agency. I wasn't thrilled when he told me 
that. I probably had a reaction much like Buddy Carter voiced 
this morning, but at the same time I will also say that as your 
former office has matured over time, it does seem to be 
providing a valuable service to patients.
    The reports that you generate at the end of every fiscal 
year--and I guess the most recent one I have is for Fiscal Year 
2015, and you were probably involved in the generation of that 
report, were you not, Ms. Bella? So it is helpful. It is not 
just a recitation of things that were done. It actually has 
some meaningful insights and perhaps legislative direction that 
the legislative branch could pursue, so I think that is a good 
and positive development.
    But again, Mr. Wing, when you mentioned the word concierge 
medicine, yes, I think that is right. When Don Berwick would 
complain, I got 20 percent of my folks spending 80 percent of 
my bucks and I need to do better with that. It seemed to lend 
itself in that direction. So I would be happy to hear your 
thoughts on that because this is the first time in all of these 
years of having these hearings that I have heard anyone 
actually mention that.
    Mr. Wing. Well, we believe the center of the universe 
really should be the doctor.
    Mr. Burgess. That is the right answer. Thank you.
    Mr. Wing. Well, it should be, but often again doesn't know 
what is going on in the community, so our people in the 
community are integrating via a laptop into the EMR with the 
doctor and we are trying to do the same thing through or 
provider integration efforts so that any encounter that we have 
with our PALS unit gets right back with the primary care 
physician. Primary care physicians armed with complete data 
will make complete decisions. Without complete decisions, they 
won't. And we need to arm them to do a better job.
    Mr. Burgess. And are you utilizing, of course, the day the 
Affordable Care Act was written the smartphone was in its 
infancy. The ability now that people have to connect even 
absent a navigator in the home, the fact that their smartphone 
can electronically transmit a daily weight, a blood pressure, a 
blood sugar, to some central facility.
    Mr. Wing. We are piloting--actually, some of our medical 
groups on their own are piloting, having a smartphone, but 
really, it is not really doing telemetry of health outcomes or 
bioreadings, but if you have a problem, here is a number to 
call. So they have a smartphone. Just call here. If you think 
you need to go to the ER, if you are uncertain, call us.
    However, we spend a lot of time on the fully duals and 
these people have a lot of cognitive impairment. Oftentimes, 
they are socially isolated. Oftentimes they have multiple ADLs 
and multiple chronic conditions. Smart anything, I don't think 
this is going to solely a technology answer. It is going to 
have to be a high touch. We need to have people there to come 
alongside to help them.
    Mr. Burgess. I don't disagree, but even as the gentlelady 
from California mentioned taking care of her parents, when I 
was in a similar situation, the ability to get that information 
to someone to help you make a decision.
    Mr. Wing. We are very supportive of that. We are very 
supportive of that.
    Mr. Burgess. Let me, again--fascinating panel, and I really 
appreciate all of you being here this morning. I am sorry Ms. 
Eshoo has already left. I am obligated to answer some of the 
charges that she made, so I have some stuff for the record, and 
I want to offer for the record an op-ed from February 7, 1997. 
The op-ed is almost old enough to vote itself. An op-ed from 
February 7, 1997, from the New York Times, ``Making the Budget 
Bearable.'' This was back in the Clinton administration. Part 
of the op-ed says, ``The President offers an important reform 
of Medicaid, proposing to control future spending by placing a 
cap on the amount of Federal spending per enrollee and allowing 
States to place enrollees in managed care without going through 
the frustrating process of begging for Washington's approval.'' 
The New York Times recommending the per capita cap. That was an 
idea of a Democratic administration back in the 1990s.
    Further evidence, Senator Murray from Washington State. 
Senator Murray speaking on the Congressional Record December 
22, 1995: ``Mr. President, I hold in my hand today a letter to 
President Clinton that is signed by all 46 members of the 
Democratic Caucus. This letter urges him to hold firm in our 
commitment to basic healthcare for children, pregnant women, 
and the elderly, and the disabled... . This letter supports a 
per capita cap approach to finding savings in the Medicaid 
program.'' This was a problem 22 years ago. It is no less a 
problem today.
    As Margaret Thatcher once aptly observed, you can 
eventually run out of other people's money. And that is a 
concern that, although this is an authorizing committee, not an 
appropriations committee, it is a concern that we should have 
as well. And I think one of the things that this panel helps us 
with today is understanding we need to be spending dollars 
wisely. It is not that we are not going to spend dollars, but 
we need to spend them wisely.
    This is not a new concept of what is being debated in this 
committee this year and over in the Senate, even as we speak, 
not a new concept, one that was embraced by a Democratic 
administration 21 years ago, Democratic Senators 22 years ago, 
the New York Times 20 years ago. So it has been an interesting 
panel this morning. I want to thank you for being here.
    Seeing that there are no further Members wishing to ask 
questions, I again want to thank our witnesses. We have 
received outside feedback from a number of organizations on 
these bills, so I would like to submit statements from the 
following for the record: Molina Healthcare, Avalere, the 
Healthcare Leadership Council, the National Association of 
Medicaid Directors, AHIP, the Association for Community 
Affiliated Plans, Bipartisan Policy Center, UPMC, and a letter 
from 12 advocacy groups on Special Needs Plans.
    Additionally, I want to submit the New York Times editorial 
from 1997 and the Congressional Record statement from 1995. 
Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Pursuant to committee rules, I remind Members they have 10 
business days to submit additional questions for the record. I 
ask the witnesses to submit their response within 10 business 
days upon receipt of the questions. Without objection, this 
subcommittee is adjourned.
    [Whereupon, at 11:59 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Greg Walden

    This morning we have a distinguished panel of witnesses to 
discuss the ways the committee can improve Special Needs Plans 
in Medicare Advantage as Congress looks to extend the authority 
for this program in the coming months. Special Needs Plans, or 
SNPs (pronounced ``SNIPS'') are private healthcare plans 
providing Medicare benefits to some of our most vulnerable 
beneficiaries. These are elderly beneficiaries who are in care 
facilities, who have chronic conditions or diseases, and who 
are low-income and are enrolled in Medicaid.
    As a committee with jurisdiction over both Medicare and 
Medicaid, we have a special obligation to thoughtfully examine 
this unique opportunity to not only extend the SNPs' authority, 
but to make refinements to policy which can improve the ability 
of States and plans to provide needed care to millions of 
beneficiaries. As we embark on our effort, we recognize and 
appreciate the good bipartisan committee work that has preceded 
us--efforts by our colleagues in the Senate and in the House 
Ways and Means Committee.
    Today, we complement previous efforts by hearing from 
experts and releasing draft legislation. Our bipartisan goal is 
to extend and enhance the program in a manner that encourages 
integrated, coordinated healthcare coverage.
    We want to ensure healthcare plans and State Medicaid 
programs have the right incentives and proper tools to offer 
the best care to vulnerable patients. We also want to help 
ensure patients have the needed protections and help when 
navigating healthcare benefits and accessing care.
    We welcome and need stakeholders' feedback on how we can 
move forward on SNPs in a manner that improves care, enhances 
quality, and best serves millions of patients. I'd like to 
thank our witnesses for being here with us today, and I look 
forward to a productive discussion that will help us move 
forward on this critical issue.

             Prepared statement of Hon. Frank Pallone, Jr.

    Thank you, Mr. Chairman, for calling this hearing to 
consider the extension of Special Needs Plans, an important 
subset of Medicare Advantage plans for some of our highest-need 
Medicare beneficiaries.
    It is so important that our committee consider the 
extension of SNPs, as they are often called, and any related 
policy changes with the program closely. These types of plans 
serve some of our most complex and vulnerable patients: those 
that are institutionalized or have serious chronic illnesses, 
and those that are dually eligible for Medicare and Medicaid.
    It is undeniable, also, that these types of Medicare plans 
have a unique interaction with Medicaid. And, as the chairman 
has heard me say so many times, the Energy and Commerce 
Committee has the critical responsibility and privilege of 
overseeing and protecting the Medicaid program. First and 
foremost, we should ensure that people who are dually eligible 
for both Medicare and Medicaid or living with a chronic illness 
have a seamless experience--regardless of what plan or 
combination of benefits they may elect to receive.
    At times, this goal has been challenging, but I know that 
we have a good opportunity before us with the reauthorization 
of SNPs to continue to further that goal.
    Today, I look forward to discussing how we can best 
continue to integrate benefits and provide high quality care to 
people that have chosen a SNP plan to provide their care. Our 
colleagues on the Ways and Means Committee and the Senate 
Finance Committee have both done excellent work over the past 
several months to further the growth and development of SNPs in 
the Medicare program. And now, I look forward to adding the 
voice of the Energy and Commerce Committee to that important 
work.

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