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

     MACRA AND MIPS: AN UPDATE ON THE MERIT	BASED INCENTIVE PAYMENT SYSTEM

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JULY 26, 2018

                                   __________

                               Serial No. 115-160

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                    __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    36-027                       WASHINGTON : 2019

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

                                 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...........................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
        Prepared statement...........................................     5
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, prepared statement........................    87

                                   Witnesses

    David Barbe, Immediate Past President, American Medical
      Association....................................................     7
        Prepared statement...........................................     9
    Frank Opelka, Medical Director, Quality and Health Policy,
      American College of Surgeons...................................    15
        Prepared statement...........................................    17
    Ashok Rai, Chairman of the Board, American Medical Group
      Association....................................................    31
        Prepared statement...........................................    33
    Parag Parekh, American Society of Cataract and Refractive Surgery    36
        Prepared statement...........................................    38
    Kurt Ransohoff, Chairman of the Board, America's Physician Groups    55
        Prepared statement...........................................    57

                               Submitted Material

    Statement of the American Academy of Dermatology Association.....    88
    Statement of the American Academy of Family Physicians...........    92
    Statement of the American College of Physicians..................    94
    Statement of Connected Health....................................   103
    Statement of the American Society of Clinical Oncology...........   106
    Statement of the Infectious Disease Society of America...........   108
    Statement of the Medical Group Management Association............   113

     MACRA AND MIPS: AN UPDATE ON THE MERIT-BASED INCENTIVE PAYMENT SYSTEM

                                  ----------

                            THURSDAY, JULY 26, 2018

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:00 a.m., in
    room 2123 Rayburn House Office Building, Hon. Michael Burgess
    (chairman of the subcommittee) presiding.
        Members present: Representatives Burgess, Guthrie, Shimkus,
    Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks,
    Hudson, Collins, Carter, Green, Engel, Matsui, Castor,
    Schrader, Kennedy, Eshoo, and Pallone (ex officio).
        Staff present: Mike Bloomquist, Staff Director; Samantha
    Bopp, Staff Assistant; Adam Buckalew, Professional Staff
    Member, Health; Daniel Butler, Legislative Clerk, Health;
    Jordan Davis, Senior Advisor; Adam Fromm, Director of Outreach
    and Coalitions; Caleb Graff, Professional Staff Member, Health;
    Jay Gulshen, Legislative Associate, Health; Ed Kim, Policy
    Coordinator, Health; Ryan Long, Deputy Staff Director; Drew
    McDowell, Executive Assistant; James Paluskiewicz, Professional
    Staff, Health; Brannon Rains, Staff Assistant; Jennifer
    Sherman, Press Secretary; Josh Trent, Chief Health Counsel,
    Health; Hamlin Wade, Special Advisor, External Affairs; Jeff
    Carroll, Minority Staff Director; Tiffany Guarascio, Minority
    Deputy Staff Director and Chief Health Advisor; Una Lee,
    Minority Senior Health Counsel; and Samantha Satchell, Minority
    Policy Analyst.

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

        Mr. Burgess [presiding]. The Subcommittee on Health will
    now come to order. And I recognize myself for 5 minutes for an
    opening statement.
        Today's hearing is one that has been in the works for quite
    some time. As many of you know, this hearing has been
    rescheduled twice. But, given that we have now enacted
    important technical changes, providers having information on
    their first performance year, and this year's Quality Payment
    Program rules to discuss, this hearing is timely now. I am glad
    we can complete our due diligence, as members of the Health
    Subcommittee, and conduct oversight and the implementation of
    the Medicare Access and CHIP Reauthorization Act of 2015.
        This bill, which came through the 114th Congress, is a
    product of careful, intricate bipartisan negotiations and was
    passed by both chambers of Congress with broad support. Signed
    into law on April 16, 2015, this bill repealed the sustainable
    growth rate formula for all time. The sustainable growth rate
    formula was for calculating annual updates to physician payment
    rates under Medicare. We now know that the formula, which was
    enacted as part of the Balanced Budget Act of 1997, turned out
    to be unwise.
        As an OB/GYN prior to coming to Congress, I was frustrated
    with the annual exercise of the sustainable growth rate
    formula, as were many other physicians, as were Members of
    Congress. I would like to take a moment to remind members of
    what the world of physician payments looked like before the
    repeal or before the passage of the Medicare Access and CHIP
    Reauthorization Act.
        Congress consistently passed legislation to override the
    SGR. That resulted in hundreds of billions of dollars spent
    that could have gone to bolstering Medicare and other health
    programs. Medicare providers and their patients by extension
    were under the constant threat of payment cuts under the
    sustainable growth rate formula. The formula's unrealistic
    assumptions of spending and efficiency have plagued the
    healthcare profession and our Medicare beneficiaries for a long
    time. The Medicare Access and CHIP Reauthorization Act repealed
    the SGR, provided for statutory updates to allow improved
    beneficiary access, and got medicine to concentrate on moving
    to broad adoption of a quality reporting system.
        One of the most important provisions in the law was a shift
    from a fee schedule system toward a merit-based incentive
    payment system. The law left behind a pass/fail quality
    reporting regime whose measures were too often set up against a
    ``one-size-fits-all'' generic standard of care with no
    financial upside for providers. Since the merit-based system
    was set to go into full effect on January 1st, 2019, the first
    payment consequence year, from reporting provided in 2017, it
    is critical that we hold this hearing and hear from our
    witnesses, in a sense, what is working, how the transition is
    progressing, and where improvements have been made while
    seeking ways to simultaneously encourage stronger participation
    and reward providers already invested in the MIPS track.
        The Medicare Access and CHIP Reauthorization Act required
    the Secretary of Health and Human Services to establish a
    methodology to assess merit-eligible practitioners and give
    each one a performance score which determines payments based on
    a scale of 1 to 100. In the first year, the performance
    benchmark was set at 3. This year it was set at 15, and the
    Centers for Medicare and Medicaid Services recently proposed
    raising it to 30 for 2019. The merit-based incentive payment
    system incorporated specific performance categories, including
    quality, resource use, clinical practice improvement
    activities, and meaningful use of electronic health records.
    The eligible population was also set to change over time. And
    the Centers for Medicare and Medicaid Services recently
    proposed to add a slate of additional providers to the program.
        Overall, stakeholders and physicians have been supportive
    of the transition. In our third hearing, we heard from
    providers getting the benefits of savings by participating in
    the advanced alternative payment model. That said, the Medicare
    Access and CHIP Reauthorization Act was a long-term project and
    a viable fee-for-service model in the form of the merit-based
    incentive payment system needed to exist. In continuing to
    follow the Medicare Access and CHIP Reauthorization Act
    implementation, certain decisions were made by the Centers for
    Medicare and Medicaid Services that were for the benefit of a
    smooth transition, but had consequences, consequences that
    affected the agency's trajectory of setting the performance
    threshold. Given this and other developments, I believed that
    the law would benefit from technical updates to improve the
    implementation based on real-time factors. The Bipartisan
    Budget Act of 2018 included three technical fixes. This was
    done by myself, Ranking Member Green, and Representatives
    Roskam and Levin from the Ways and Means Committee.
        The Medicare Access and CHIP Reauthorization Act changed
    the world of Medicare provider payments. It has laid the
    groundwork for increased access to quality care for
    beneficiaries by eliminating the uncertainty of the past,
    reducing physician burden, and providing incentives where
    previously there were none. It was never a law that was going
    to be fully implemented with the flip of a switch or a signing
    ceremony. It was designed as a long-term effort to move the
    Medicare program down the value continuum.
        So, once again, I want to thank our witnesses for joining
    us today. I look forward to hearing from each of you about how
    the implementation of this important law is progressing.
        I yield back the balance of my time and recognize the
    ranking member of the subcommittee, Mr. Green, 5 minutes for an
    opening statement.
        [The prepared statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        Today's hearing is one that has been in the works for quite
    some time. As many of you know, this hearing has been
    rescheduled twice, but given that we now have enacted important
    technical changes; providers having information on their first
    performance year; and this year's Quality Payment Program
    Proposed Rule to discuss, I think the hearing will be better
    for it. So, I am glad we can now complete our due diligence as
    members of the Health Subcommittee and conduct oversight of the
    implementation of the Medicare Access and CHIP Reauthorization
    Act of 2015, also known as MACRA.
        MACRA, which I championed through the 114th Congress, is
    the product of careful, intricate, bipartisan negotiations and
    passed both chambers of Congress with broad support. It was
    signed into law on April 16, 2015. Most notably, this bill
    repealed the sustainable growth rate (SGR) formula for
    calculating annual updates to physician payment rates under
    Medicare. We now know the SGR formula which was enacted as part
    of the Balanced Budget Act of 1997 was a misguided attempt to
    restrain federal spending in Medicare Part B.
        As an OB/GYN prior to coming to Congress, I was
    overwhelmingly frustrated with the annual exercise of the SGR,
    as were many other physicians and members of Congress. I would
    like to take a moment to remind members what the world of
    physician payments looked like before MACRA.
        Congress consistently passed legislation to override the
    SGR, which resulted in hundreds of billions in spent funds that
    could have gone to bolstering Medicare and other vital health
    care programs. Medicare providers, and their patients by
    extension, were under constant threat of payment cuts under the
    SGR. The formula's unrealistic assumptions of spending and
    efficiency have plagued the healthcare profession and our
    Medicare beneficiaries for 13 years. MACRA finally repealed the
    SGR, provided for statutory updates to allow improved
    beneficiary access, and got medicine to concentrate on moving
    to broad adoption of the unified MACRA quality reporting
    system.
        One of the most important provisions in the law was the
    shift from a fee schedule system towards the merit-based
    incentive payment system, or MIPS. The law left behind a pass/
    fail quality reporting regime whose measures were too often set
    against a ``one size fits all'' generic standard of care with
    no financial upside for providers. Since MIPS is set to go into
    full effect on January 1, 2019--the first payment consequence
    year from reporting provided in 2017--it is critical that we
    hold this hearing and assess what is working, how the
    transition is progressing, and where improvements have been
    made, while seeking ways to simultaneously encourage stronger
    participation and reward providers already invested in the MIPS
    track.
        MACRA required the Secretary of Health and Human Services
    to establish a methodology to assess MIPS-eligible
    practitioners and give each one a performance score which
    determines their payments based on a scale of 1 to 100. In the
    first year, the performance benchmark was set at 3. This year,
    it was set at 15 and the Centers for Medicare and Medicaid
    Services recently proposed raising it to 30 for 2019. MIPS
    incorporated specific performance categories, including,
    quality, resource use, clinical practice improvement
    activities, and meaningful use of electronic health records.
    The eligible population was also set to change over time, and
    the Centers for Medicare and Medicaid Services recently
    proposed to add a slate of additional providers to the program.
        Overall, stakeholders and physicians have been supportive
    of the transition to MIPS and to value-based payments. In our
    third hearing, we heard from providers reaping the benefits and
    savings by participating in an Advanced Alternative Payment
    Model. That said, MACRA was not a sprint but a marathon and a
    viable fee-for-service model, in the form of MIPS, needed to
    exist. In continuing to follow MACRA implementation, certain
    decisions were made by the Center for Medicare and Medicaid
    Services that were for the benefit of a smooth transition, but
    had consequences that would have affected the agency's
    trajectory of setting the performance threshold. Given this and
    other developments, I believed the law would benefit from some
    technical updates to improve the implementation of MIPS based
    on real-time factors. The Bipartisan Budget Act of 2018
    included three MACRA technical fixes authored by myself along
    with Ranking Member Green, Representatives Roskam and Levin.
        MACRA changed the world of Medicare provider payments as we
    knew it. It has laid the groundwork for increased access to
    quality care for beneficiaries by eliminating the uncertainty
    of the past, reducing physician burden, and providing
    incentives where there were none. MACRA was never a law that
    was going to be fully implemented with a flip of a switch, it
    was designed as a long term effort to move the Medicare program
    down the value continuum.
        I want to thank all of our witnesses for joining us today.
    I look forward to hearing from each of you and learning more
    about how the implementation of this important law is
    progressing.

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

        Mr. Green. Thank you, Mr. Chairman, for holding today's
    hearing on the Medicare Access and CHIP Reauthorization, MACRA,
    and the merit-based incentive payment system, MIPS.
        I also thank our esteemed panelists for joining us this
    morning.
        The sustainable growth rate, SGR, was a thorn in the side
    of Medicare and doctors who treated Medicare patients for over
    decade after it was created in 1997. SGR's formula led to a
    reduction of physician payments, starting in 2002, that had to
    be patched annually by Congress.
        In 2014 and 2015, our committee, along with other
    committees with jurisdiction, came together and passed
    bipartisan legislation, the Medicare Access and CHIP
    Reauthorization Act, which permanently repealed the SGR. MACRA
    did more than just repeal the flawed SGR formula. It was
    designed to overhaul and realign payment incentives for
    Medicare and transition of our health system to one that
    rewards value instead of just the volume of care. MACRA
    provides civility to Medicare payments for providers for the
    years immediately after the enactment and made it easier for
    providers to report on and deliver high-quality care.
        Critically, MACRA encourages providers to move away from
    fee-for-service and participate in a new delivery model that
    would reduce costs while increasing quality. Under the law,
    physicians who treat Medicare beneficiaries have a choice
    between participating in MIPS or the advanced alternative to
    payment plan, APMs, to make the shift from fee-for-service and
    volume-based payment system to a value-based payment system.
    MIPS streamlined three prior quality incentive programs that
    were sunset in 2016 and have been replaced by a new MIPS
    category, quality, improvement activities, meaningful use, and
    cost.
        Since starting in 2017, healthcare providers could choose
    whether to participate in APM or MIPS. Providers are exempt
    from MIPS if they fall below the low-volume threshold. For
    2017, the Centers for Medicare and Medicaid set the low-volume
    threshold for providers who see fewer than 100 Medicare Part B
    patients or have less than $30,000 in Part B charges annually.
    For 2018, CMS increased the low-volume threshold to $90,000 in
    Part B charges or fewer than 200 Medicare patients per year.
    And for the next year, CMS has proposed maintaining the low-
    volume threshold for MIPS while adding a third exemption route
    for clinicians providing less than 200 covered services. CMS
    has proposed allowing clinicians who meet the exemption
    criteria to opt into MIPS.
        Under MACRA, the Department of Health and Human Services is
    required to set the performance threshold by 2019 at the mean
    or median of final scores for all MIPS-eligible clinicians. In
    February, Congress passed legislation changing the timeline to
    ease the burden of the MIPS transition. The Bipartisan Budget
    Act of 2018 granted HHS an additional 3 years to ensure
    gradual, incremental transition to the mean or median of
    performance.
        I look forward to hearing from our panelists regarding
    their experience with MIPS and recent changes made by Congress,
    whether additional action is necessary to ensure physicians
    participating in MIPS is generating savings to Medicare and
    improving patient outcomes.
        Thank you, Mr. Chairman. I yield back my time. There is
    nobody on our side. So, I don't think they want any time.
        [The prepared statement of Mr. Green follows:]

                     Prepared statement of Hon. Gene Green

        Mr. Chairman, thank you for holding today's hearing on the
    Medicare Access and CHIP Reauthorization Act (MACRA) and the
    Merit-Based Incentive Payment System (MIPS).
        I also thank our esteemed panelists for joining us this
    morning.
        The Sustainable Growth Rate (SGR) was a thorn in the side
    of Medicare and doctors who treated Medicare patients for over
    a decade after its creation in 1997.
        SGR's formula led to a reduction of physician payments
    starting in 2002 and had to be patched annually by Congress.
        In 2014 and 2015, our committee, along with other
    committees of jurisdiction, came together and passed bipartisan
    legislation, the Medicare Access and CHIP Reauthorization Act,
    which permanently repealed the SGR.
        MACRA did more than just repeal the flawed SGR formula. It
    was designed to overhaul and realign payment incentives for
    Medicare and transition our health system to one that rewards
    value instead of just volume of care.
        MACRA provides stability in Medicare payments for providers
    for the years immediately after its enactment and made it
    easier for providers to report on and deliver high quality
    care.
        Critically, MACRA encourages providers to move away from
    fee-for-service and participate in a new delivery model that
    will reduce costs while increasing quality.
        Under the law, physicians who treat Medicare beneficiaries
    have a choice between participating in MIPS or the Advanced
    Alternative Payment Models (APMs) to make the shift from fee-
    for-service and volume-based payment system to a value-based
    payment system.
        MIPS streamlined three prior quality incentive programs
    that were sunset in 2016 and have been replaced by new MIPS
    categories: Quality, Improvement Activities, Meaningful Use,
    and Cost.
        Starting in 2017, health care providers could choose
    whether to participate in an APM or MIPS. Providers are exempt
    from MIPS if they fall below the ``low volume'' threshold. For
    2017, the Centers for Medicare and Medicaid Services (CMS) set
    the low volume threshold for providers who see fewer than 100
    Medicare Part B patients or have less than $30,000 in Part B
    charges annually.
        For 2018, CMS increased the low volume threshold to $90,000
    in Part B charges, or fewer than 200 Medicare patients per
    year. And for next year, CMS has proposed maintaining the low
    volume threshold for MIPS, while adding a third exemption route
    for clinicians providing less than 200 covered services.
        CMS has also proposed allowing clinicians that meet the
    exemption criteria to opt into MIPS.
        Under MACRA, the Department of Health and Human Services is
    required to set the performance threshold by 2019 at the mean
    or median of final scores for all MIPS eligible clinicians.
        In February, Congress passed legislation changing the
    timeline to ease the burden of the MIPS transition period.
        The Bipartisan Budget Act of 2018 granted HHS an additional
    three years to ensure a gradual and incremental transition to
    the mean or median of performance.
        I look forward to hearing from our panelists regarding
    their experience with MIPS, the recent changes made by
    Congress, and whether additional action is necessary to ensure
    physicians participating in MIPS are generating savings to
    Medicare and improving patient outcomes.
        Thank you, Mr. Chairman. I yield the remainder of my time.

        Mr. Burgess. I thank the gentleman for yielding back. The
    gentleman does yield back.
        There is 3 minutes left on the vote on the floor. We are
    going to recess until immediately after the vote on the floor.
        [Recess.]
        Mr. Burgess. I call the committee back to order.
        We are still waiting on the return of the ranking member
    and the chairman of the full committee, but anticipating that
    they will arrive, let's thank our witnesses for being here
    today and taking time to testify before the subcommittee.
        Each witness is going to have the opportunity to give an
    opening statement, followed by questions from members. Today we
    will hear from Dr. David Barbe, the Immediate Past President of
    the American Medical Association; Dr. Frank Opelka, Medical
    Director, Quality and Health Policy, American College of
    Surgeons; Dr. Ashok Rai, Chairman of the Board, American
    Medical Group Association; Dr. Parag Parekh, American Society
    of Cataract and Refractive Surgery, and Kurt Ransohoff,
    Chairman of the Board, America's Physician Groups.
        We appreciate you being here today, Doctors.
        And, Dr. Barbe, you are now recognized for 5 minutes to
    give an opening statement, please.

       STATEMENTS OF DR. DAVID BARBE, IMMEDIATE PAST PRESIDENT,
        AMERICAN MEDICAL ASSOCIATION; DR. FRANK OPELKA, MEDICAL
       DIRECTOR, QUALITY AND HEALTH POLICY, AMERICAN COLLEGE OF
       SURGEONS; DR. ASHOK RAI, CHAIRMAN OF THE BOARD, AMERICAN
     MEDICAL GROUP ASSOCIATION; DR. PARAG PAREKH, AMERICAN SOCIETY
      OF CATARACT AND REFRACTIVE SURGERY, AND DR. KURT RANSOHOFF,
           CHAIRMAN OF THE BOARD, AMERICA'S PHYSICIAN GROUPS

                      STATEMENT OF DR. DAVID BARBE

        Dr. Barbe. Chairman Burgess, Ranking Member Green, and
    committee members, thank you very much for the opportunity to
    come here today and to update you on the continuing
    implementation of MACRA.
        I am a practicing family physician from rural southern
    Missouri, actually in Congressman Long's neck of the woods, and
    as you say, Past President of the AMA.
        Physicians are familiar with value-based payment
    mechanisms. We have been subject to those for over 10 years,
    starting with PQRI, which was the original quality-based
    program. That was in 2007. Meaningful use came in in 2009.
    Value-based payments began in 2013. But each of these programs
    came in at separate times under separate bills, were never
    harmonized, never even contemplated working together. And all
    of them started as incentive programs, but most of them have
    transitioned into penalty programs which are additive.
        As of now, a physician who is not able to perform, for
    whatever reason, in those programs could be subject to up to
    11-percent negative adjustment in their Medicare reimbursement.
    That was simply not sustainable, and we thank you and the
    others that worked so hard on MACRA in 2015. That is a
    significant step forward. Not only did it repeal the SGR, as
    has been noted, but it began to harmonize these programs,
    bringing them under one administration, if you will, and it
    also reset, very importantly, the incentive and penalty
    corridor, such that for performance in the first year of 2017,
    it was a plus or minus 4 percent, certainly a better
    opportunity for physicians to succeed under that particular
    framework. So, we appreciate the work that went into that.
        We share a common goal with you in seeing that these new
    quality payment programs are implemented appropriately, that
    the transition is smooth. Because we believe that the success
    of these programs has a real opportunity to improve quality for
    patients, to bend the cost curve. But, for them to be
    successful, physicians have to be able to succeed under these
    programs as well. Again, MACRA took us a significant step
    toward physician success and improving these programs.
        In your opening remarks, you mentioned BBA 2018 and the
    significant improvements and technical fixes that were made. We
    really appreciated those as well. We will continue to work
    closely with you because, as you also suggested, this wasn't a
    one-and-done. This is an evolving process. And hearings like
    this today, allowing us to update you, are critical in
    continuing to improve that process for patients, physicians,
    and for the Medicare program.
        As a part of the BBA 2018, we strongly support the Part B
    drug cost exclusion. We support flexibility for CMS to re-
    weight the cost performance measures. We appreciate the
    performance threshold flexibility that you gave CMS. We need
    now for CMS to use the flexibility that you gave them to make
    this transition appropriate. So, we will continue to work with
    them. We have made multiple suggestions already, and we will
    continue to try to make this transition appropriate.
        One of the other pretty important parts of what you enabled
    was for PTAC to consult with physician groups as we develop
    physician-focused payment models. The PTAC has been doing what
    you have wanted it to do. They have received dozens of
    proposals, and they have even recommended about 10 of those
    onto CMS. Unfortunately, CMS has not seen fit to adopt any of
    those yet, and I think it is thwarting the creativity and
    innovation that physicians are willing to bring to the table.
    So, we will continue to work with CMS to try to get them to
    consider and adopt some of those alternative payments models
    that are physician-focused that PTAC has recommended.
        And I think, lastly, you may hear some discussion today
    about the limitation of the upside opportunity to something in
    the 2-percent range, rather than the 4 percent that was
    originally contemplated. Again, the goal is to help physicians
    succeed. All of the organizations represented here represent a
    wide range of physician practices, physician styles. The AMA
    certainly does. We represent physicians from all specialties,
    all practice types.
        It is critically important that all those physicians have
    an opportunity to succeed under this program. Whether you are a
    large megagroup like the one I am in or whether you are a
    single, independent physician practicing someplace else in
    Missouri, you need an opportunity. And so, CMS needs
    flexibility. We need a smooth transition, and we really
    appreciate the continued opportunity we have to dialog with you
    on this.
        [The prepared statement of Dr. Barbe follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Dr. Barbe.
        Dr. Opelka, you are recognized for 5 minutes, please.

                     STATEMENT OF DR. FRANK OPELKA

        Dr. Opelka. Chairman Burgess, Ranking Member Green, members
    of the committee, on behalf of the 80,000 members of the
    American College of Surgeons, we appreciate the invitation to
    share our thoughts with you today.
        The American College of Surgeons again expresses our thanks
    to Congress for the aspects of MACRA which have eliminated the
    sustainable growth rate and led to efforts designed to link
    payment more closely to quality and value. Congress' efforts
    have not only reduced maximum penalties, your efforts seek to
    phase in new incentives and provide potential for positive
    updates. Particularly noteworthy are the congressional efforts
    to combine and simplify value-based goals for measuring quality
    improvement. After all, we measure, so that we can improve, not
    just get paid. We also appreciate the congressional directives
    for moving from fee-for-service to alternative payment models.
    We would wish CMS would improve their efforts to work with the
    American College of Surgeons', ACS, physician-focused payment
    model. We are mindful of Congress' interest in oversight of
    CMS's implementation of MACRA.
        In order for clinicians to assume risk in value-based
    payment programs, physicians must have reliable and valid
    measures of both quality and the cost of care. The American
    College of Surgeons seeks to support the congressional intent
    of MACRA through our work product for building meaningful
    quality measures for surgical patients and surgeons, as well as
    proffering the CMS our APMs which are based on true total cost
    of care.
        The American College of Surgeons began over 100 years ago,
    when America had more hospitals than we have today. They were
    small and care was not standardized. To standardize quality, we
    formed the College of Surgeons, and we created the first
    hospital accreditation. In later years, this became The Joint
    Commission. Today, we continue those verification programs in
    order to promote standards for quality of care in trauma
    centers, such as Level I, Level II, and Level III trauma
    centers.
        Neither the Federal Government nor commercial payers do
    much to recognize the over 200 quality standards we create to
    maintain a national trauma system for this country. Our
    verification programs are a model which measure what matters to
    patients. We measure the team and the totality of care. We
    worry less about measuring the individual surgeon and focus
    more about measuring the outcome to patients. We, then, credit
    the entire team with its successes and we use the knowledge
    gained from our programs to create learning networks which
    teach others and spread improvement widely, none of this
    recognized in payment programs.
        In much the same way, we have created cancer verification,
    breast care verification, bariatric care, pediatric surgical
    care, and now more. Yet, CMS offers meaningless measures which
    do little to help the surgical patient. CMS feels constrained
    from measuring team-based measures, instead seeking simply
    constructed measures such as surgeons having to track patients'
    immunizations, rather than measuring the surgical team. The end
    result is measures become meaningless, burdensome, and
    distractions. Hospital CEOs end up defunding valued surgical
    quality programs to chase the wrong measures, simply because
    that is how they get paid.
        It is time we, as the American College of Surgeons, seek
    congressional directives for CMS to build a strong surgical
    quality program for each major surgical domain, just as the
    College has done in our team-based models for hospitals for
    trauma, for cancer, and more. It is time that we measure what
    matters. It is time for payment models to align with clinical
    care and not force clinical care to conform to payment.
        Lastly, the American College of Surgeons serves as a leader
    in digital information and health IT. We are focused on
    patient-centered digital records, not just EHRs, since
    patients' lives exist in more than one EHR. This calls for an
    expansion of our thinking beyond EHRs into a world of
    interoperability, connecting patients across EHRs, across smart
    devices, across clinical registries, for activities such as
    clinical decision support, machine learning, and artificial
    intelligence. There is so much more we can do for quality and
    for lowering cost by leveraging digital information. We have to
    stop thinking of EHRs and think beyond them. We could use your
    support in promoting this level of interoperability to make an
    interoperable digital patient medical record. We look forward
    to working with the Congress to help surgeons care for
    patients.
        Thank you very much.
        [The prepared statement of Dr. Opelka follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Doctor.
        And, Dr. Rai, you are recognized for 5 minutes, please.

                       STATEMENT OF DR. ASHOK RAI

        Dr. Rai. Chairman Burgess, Ranking Member Green, and
    distinguished members of the Energy and Commerce Committee on
    Health, thank you for the opportunity to testify today.
        I am Dr. Ashok Rai, and I am here today as Chair of AMGA,
    which represents multi-specialty medical groups and integrated
    delivery systems. Our membership provides care for one in three
    Americans.
        I am a board-certified internist with 17 years of
    experience, providing care to patients in Green Bay, Wisconsin.
    Since 2009, I have served as the President and CEO of Prevea
    Health, a multi-specialty medical group which employs more than
    350 providers, including 60 medical specialties. In total, we
    employ more than 2,000 people, and I am proud of the impact we
    have on the people of Wisconsin.
        I wanted to express my appreciation to Congress for
    repealing the SGR formula for Medicare Part B payments. The
    annual SGR cliffs were obstacles to sound planning and hindered
    our ability to make strategic decisions that would help us care
    for patients.
        I applaud the committee's leadership role in passing the
    much-needed MACRA law which puts providers on a path towards
    value-based care. We agree with Congress that the current fee-
    for-service payment system is not sustainable, nor is it good
    for our patients. We need to move to a system where the payment
    aligns with the way medical groups focus on the health of a
    population, rather than only the sickness of patients.
        Under MACRA, CMS combined existing programs such as the
    physician quality reporting system, the value-based modifier,
    and meaningful use programs to create the merit-based incentive
    payment system, better known as MIPS. Under the MACRA statute,
    MIPS providers would have the opportunity to have positive or
    negative payment adjustments based on their performance,
    starting at plus or minus 4 percent in 2019 and eventually plus
    or minus 9 percent in 2023.
        By putting provider reimbursement at risk, I believe
    Congress intended to move Medicare to a value-based payment
    model where high performance was rewarded and poor performers
    were incented to improve with lower payment rates. In fact,
    high-performing groups like Prevea Health have been preparing
    for this value transition for years by participating in MIPS's
    legacy programs such as PQRS, VM, and MU. As a result, our
    efforts to perform in these legacy programs have improved the
    value of care provided through increased quality and decreased
    cost.
        But the problem we face now as healthcare providers is that
    CMS is excluding a majority of providers from the MIPS program.
    CMS has bypassed the intent of MACRA by excluding 58 percent of
    providers from MIPS requirements for performance year 2019 and
    the recently-proposed quality payment program, or MACRA rule.
    This will result in the 2021 payment year adjustment being
    around 2 percent for high-performers, instead of closer to 7
    percent, which the statute dictates. Last year, CMS excluded 60
    percent of eligible clinicians, which collapsed the potential
    reward for high-performers from 5 percent to 1.5 percent.
        To give you a real-life example of how this works, in the
    four Tax Identification Numbers that Prevea Health bills under
    in partnership with our hospital partners, Hospital Sisters
    Health System, Prevea Health scored three perfect scores of 100
    and one of 97. However, because of the MIPS exclusions, our
    payment adjustment was only 2 percent. Why is this important?
    To get to value, to create change is incredibly difficult. It
    requires changes in how we deliver care, how we set up our
    administrative and financial processes. It means investing
    millions of dollars in information technology and people.
    Importantly, it requires buy-in from every member of the team,
    especially the providers.
        The changed management challenges presented by creating a
    new value-based delivery system are enormous. And Prevea Health
    undertook this challenge because we viewed MACRA as the
    incentive program that would reward us for making these changes
    and doing well by our patients. Now, though, I have to go back
    to the physicians and providers at my group and say the
    investments we made, they weren't rewarded. The better care we
    delivered was not recognized. That is a difficult message to
    deliver, and I don't think that is the message that this
    committee or Congress wanted us to make, but it is the one we
    have to tell providers at Prevea because of the way MACRA is
    being implemented.
        I appreciate the concerns so ably expressed today by my
    colleagues for physicians practicing in solo or smaller
    practices. The reporting burden on them is real. However, I
    have to point out that the MIPS program is a continuation of
    quality programs that have been in existence for years, and no
    one is excluded from these programs, certainly not 58 percent
    of them. I firmly believe Congress passed MACRA to push the
    transition to value in Medicare Part B. Ironically, by
    excluding the majority of clinicians from MIPS, if anything, we
    have taken a step back from this transition. These exclusions
    need to end. Only then can MACRA meet your goal of moving
    Medicare meaningfully towards value. AMGA stands ready to work
    with Congress and CMS to ensure MIPS, and MACRA, serves as the
    transition tool to value, as it was intended to be.
        Thank you.
        [The prepared statement of Dr. Rai follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Doctor.
        Dr. Parekh, you are recognized for 5 minutes, please.

                     STATEMENT OF DR. PARAG PAREKH

        Dr. Parekh. Chairman Burgess, Ranking Member Green, and
    members of the Health Subcommittee, thank you for the
    opportunity to provide feedback on MACRA implementation.
        I am here today on behalf of the Alliance of Specialty
    Medicine, a coalition of 15 medical specialty societies,
    representing more than 100,000 physicians and surgeons. My name
    is Dr. Parag Parekh. I am a private-practicing eye surgeon in
    rural western Pennsylvania and the only board-certified,
    fellowship-trained ophthalmologist specializing in cataract and
    refractive surgery as well as cornea and glaucoma surgery in
    that entire geographic area. I chair the Government Relations
    Committee of the American Society of Cataract and Refractive
    Surgery, one of the alliance member organizations.
        The alliance greatly appreciates your leadership to repeal
    the SGR, create MACRA, and revamp the legacy quality reporting
    programs. Listening to physicians' concerns, Congress created
    MIPS, which streamlined the existing programs and allows
    physicians to focus on the measures and activities that most
    closely align with our practices. Successful implementation and
    long-term viability is important, since MIPS is the only pay-
    for-performance option for many specialists. We also appreciate
    the technical corrections advanced earlier this year, which
    strengthen the law, continue progress made to date, and will
    improve the ability of specialty physicians to engage in
    quality improvement activities.
        MACRA provides two value-based reimbursement tracks for
    physicians under Medicare. Under one, physicians can opt to
    remain in fee-for-service and participate in MIPS. In the
    other, physicians can participate in advanced alternative
    payment models. For many specialists, including
    ophthalmologists like me, MIPS is the only meaningful and
    viable pathway. Many specialists have no opportunities to
    participate in advanced APMs, given that they are designed with
    a primary care focus.
        While there is always more work to be done, many
    specialists have made significant strides to deliver high-
    quality and efficient care. In the last 50 years,
    ophthalmologists have made tremendous strides in cataract
    surgery by reducing complications and the variations in cost.
    Ophthalmology has developed meaningful outcomes measures,
    including for cataract surgery, which are being reported
    through the MIPS program. And CMS proposed to include cataract
    episode cost measures as well. Therefore, it is critically
    important that Congress maintain a viable fee-for-service
    option in Medicare Part B, along with the MIPS program, to
    ensure that specialists can continue to meaningful engage in
    the quality improvement initiatives and deliver high-quality
    care.
        The MIPS technical corrections gives CMS additional
    flexibility to determine the appropriate weight of the MIPS
    cost category, allow CMS to gradually increase the performance
    threshold before reaching the mean or median standard, and
    exclude Medicare Part B drugs from MIPS payment adjustments and
    eligibility determination.
        However, additional modifications are needed to support
    more meaningful measures and lessen the complexity of reporting
    and scoring. Currently, clinicians must comply with four
    performance categories, each with distinct requirements and
    scoring methodologies. Allowing clinicians to get credit across
    multiple MIPS categories by engaging in a single set of actions
    would make the program much less confusing.
        For example, tracking outcomes through a clinical data
    registry and using such data to improve patient care should
    count for multiple categories of MIPS. Alliance specialty
    societies continue to invest heavily in the development of
    quality measures, including outcome measures and those reported
    by patients, and have established robust clinical data
    registries that have been qualified for use in the MIPS
    program. In my own specialty, the American Academy of
    Ophthalmology has the IRIS registry, which serves as a key tool
    in reporting MIPS data and tracking outcomes.
        Measure implementation is another ongoing challenge. Our
    member societies continue to develop new specialty-focused
    measures, but CMS threatens to eliminate them when they do not
    immediately produce enough data to set reliable performance
    benchmarks. In addition, for more established measures
    previously developed by specialties, CMS has determined some of
    them to be topped-out and, then, remove them from the program,
    even though these measures continue to improve care and
    continue to be meaningful to specialty physicians. Removing
    them from the program limits our ability to participate in
    MIPS.
        Finally, the alliance opposes MedPAC's recommendation to
    eliminate the MIPS program and replace it with the voluntary
    value program, which relies on population-based measures geared
    towards primary care and eliminates the one program, MIPS, that
    specialists can actually use to demonstrate and improve their
    quality and overall value. The VBP would discourage specialists
    from developing relevant quality and outcomes measures,
    disincentivize the use of high-value clinical data registries
    to track patterns of care, and thwart efforts to collect and
    report performance data.
        Again, thank you for your work to ensure successful and
    timely implementation of MIPS.
        [The prepared statement of Dr. Parekh follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Doctor.
        And, Dr. Ransohoff, you are recognized for 5 minutes,
    please.

                    STATEMENT OF DR. KURT RANSOHOFF

        Dr. Ransohoff. Thank you, Chairman Burgess, Ranking Member
    Green, and esteemed members of the committee, for inviting me
    to present today.
        For the last few years, my group, Sansum Clinic in Santa
    Barbara, California, has been on a journey going from the SGR
    payment system to become a devoted MIPS provider, only to
    evolve into a Track 1+ ACO. Our journey will provide some
    insight into what is good and what is less good about the
    recent shifting of the tectonic plates on which the Medicare
    physician payment system stands.
        Before going further, let me tell you about me and my
    group. I am a general internist. I have practiced in the same
    exam rooms for the last 26 years. I have been doing this long
    enough to recall handwriting my patient progress notes and to
    have cared for multiple generations of families. I have been
    able to say to a 70-year-old man, ``Your murmur sounds exactly
    like your dad's did at your age.'' I have been honored to have
    practiced for that long in the same setting.
        Sansum Clinic is a nearly 100-year-old not-for-profit
    medical foundation with 200 doctors. It is an oddity in that it
    is not affiliated with a hospital. We have participated in the
    whole alphabet soup of modern health insurance from HMOs to
    PPOs to ACOs.
        For the last 2 years, I have been the Board Chair of
    America's Physician Groups. APG is a professional association
    representing more than 300 of the nation's most advanced
    medical groups in the country, many of whom take full financial
    risk in caring for their patients.
        With that background, let me return to our story of our
    journey from the SGR days to being a Track 1+ ACO. Whatever
    criticisms there are about MIPS and MACRA, almost all doctors
    will say thank you, as all of us have, to Congress for doing
    away with that flawed process. In the SGR days, our budgeting
    process was basically chaos. The cut that was generated by the
    formula would mean that we would be entirely unable to balance
    our books. So, we just ignored it and prayed that the
    implementation would be put off, as it was every year, usually
    at the 11th hour. We also had a great sigh of relief when the
    SGR was repealed.
        Then, there was this new process, MACRA, on the scene. Over
    the last few years, our clinic became a very successful MIPS
    participant. We got 100 and we made lot of investments in care
    processes to enhance the health of our populations and
    patients. And yet, we have left MIPS and we have gone on to
    become a Track 1+ ACO. The details in the journey are included
    in my remarks, but I will try to summarize the take-home
    messages of our journey.
        What have we learned? SGR was really problematic, and
    though there remains some issues within the MIPS program that
    need to be addressed, it is far and away a better system than
    the dreaded ``doc fix'' gamble that we all had to rely on for
    years. The way MIPS has been implemented is not the way it was
    planned. It is an asymmetric process. The intended larger
    reward for high scorers is gone, but the intended large loss
    for those who score poorly is still there. Most of that is
    because so many doctors are excluded from MIPS, more than half
    a million, according to The Federal Register.
        We fully recognize that exemptions are necessary in some
    cases, but this level of exemptions undermines the spirit of
    the law and impedes the goal of moving our nation's healthcare
    system to value. There are real benefits to the patients and to
    the healthcare system that come from the clinical processes
    that are put in place to try to do this work well. At the same
    time, the metrics on which doctors are graded need to be
    relevant for their specialty and their practice.
        Here are a few suggestions that we think can encourage the
    movement from volume to value:
        Lower the threshold for excluding groups entirely from MIPS
    and, thereby, increase the number of physicians participating
    in the program. At the same time, in recognition of the fact
    that smaller groups have fewer resources, MIPS for smaller
    groups may need to look different than MIPS for larger groups.
    In other words, give smaller groups a different test more
    suitable for their resources, instead of excluding them
    entirely.
        Even if there are flaws in MIPS, there is value for
    individual patients and populations and, importantly, the payer
    of all of this, the American taxpayer, in encouraging data
    collection and encouraging the use of, and the reporting of,
    high-quality and high-value care. The processes that are
    created to do that will help move Medicare from volume to
    value. We should find ways of making it feasible for more
    providers to participate in that process, instead of excluding
    them. MIPS can and should be fixed. It should not be discarded.
        Thank you for allowing me to speak, and I will be happy to
    answer any questions.
        [The prepared statement of Dr. Ransohoff follows:]
        [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. Thank you, Dr. Ransohoff.
        I don't see our chairman or the ranking member of the full
    committee back yet. So, we will proceed with the question-and-
    answer portion of the hearing. If either the chairman or the
    ranking member do show up, we will, obviously, yield to them
    for their statements as well.
        And I, again, want to thank each of you for being here.
        Many of you have mentioned different milestones along the
    journey that took us from where we were in the early 2000s to
    where we are now. I will just say, when I first got here, the
    goal of repealing the SGR became one my primary focus, and
    early on it was to repeal the sustainable growth rate formula.
    I thought if I replaced that with the Medicare Economic Index
    plus an inflation factor every year, so MEI plus 1 sounded
    reasonable to me, pretty simple and straightforward. So, that
    was my original proposal. The Congressional Budget Office threw
    about $300 billion of cold water on that idea, and I attracted
    no supporters, and I literally was pursuing that by myself, I
    think through two Congresses.
        So, that is part of what led to the journey of where we are
    now. Obviously, things have happened along the way. The PQRS,
    many of you mentioned having to come to a conclusion at the end
    of every year and provide a ``doc fix''. And how many remember
    PQRS in 2006 was sort of Bill Thomas' parting gift to medicine,
    if I can use that term? But PQRS was to pay for the ``doc
    fix,'' right? That is how we got PQRS, and PQRS is one of those
    legacy programs that now finds itself in MIPS.
        One of the largest contacts I get on social media is about
    a new payment rule for labs in Medicare, and I appreciate that
    it is causing some stress. That is based upon a provision in
    what was really literally the last ``doc fix'' in 2014, a bill
    called PAMA that, again, provided the dollars to bring us to
    ``doc fix''.
        So, underscoring everything else, the SGR is gone and we
    are not having to deal with the ``doc fix'' at the end of the
    year, as I think, Dr. Barbe, you mentioned having to go to your
    banker every year and explain, ``Well, it isn't really going to
    happen.'' Right? ``They say it, but it isn't really going to
    happen.'' So, that burden also has been lifted. And now that it
    is no longer there, we kind of forget that it was something
    that literally it was the end of every Congress every December
    of every year that I was here for quite some time.
        So, having provided that background, obviously, I am going
    to ask the easy question first, and I do want everyone to
    answer. In the tradition of Chairman Dingell, I am going to
    make this a yes-or-no question. Better off today under the
    system that we have or were we better off under the SGR legacy?
        Dr. Barbe, I will start with you. Better off today?
        Dr. Barbe. Much better.
        Mr. Burgess. Dr. Opelka?
        Dr. Opelka. Absolutely.
        Mr. Burgess. And Dr. Rai?
        Dr. Rai. We are better today.
        Mr. Burgess. That is an affirmative.
        Dr. Parekh?
        Dr. Parekh. Much, much better.
        Mr. Burgess. Affirmative also.
        And Dr. Ransohoff?
        Dr. Ransohoff. A rare opportunity for five doctors to
    agree.
        [Laughter.]
        Mr. Burgess. OK. I wasn't going to do this, but you
    reminded me. One of my greatest wishes is to someday come into
    this committee hearing, having five doctors at the table who
    are going to discuss how economists should be paid.
        [Laughter.]
        We will save that for another day. This group gets it.
        The economists don't think that is funny, and I have tried
    that on them from time to time.
        So, no program is absolutely perfect, and I appreciate, I
    guess, Dr. Ransohoff, your journey that took you, first, to the
    direction of the small practice and, then, to the alternative
    payment method.
        And I will also add, as we were going through the
    discussions that led to this bill finally getting firmed up, I
    believed it would take 10 years in this process. Once again, I
    had a simple formula; let's do 10 years with a 1-percent update
    every year. That seemed like a good fit. Again, the CBO threw a
    bunch of cold water on that idea, and it was condensed down to
    5 years at a 0.5-percent update, which actually got a little
    further lowered after that. But I always thought it would take
    longer.
        This is a big change, and more than just having the change
    and having the bill signed, it is important to get it right.
    And I hope, if nothing else, this hearing today--this is the
    fourth hearing we have had on the implementation of this law.
    And if anyone at the agency is listening, I want them to
    understand this as well. It is important that we get it right.
    It is not important that we passed the bill and that we had a
    signing ceremony down at the White House. It is important that
    we get it right, because, obviously, patients are counting on
    it. Obviously, doctors are counting on it, and the taxpayer is
    also one of the variables in this equation that we have to
    consider as well.
        So, I think I have heard the answer to this question during
    your testimony, but I will ask you for the record. Would it be
    better for Congress to continue to work with the agency, with
    the Centers for Medicare and Medicaid Services, to implement
    the merit-based system as laid out in statute or just scrap it
    entirely and go back to the drawing board?
        Dr. Barbe, we will start with you.
        Dr. Barbe. We are eager to continue to work on this. We
    think it has potential.
        Mr. Burgess. Thank you.
        Dr. Opelka?
        Dr. Opelka. Mr. Chairman, quality is a never-ending cycle.
    We have to continuously work on this.
        Mr. Burgess. That is great. Thank you. I am going to steal
    that quote.
        Dr. Rai?
        Dr. Rai. I would agree that we need to continue to work
    with you on MIPS.
        Mr. Burgess. Dr. Parekh?
        Dr. Parekh. I also agree. In business school, they teach us
    about continuous quality improvement, and I think that
    principle applies here, too.
        Mr. Burgess. Yes, sir.
        Dr. Ransohoff?
        Dr. Ransohoff. There is a lot of good to this program, and
    it should be continued to be worked on.
        Mr. Burgess. I have some other questions, but I will submit
    them for the record.
        Just one last story about the journey that got us here.
    There was one morning when the then-Majority Leader came up to
    me, and I was whining about this problem not having been
    solved. And he said, ``Well, Doc, would it be easier if we put
    everybody into an ACO?'' Well, the short answer to his question
    is, yes, it would be easier, but it wasn't the right thing.
        I appreciate the journey that you have been on, Dr.
    Ransohoff, and I think that kind of told me what, in fact, I
    was telling the Majority Leader that morning. We are not quite
    sure about what the journey that different practices will have
    to take, and it is important for the entire panoply of
    practices to be able to prosper in the environment.
        And I will yield back and recognize Mr. Green for 5
    minutes, please.
        Mr. Green. Thank you, Mr. Chairman.
        And thank each of you for joining us today.
        MACRA was an important step forward for our healthcare
    system, building on the successes of the Affordable Care Act.
    One of the key goals was to further reforms that would promote
    value over volume and incentivize providers to find new ways to
    offer more coordinated and efficient care. In order to further
    that goal, MACRA created the Physician-Focused Payment Model
    Technical Advisory Committee, PTAC, and to make recommendations
    to the Secretary for proposals for physician-focused payment
    models that would help control healthcare spending and improve
    quality.
        Dr. Opelka, can you describe why MACRA and the creation of
    PTAC was so critical to our efforts toward delivery system
    reform?
        Dr. Opelka. I think the key here is--and we really
    appreciate the congressional action to create the physician
    input into business models--the care models have changed, and
    they change every year. They have changed over the last 50
    years. The payment model has been stuck from 50 years ago. So,
    we need to take the care model and put a business model on top
    of it that works, which means that the payer community,
    particularly in our case the agency, needs to listen to us and
    figure out how are we going to incentivize quality; how are we
    going to reach the congressional goal of value by actually
    putting a payment model that maps to the care model? And having
    that relationship, the Congress open that door, and what we
    need now is for an agency that is willing to, and has the
    resources to, accept that.
        Mr. Green. Does anyone else on the panel want to comment on
    how it was working with the PTAC?
        Yes, sir, Doctor?
        Dr. Barbe. Thanks for asking that. As I mentioned earlier,
    physicians want to be engaged and involved in this process.
    PTAC was created for that very reason. They have received
    dozens of proposals that come from the ground level, physicians
    that are practicing that know what will work in their
    practices, and perhaps in their specialty. And yet, none of
    these have been adopted by CMS or, really, we think given
    serious consideration. And these span everything from very
    focused proposals in GI medicine to reduce rehospitalization in
    Crohn's patients, all the way up to the end-stage renal disease
    that could have a very broad effect on improving care and
    reducing costs for dialysis patients. So, we think there is
    great opportunity there if CMS will listen to us.
        Mr. Green. Any other comments?
        [No response.]
        Which gets me to my point, I want to turn to the CMS
    decision not to test many of the models that the PTAC has
    submitted for testing.
        And, Dr. Barbe, you get the first one. Can you expand on
    your remarks in your testimony about the Secretary of HHS
    decision not to implement or test most of the physician-focused
    models that PTAC has submitted for testing? Why is it so
    problematic for MACRA implementation?
        Dr. Barbe. So, the original ideas, these very innovative
    ideas were brought forth from the ground level. PTAC was
    designed to evaluate these, look at the merit, look at the
    rigor, and make recommendations. And they have not recommended
    positively on all of these proposals, but they have recommended
    positively on 10. Again, up to this point, CMS has not seen fit
    to continue to work on those, to dialog and say, ``Well, this
    is what we don't like'' or ``what we do like about this
    proposal. If you could change it, maybe we could adopt it.''
    They seem to be interested in coming up with ideas on their
    own, and I think that is not only reinventing the wheel
    potentially, but it is not taking advantage of some very
    creative and innovative proposals that have come forward.
        Mr. Green. Anyone else?
        Yes, sir, Dr. Opelka?
        Dr. Opelka. So, Congressman Green, we did propose to the
    PTAC. We were early on accepted. We were, then, accepted in a
    letter by the Secretary for consideration by the Innovation
    Center. The Innovation Center had a few conference calls with
    us and one 2-hour in-person meeting on a product that we
    developed that took almost 5 years in the making. There is no
    resources and no capability in the Innovation Center to
    complete a design and, then, to create an implementation and
    have a sandbox or a pilot area in which to test.
        And so, the PTAC has done a fantastic job. The Secretary
    vetted us. And I think we are the only one that went from the
    Secretary and was recommended to the Innovation Center, and it
    died in there because it is just not wired to really innovate.
    And we really need to turn that on.
        Mr. Green. Dr. Barbe, or anyone else, has the AMA or any
    other specialty societies received further feedback from HHS or
    CMS on why HHS is not testing these models that the PTAC has
    recommended? Have you gotten any feedback other than--well, I
    want to hear from Dr. Barbe.
        Dr. Barbe. We have submitted just a month ago a four-page
    letter outlining what we believe are some merits of a few of
    the very specific proposals that PTAC recommended on up to CMS.
    And while they acknowledge receipt of those, they acknowledge
    the work that the PTAC has done, they really have not offered
    any explanation. As I said, we would be happy to work through
    PTAC with them to modify, if there was a deficiency they saw in
    the model and they said the idea is good, but it won't go for
    this reason. I think we are all eager to work with them. We are
    3 years into a 6-year program on this particular issue and
    still don't have a model that physicians can embrace and use
    that has been approved.
        Mr. Green. Mr. Chairman, my time is out, but somewhere
    along the way HHS should clarify and have coordination between
    not just AMA, but also the specialty societies, because, as you
    know, specialties sometimes are different than a doctor down
    the road. And we need to see whether our subcommittee can maybe
    encourage HHS and CMS to give feedback and coordinate with you
    on where we are going with this.
        Thank you.
        Mr. Burgess. I don't disagree. A future hearing that would
    include both the agency and stakeholders on PTAC issue seems
    like a good idea.
        The Chair recognizes Mr. Guthrie, 5 minutes for questions,
    please.
        Mr. Guthrie. Thank you very much, Mr. Chairman.
        Thank you, everybody, for being here.
        And I know you have touched on some of this in your opening
    statements, but I know that the 5 minutes is kind of limited.
    So, I want to just go back and give you each a chance to ask--I
    will do these two questions together.
        So, my question is, for each of you, what specifically has
    each of you done, or are doing, in your own practices to daily
    set yourselves up for success under MIPS, and if you went
    through MIPS and out of MIPS specifically? And what can
    physicians do right now to position themselves to succeed in
    MIPS?
        So, I will just start with Dr. Barbe. Or, no, let me go
    right to left, since we went the other way. Dr. Ransohoff, I
    will start with you, then, and go left.
        Dr. Ransohoff. Thanks. That is an excellent question,
    Congressman.
        I will give an example. We became a patient-centered
    medical home. We had a long history of capitated care. So, we
    are a very integrated medical group. But, going into MIPS, even
    we, who are pretty far along, decided that we needed to have a
    culture change within our organization. And so, we adopted this
    PCMH model, which really has changed the way we do things. Our
    medical assistant, our nurse will, as the patient is coming
    into the room, will find out have you had a mammogram that we
    don't know about; have you had a vaccination that we don't know
    about. So, we can update it in our system. It is a small thing,
    but it turns out that is actually an important culture change
    because it has engaged us in a much more team-focused approach
    to care. So, that is one example of how MIPS has sort of
    propelled us along in what we think is the right direction.
        Mr. Guthrie. OK. Thank you.
        Dr. Parekh?
        Dr. Parekh. Thank you for the question.
        I would say that there is a two-pronged approach to
    answering your question. One is on a personal level, and then,
    the other one is our professional society. So, within the eye
    doctor, eye surgeon community, we have, of course, my
    organization, the American Society of Cataract and Refractive
    Surgery, and we have the American Academy of Ophthalmology. We
    work very closely together to develop measures that are
    relevant to my day-to-day practice and that align very much
    with what patients want, I think with what you all want, and
    with what we want in terms of what is best for our patients.
        So, part of it is developing outcome measures, which we
    have, developing cost measures. It is not an easy task. I
    personally serve on some of these committees. We spend hours
    and hours and hours on this, but it is hugely important on a
    global level to have that, your professional society helping to
    create those measures.
        And then, it's like a one-two punch almost. On a personal
    level, I will tell you, participating in MIPS and getting good
    scores has not been very difficult. My EMR makes it very
    simple. I have a coach through my EMR system. We talk
    regularly. We email regularly. I can keep track of my score of
    how I am doing this year. And so, having the good measures is
    very important, and then, having a good EMR system, and then,
    just putting forth the personal effort to pay attention to
    those measures. And then, improve my deficiencies, become a
    better surgeon, become a better doctor, and also keep track of
    those measures. So, it has been a two-pronged approach.
        Mr. Guthrie. Thank you.
        Dr. Rai?
        Dr. Rai. So, to answer your first question, what have we
    done to prepare for MIPS and MACRA, really, it is redesigning
    how we practice. The physician is no longer the center of the
    healthcare system. The patient should be. And we have
    redesigned all of our practices, both primary care and
    specialty care, to put the patient in the middle and establish
    team-based care, making sure that nurse care managers are
    interacting with patients, making sure that if you have a
    chronic disease, your visit never ends. It is just how often we
    connect with you.
        And we have also made significant investments in data
    infrastructure. An EMR without the ability to draw the data in
    is just a really expensive word processor. And we have had to
    make significant investments in drawing the data out, but,
    then, also make significant digital investments that are
    patient-facing and forward to identify gaps in their care, to
    establish online scheduling, all of which we have done in this
    last year.
        Your other question, what should other physicians do to
    prepare, really, it is no longer focusing on the sickness of
    our patients, but the health of our population. We need to make
    more investments on keeping people out of the hospital, even
    out of our clinics, which isn't always financially viable, but
    we, through MACRA, through MIPS investments, are rewarded for
    that. And we have to use those value rewards to redesign how we
    practice medicine.
        Mr. Guthrie. OK. Thanks.
        Dr. Opelka, we are about out of time. So, go ahead, if you
    have got a couple----
        Dr. Opelka. Very quickly, for the most part, MIPS does not
    measure surgical care. So, we do the best we can to help our
    surgeons get the credit they need for payment purposes, but,
    then, we try to refocus them on the quality metrics programs
    that we have separate from MIPS.
        Mr. Guthrie. OK. Dr. Barbe, do you have just one quick
    thought?
        Dr. Barbe. Our group has been very successful, but we have
    invested heavily over a decade in order to be successful. I am
    concerned that some of these programs now simply don't give
    physicians enough upside opportunity to invest like that in
    order to be successful.
        Mr. Guthrie. OK. Thank you.
        And I yield back.
        Mr. Burgess. The Chair thanks the gentleman. The gentleman
    yields back.
        The Chair recognizes the gentleman from Oregon, Dr.
    Schrader, 5 minutes for your questions, please.
        Mr. Schrader. Well, thank you, Mr. Chairman.
        Dr. Rai, why are 58 percent of the practices excluded from
    MIPS? What is your opinion?
        Dr. Rai. I think CMS created those exclusions because
    physicians felt they weren't ready to participate. But, for
    MIPS to be successful, for MACRA to be successful, there has to
    be a plus and a negative. It is a budget-neutral program. So,
    there has to be a carrot and a stick.
        The 58 percent really came from CMS----
        Mr. Schrader. But why are they excluded? Why are they not
    ready?
        Dr. Rai. Why are they not ready? I think some consider
    themselves not ready because they have not made the investments
    or are willing to make the investments or take the risks that
    are involved in now making that transition from fee-for-service
    to value.
        Mr. Schrader. Investments in terms of expensive computers,
    or whatever, or what are you talking about?
        Dr. Rai. I think the investments are multi-fold. I think
    probably the most significant investment that we have made is
    in people, in making sure that we redesign how we practice
    healthcare. It is in staff. It is not only in staff, but in----
        Mr. Schrader. So, it is basically a decision by those
    offices not to engage, frankly, in the new era of modern
    medicine?
        Dr. Rai. It is. It is. It is people that would really like
    to hang on to fee-for-service for as long as they can.
        Mr. Schrader. All right. All right.
        So, I guess, Dr. Parekh, why is MIPS the only option for a
    specialist? I would understand that you are not a primary home
    model type of thing, but why is that the only APM? Or why
    doesn't some other form of APM work for you?
        Dr. Parekh. Again, I will give you my answer, multiple key
    reasons. First and foremost, most practically speaking, there
    are no APMs in my area that I could join, even if I wanted to.
        Mr. Schrader. Sure.
        Dr. Parekh. So, there is just a geographic barrier to that.
    You will know better than I about the spread of those APMs
    through the country, but, certainly, in my area it is just not
    a choice.
        The ACOs are very primary care-focused. When I think of how
    an ACO works and what the potential is to save money and to
    improve quality of care, it makes the most sense for primary
    care to be doing that because they are the quarterbacks of the
    team. They help coordinate the entire ship. My wife is an
    internist. I mean, we have this discussion at the dinner table
    all the time.
        When we in ophthalmology are trying to improve our
    patients' care, I mean, think of it from our perspective. I am
    trying to do a good job on cataract surgery. I am trying to
    lower my patient's eye pressure from glaucoma, so that they
    don't go blind. But, if we were in a big model, those measures
    are likely not going to be used. So, they wouldn't actually do
    anything for my patients. They wouldn't actually give me a
    solid, meaningful measure that I could do, I could measure
    myself; I could say, oh, I am deficient; I want to improve.
    That is not going to exist because the system is so big. So, I
    think we lose something when you have such a massive system.
    The primary care gets the weight of that in these bigger
    systems and I think the specialists are lost.
        MIPS, on the other hand, gives me a measure that directly
    affects what I do. If I am----
        Mr. Schrader. Do you interface with primary care systems at
    all? Is there any primary care system in your geography?
        Dr. Parekh. No.
        Mr. Schrader. OK. All right. In rural Oregon, we have been
    able to make that happen. I am not talking to your situation,
    but just for the sake of the panel and others, there are ways
    to make APM systems work, ACOs work in rural settings. It is a
    culture, and after a while you figure out how to do it, like
    you all are doing as you adopt new practices and stuff.
        So, Dr. Ransohoff, you suggested maybe lowering the
    exclusion threshold in the MIPS program. Could you elaborate on
    that a little bit? To my investments, I mean, I would assume
    that the outcomes, whether you are a large practice or a small
    practice, the outcomes shouldn't really change. If it is
    patient-centered, you want the patient to be healthy, less
    readmissions, less time between surgeries, whatever the option
    is. Could you talk a little bit about that?
        Dr. Ransohoff. Yes. I think that the main issue is just
    trying to get more doctors involved in the process. The way it
    is set up now, in a way what you have is you have a bunch of
    people who are believers, if you will, and are kind of going
    down that path, and then, you have a bunch of people who are
    just saying, ``Thank goodness this doesn't affect me,'' and are
    not making any efforts to change.
        Mr. Schrader. Right.
        Dr. Ransohoff. I think that, in the absence of change, I
    don't understand how any of this gets to be affordable. And so,
    I do think there is going to have to be some change. By
    lowering the threshold from $90,000 to some number less than
    that, you would start a gradual transition. People would know
    it was coming.
        I do think that, as my colleague here in solo practice
    points out, I think that this is doable. It is just that people
    don't want to do it.
        Mr. Schrader. So, maybe some sort of phase-in with the
    thresholds, so that people can see a path or eventually develop
    a path going forward?
        Dr. Ransohoff. Correct.
        Mr. Schrader. So, the last question real quick, Dr. Barbe,
    everyone has pretty much referenced electronic medical records
    and EHR. I am very, very concerned that, while individual
    practices and groups are making huge investments--originally,
    there was some money from the Federal Government to help out;
    gone now. Maybe that is something we should continue or think
    of strictly for small practices. But I am concerned about the
    systems--and you guys have alluded to this--not talking to one
    another. And there is a vested interest, with all due respect
    to our EHR developers, to keep that system pretty proprietary
    and pretty unique, so that you have got to buy their stuff.
    Could you talk a little bit about trying to broaden that out?
    Is there a role for the Federal Government to require some of
    these developers to make it easier for doctors to share their
    information across specialties, primary care, frankly,
    nutritionists, the whole gamut?
        Dr. Barbe. So, yes, we believe the Office of the National
    Coordinator can facilitate better interoperability. Many groups
    are trying workarounds now, all the way from health information
    exchanges to other cloud-based. Dr. Opelka earlier referenced
    activities of the American College of Surgeons. The AMA has
    significant activities around an IHMI, or Integrated Health
    Model Initiative, that we believe has some great potential. But
    all of those are workarounds because the industry has not made
    data interoperable and, in fact, has blocked data in many
    cases.
        Mr. Schrader. Thank you. And my time is up, but I think
    that is a critical issue for this committee to address, if we
    are going to be successful going forward.
        Thank you very much, Mr. Chairman.
        Mr. Burgess. Thank you, Dr. Schrader.
        I would just point out that the third title in the Cures
    bill that we were planning on having oversight of the
    implementation was the electronic health records. We did have
    the mental health title evaluation earlier this week, I think,
    or was it last week? But, in any case, that has been held up
    because a rule has been stuck at the Office of Management and
    Budget, and we had initially planned to have that hearing in
    June and it was postponed because of that reason. Then, we are
    eventually just likely going to have to have the hearing
    without the rule having been finalized or released by OMB.
        I would now like to recognize the gentleman from Illinois,
    the chairman of the Subcommittee on Energy and Environment,
    Chairman Shimkus, 5 minutes.
        Mr. Shimkus. Thank you, Mr. Chairman. This is a great
    hearing. Tough names out there. So, if I butcher them, I
    apologize for that.
        For Dr. Schrader, I think we do need to look at this as an
    exemption issue. If this is a movement forward, and there are
    cost challenges, we ought to get everybody onboard on the
    quality bandwagon.
        I can't remember who mentioned it in their opening
    statement, but someone, one of you mentioned that high-
    performers are not getting rewarded. Can you just address that
    a minute? Because, obviously, you mentioned, I think--correct
    me if I am wrong--poor-performers are being identified, but
    high-performers are not being rewarded.
        Dr. Rai. Yes, I think both Kurt and I mentioned that. At
    the end of the day, for the budget neutrality to work, there
    has to be just as many people involved in this. And that is
    what the exclusions created, was the incentive was cut in half
    for high-performers. Because there weren't as many people in
    there, the threshold was changed. So, from expecting a 4-
    percent to a 2-percent increase, yet making all the investments
    to value, is where we felt that high-performers were literally
    being penalized for making the right investments.
        Mr. Shimkus. Any more? Dr. Ransohoff, I am going to go with
    you to the next question, too. So, why don't you answer that
    also?
        Dr. Ransohoff. Yes, we have the same issues. We spent
    probably half--we will get a 2.02-percent reward for getting
    100--we probably spent half of that trying to get it. Now we
    had done that because we thought that the reward would be
    significantly more, and it is the right thing to do, but there
    is an economic issue with it.
        Mr. Shimkus. Yes, and I am going to talk economics a little
    bit, too. But I want to go back. What intrigued me about your
    comment to another question was, electronic health records or
    whatever, EMR, or whatever you want to call them, asking
    patients about indices that they may not be there for. We have
    been dealing with that with the opioid issue and trying to
    change law, so that there is a little more conversation. As you
    all know, there are catastrophic stories of the firewall
    between information, which has turned out deadly, and this
    whole committee has been trying to do things that we can do to
    address that. So, I applaud that, and hopefully, the
    legislation that we are moving forward, hopefully, with the
    Senate concurrence and a presidential signature, will start
    making that a little more available.
        The concern is always going to be data privacy, personal
    privacy, and the like. So, you are the folks in the field and
    you are the ones who have to really help us see and help direct
    us on protection versus sharing of information throughout the
    practice. Especially if we are doing a patient center, as you
    guys were mentioning, holistic, with different people around,
    that information has to be shared throughout the practice. So,
    excellent point.
        I wanted to ask, I wanted to kind of go off, not totally
    off-script, and I am not trying to get this partisan or
    political, but in this current world today how much is, what
    are you paying--how do you want to answer this question. I have
    always been worried about uncompensated care. Even with a
    government-run healthcare policy, high deductibles, can you
    talk to me about--and that is all the time I am going to have.
    So, whoever wants to talk to me about, even in a system where
    we are doing Medicare and Medicaid, that doesn't pay costs,
    even if we are moving to high performance. So, if we are not
    paying the cost of care, and then, you have folks, and then,
    you are eating uncompensated care, that is where I think our
    system just breaks down. Anyone want to talk about
    uncompensated care or charity writeoffs, or however you want to
    define it?
        Dr. Barbe. So, what the AMA would like to see is no
    uncompensated care not from our side, but because that means
    patients have coverage that will help them get access to care.
    That is the bottom line here. So, it is not a matter of how we
    handle uncompensated care. It is how do we get more people
    covered, so that they can have access?
        Mr. Shimkus. Quickly, anybody else want to jump in?
    Everybody else is compensated fully and there are no writeoffs?
    That is what you are saying? Or you just don't want to go into
    this debate right now?
        Dr. Opelka. Well, you have opened up a very complex subject
    matter.
        Mr. Shimkus. Yes, right.
        Dr. Opelka. The bottom line is that the uncompensated care
    patients, when they come in to seek surgical care, it is
    already too late. They are way behind the power curve. And that
    is the most unfortunate thing. We all see them. We all treat
    them. We take care of them.
        Mr. Shimkus. We should take care of them in the internist
    level or early intervention and provide that care----
        Dr. Opelka. Their cancers are diagnosed late. So, they have
    a poor outcome. Let's get in front of the disease, and the
    uncompensated care patients come in a day late and a dollar
    short.
        Mr. Shimkus. My time has expired. Thank you, Mr. Chairman.
        Mr. Burgess. The Chair thanks the gentleman. The gentleman
    yields back.
        The Chair will recognize the gentlelady from California,
    Ms. Matsui, 5 minutes for questions, please.
        Ms. Matsui. Thank you, Mr. Chairman.
        And I thank the witnesses for being here today.
        We were talking about telehealth, and a group of us on the
    Energy and Commerce worked together to advance telehealth
    legislation, legislative and with the administration. As we
    have worked on legislative efforts, we have found CMS and CBO
    to be resistant to expanding access to telehealth due to cost
    concerns. Expansion has often been judged as adding a new
    service that could be overbilled, rather than taking into
    account that reducing hospital and ER visits would result in
    better care that could result from getting patients access to
    care sooner and more conveniently.
        I am encouraged that CMS has taken steps in this recently-
    proposed rule to expand access to telehealth in Medicare, as
    this is what we have been working toward. There will be no way
    to prove success in the Medicare population without covering
    services. And I am curious to hear from our witnesses about the
    types of telehealth services that they currently implement.
        Starting with you, Dr. Barbe.
        Dr. Rai. I would be happy to start.
        Currently, in our organization we provide telestroke
    coverages to rural hospitals.
        Ms. Matsui. OK.
        Dr. Rai. We also are opening up very small cities in
    Wisconsin, northern Wisconsin, so just Ladysmith at the new
    site, and we would love to provide more services to there. Some
    of our specialists live 5 to 6 hours from there----
        Ms. Matsui. Right.
        Dr. Rai [continuing]. But easily could provide followup
    services or counseling services. There is not a lot of times in
    medical specialties especially, such as endocrinology, that we
    generally necessarily need to examine the patient. We need to
    be able to have that conversation and counsel that patient, or
    other services that are not even physician-based. But,
    unfortunately, we run into the wall with CMS and other payers
    without an ability to pay for that infrastructure, which does
    not come cheap. But we have done it with telestroke. We have
    done it. We have done it very well. We hope to do more.
        Ms. Matsui. OK. That is great.
        Anyone else want to comment on that?
        Dr. Barbe. So, there are many types of services and sites
    of services----
        Ms. Matsui. Right.
        Dr. Barbe [continuing]. That are actually prohibited from
    participating in telehealth or digital medicine. We can start
    by getting rid of some of those restrictions. We can start by
    unbundling some of these payment codes, so that we can charge
    differently for consults versus remote patient monitoring.
        Ms. Matsui. Right.
        Dr. Barbe. My particular group is very robust in what we
    call virtual care, which is digital medicine, and we put
    monitoring devices in patients' homes. We will even run the
    internet to their home, because in rural southern Missouri many
    don't have that. So, there are a lot of things, but we can's do
    this because there is no direct payment. The only reason we can
    do it now is we are in some risk-sharing arrangements.
        Ms. Matsui. All right. Anyone else here?
        Dr. Opelka. Just very quickly, where there are capitated
    environments, all these barriers to payment go away, and
    telehealth actually becomes very creative and innovative. In a
    capitated environment, in my former practice we dealt with
    rural, like was mentioned, but we also dealt with prisoners,
    and putting telehealth in the prison became a very effective
    way of getting better care to the prisoner, rather than having
    to transport somebody with all kinds of guards and other
    security. Telehealth was a savior.
        Ms. Matsui. OK. Let me just go on. One of my legislative
    efforts with Representative Bill Johnson on Energy and Commerce
    is H.R. 3482, which would remove originating site and
    geographic restrictions on telehealth in Medicare. And the
    steps CMS has taken to pay for virtual check-ins is very much
    in line with this idea. We passed a limited version of that
    bill for opioid service in the House opioids packages, and I
    hope the Senate will move to take this important legislation.
    And I really do look forward to having it expand further, and I
    think it would be helpful for all of you.
        I have been working to advance interoperability between
    electronic health records, and the proposed rule has
    implemented a performance measurement in order to promote
    interoperability. I guess, Dr. Opelka, you have talked about
    this. What success have providers had in working toward a goal
    of interoperability? Do you feel that the implementation of
    MACRA has been helpful?
        Dr. Opelka. I don't know that MACRA itself has actually
    drawn attention to this. When we moved away from dealing with
    the EHRs and we created a patient cloud, and we began moving
    data into the cloud environment, in which we could represent
    information either to a patient or to a clinician from wherever
    that patient was seen, those models are now emerging separate
    from the EHR vendors. It is making a huge difference in care in
    those environments. That is the direction we need to go in, and
    that is where we need to actually educate the government to
    help us push incentives that drive us more to a patient cloud
    environment, rather than to say, this hospital, this EHR, it is
    this patient and all the hospitals they get care in.
        Ms. Matsui. Right. OK.
        I think I have run out of time. I yield back. Thank you.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from Ohio, Mr. Latta, 5
    minutes for questions, please.
        Mr. Latta. Thank you. Thank you, Mr. Chairman. I want to
    thank you for the hearing today.
        And I want to thank all of you for being with us today.
    Because I am sitting here looking at you thinking to myself of
    all the patients you would be seeing right now in the time that
    you are taking to testify before us on this important matter.
        One of the great things that we get to do, we travel around
    in our districts. We talk to our docs back home. And we also
    have the ability to see a lot of the third-year, four-year
    medical students from our states come through. They are working
    on a lot of their specialties and everything else, but, at the
    same time, they kind of bring up with you all the sundry things
    that they are going to have to be doing to practice medicine.
        And I wonder if you all would mind answering a question for
    me, just going down the line, if you wouldn't mind. How much
    time do you take out, if you took a percentage, that you are
    practicing medicine or you are doing the administrative side of
    your job?
        Dr. Barbe. I can answer that very precisely. The AMA has
    done two studies. It shows that physicians spend about two
    hours in front of their computer screen or doing other
    paperwork for every hour they have in direct clinical contact.
    We did a second study that shows, for primary care physicians,
    they spent 60 percent of their day in non-direct-patient-care
    activities.
        Dr. Opelka. And it is roughly about 20 percent of their
    time doing administrative burden.
        Dr. Rai. It is ballpark around that same number. We at our
    own organization started to look at EMR utilization after 5:00
    or 6:00 p.m., when they log in from home after dinner, and how
    long they are on it. A significant amount of our primary care
    physicians are logging in late at night to complete their day,
    which is definitely leading to a nationwide situation with
    burnout.
        Dr. Parekh. I will echo the comments. I mentioned earlier
    my wife is an internist, and the kids go to bed around 9:00
    p.m. and we get on our computers.
        Dr. Ransohoff. We have done the same kind of study. We see
    that internists, it varies somewhat by specialty, but in
    primary care it is not uncommon for doctors to spend 20 hours a
    week after hours doing documentation on the computer.
        Mr. Latta. And I know they are calling votes on us right
    here. I am going to ask just one question then. The clinical
    data registries and the certified EHRs that are envisioned by
    MACRA as serving as critical reporting mechanisms for providers
    to interact with the Medicare, would these represent a decrease
    in that administrative burden then? And just go down the line.
        Dr. Barbe. They haven't yet. The EHRs still just don't work
    for physicians. There is too much point, click, move from one
    field to the next. Even in the certified technologies, which we
    have, we are still burdened significantly by that.
        Dr. Opelka. So, the clinical data registries, we run about
    seven international registries. They actually pull data in and
    generate knowledge, and that knowledge is delivered at the
    moment of care that allows for clinical decision support, that
    allows for better care, higher quality, et cetera. So, while
    they may take on time, they actually reduce burden and improve
    patient outcome. So, they are very welcome.
        Dr. Rai. I would echo that. The registries are welcome.
    They help us identify gaps in care that patients may need on an
    active basis, on a more timely basis, and the ability to access
    a patient to make sure that we get in front of them before they
    get in front of us in an acute situation.
        Dr. Parekh. As I mentioned in my testimony, the Academy of
    Ophthalmology created the IRIS, I-R-I-S, registry, and it has
    been a huge help. I will give you an example. Let's say, 2 days
    ago, I was doing surgery. My EMR records the date of the
    surgery on the right eye, for example. And then, when we see
    the patient back, of course, we record how the vision is doing.
    And one of our measures is, is the patient 24/40 or better
    within 90 days? So, it is an outcome measure, like I said, very
    important to our specialty, very important to our patients. And
    so, as soon as that vision reaches that threshold, the EMR
    automatically captures that data. The point is, we are getting
    outcomes data and it is very little additional work because the
    registry is able to grab that info without me typing it in
    again for the registry. So, it has been great.
        Dr. Ransohoff. There is nothing faster than ineligible
    handwriting that is not shared with anyone.
         [Laughter.]
        And I practiced in those days. The computer systems that
    are out there now are more time-consuming. I do think they are
    much better.
        I prescribed recently--the patient was on two unusual
    medications, and they computer said there is going to be a drug
    interaction. And so, there are real benefits to it, but it is
    definitely more time-consuming.
        Mr. Latta. OK. Well, Mr. Chairman, my time has expired, and
    I yield back.
        And I thank our witnesses again for spending time with us
    today. Thank you.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair does acknowledge there is nothing faster than bad
    handwriting, particularly if you are lefthanded.
        The Chair now recognizes the gentlelady from California,
    Ms. Eshoo, 5 minutes for questions, please.
        Ms. Eshoo. Thank you, Mr. Chairman.
        And thank you to the witnesses. You represent so many that
    practice medicine across our country in the different
    disciplines, and have headed up, and do head up, organizations
    that are representing them.
        I would like to go to Dr. Rai and Dr. Ransohoff with this
    question. Earlier this month, CMS released a proposed rule that
    estimated that 42 percent of physicians participating in
    Medicare will need to comply with MACRA. So, my question to
    both of you is, with so many physicians that are exempt from
    both APMs and MIPS, has CMS undermined the original intent of
    MACRA? Would that be your take? And with so many physicians
    exempt, will MACRA meet the original payment reform goals it
    set out to achieve?
        Dr. Rai. I do believe CMS has gone against the intent of
    MACRA with the exemptions. For this to work, for us to truly
    move to value, the intent of MIPS, as one of my colleagues has
    been quoted to say, MIPS was the on-ramp to value and CMS has
    created an exit ramp.
        Ms. Eshoo. Why do you think they are doing this?
        Dr. Rai. Change is never easy. The change of going from
    fee-for-service to value, to taking risks----
        Ms. Eshoo. Oh, we have been doing that for a long time.
    This isn't exactly something that happened in the last 90 days.
    We have been in transition since I first came into the Congress
    on this thing, and I have been here for a while.
        Dr. Rai. I don't disagree with you at all. The legacy
    programs did not have the exemptions. And now, all of a sudden,
    we are exempting people, and it is truly preventing--it is
    another kick-the-can-down-the-road. It is becoming SGR 2.0 if
    they continue that behavior.
        Ms. Eshoo. Well, how do you think CMS can improve the MIPS
    implementation?
        Dr. Rai. Implement it as it was written. Really implement
    what you passed.
        Ms. Eshoo. Great. Good answer. Good. All right. Well, that
    is confidence in the work that we have done, Mr. Chairman.
        To Dr. Opelka and Dr. Parekh--is it ``Parak'' or
    ``Paresh''?
        Dr. Parekh. Parekh.
        Ms. Eshoo. Parekh.
        I have heard from physicians in my congressional district--
    it is the Silicon Valley district in California--that those in
    small practice and who practice specialty care face barriers in
    participating in MIPS. Do you face barriers, as some of my
    physicians have reported? And if so, what are they?
        Dr. Parekh. Thank you for the question.
        As an ophthalmologist, again, I feel very lucky. We have
    amazing professional societies. We have been working for a long
    time, as you said, coming up with measures. We have been
    preparing for this moment for a while, coming up with outcomes
    measures, coming up with process measures, creating cost
    measures, having a registry. So, I am very fortunate--knock on
    wood, I thank our professional societies--it hasn't been that
    hard for us in ophthalmology.
        Ms. Eshoo. Well, that is good. Do you know Dr. Chang?
        Dr. Parekh. Dr. David Chang.
        Ms. Eshoo. Dr. David Chang, yes.
        Dr. Parekh. Yes, he is one of my very good friends. In
    fact, he knew that I was coming today and sent me a very kind
    email.
        In ophthalmology, I think our numbers to some extent back
    up what I am saying. I think people who participated in our
    registry, I think 85 percent got a score of 100, getting the 2
    percent that was mentioned earlier, and I think 99 percent got
    some type of bonus. So, again, we have been working very hard
    at this, and I think it is blossoming.
        Ms. Eshoo. Would you recommend anything to us that would
    lessen the burden on physicians, so that you can more actively
    participate in MIPS or do you think it is just working
    swimmingly?
        Dr. Parekh. I think there is always room for improvement.
        Ms. Eshoo. Always, yes.
        Dr. Parekh. Like I said, it is a continuous quality
    improvement mindset that we have to have.
        Ms. Eshoo. But do you have something, anything specific?
    Anyone have anything specific?
        Dr. Opelka. Sure. So, this whole matter of participating or
    exclusions, if you don't measure what matters, putting money
    and investments into something that is senseless, nobody wants
    to participate.
        Ms. Eshoo. And that is what we are doing?
        Dr. Opelka. So, all the surgical specialties, all of them,
    including ophthalmology, the majority of their measures have
    nothing to do with surgical care.
        Ms. Eshoo. Wow.
        Dr. Opelka. They are measuring primary care. So, it doesn't
    surprise me that primary care says everyone should be in, but
    it also doesn't surprise me when surgery care says, ``It
    doesn't matter to the patients I am treating. So, why am I
    spending money in my practice to send CMS tobacco cessation and
    immunization rates?'' Nobody comes to me as a surgeon with
    breast cancer to talk about those things. We are not measuring
    what matters. And so, as long as we are going to measure silly
    things, everyone is going to say, ``I want to be excluded.'' If
    you want to measure what matters, put me in. Put me in, coach.
    I want to play. But that is not what we are getting.
        Ms. Eshoo. Well, I think that that is highly instructive to
    us, Mr. Chairman.
        Mr. Burgess. That is the reason we are having the hearing.
        Ms. Eshoo. Yes. Well, that is what happens in hearings.
        Mr. Burgess. And I appreciate your----
        Ms. Eshoo. But what I am suggesting is that we work with
    CMS to get rid of what was just described as the--did you use
    the word ``silliness''?
        Dr. Opelka. Yes.
        Ms. Eshoo. OK. Thank you to all of you. You are the healers
    of the Nation. So, thank you for what you have devoted
    yourselves to, and taking on the extra responsibility of
    heading up organizations.
        Mr. Burgess. If the gentlelady will conclude her
    soliloquy----
        Ms. Eshoo. Thank you.
        Mr. Burgess [continuing]. We have about a minute left on a
    vote on the floor.
        Ms. Eshoo. I yield back.
        Mr. Burgess. I am going to recess after I acknowledge the
    presence of Dr. Boustany, former Member of Congress and member
    of the Ways and Means Committee. We appreciate your attendance
    here today.
        And we will stand in recess until after this vote.
        [Recess.]
        Mr. Guthrie [presiding]. The committee will come back to
    order. Thank you.
        There will be other members that are voting and will be
    back shortly to ask questions, but we are going to continue the
    question period.
        All right. The Chair recognizes Dr. Bucshon for 5 minutes
    to ask questions.
        Mr. Bucshon. Thank you, Mr. Chairman. I appreciate that.
        And thank you to all the witnesses for being here. I was a
    cardiothoracic surgeon before coming to Congress, and this is
    critically important for our patients at the end of the day,
    right? And that is what I try to focus on.
        As you know, the participation in MIPS is low. Everyone
    outlined roughly 60 percent of physicians are excluded from the
    program, leaving only $118 million of the $70 billion baseline
    for incentive payments for practices. Participation in the
    alternative payment models in MACRA is even smaller, with only
    5 percent of physicians enrolled in an APM. CMMI has not
    approved a single APM submitted from PTAC, and PTAC cancelled
    its June meeting due to lack of APMs to review.
        I am interested in ways to increase participation in and
    the number of APMs, which is why I introduced the Medicare Care
    Coordination Improvement Act, H.R. 4206, which three of you on
    the panel's organizations have signed a letter in support of--
    and I will get to that in a minute--which would encourage
    development, testing of participation in APMs by exempting
    practices from the volume and value prohibitions in the Stark
    law. After all, how can practices deliver on value-based care
    if they cannot remunerate their physicians based on value?
        Mr. Chairman, I ask unanimous consent to submit the letter
    to the record.
        Mr. Guthrie. Without objection, so ordered.
        Mr. Bucshon. The American College of Surgeons, the American
    Medical Association, and AMGA, among many others, have signed
    onto the letter.
        Basically, it says they are in strong support of the act
    that we introduced and ``The legislation would substantially
    improve care, coordination for patients, improve health
    outcomes, and restrain costs by allowing physicians to
    participate and succeed in alternative payment models.'' The
    bill would modernize the Stark self-referral law enacted nearly
    30 years ago.
        The things that it would do is provide HHS with the same
    authority to waive the prohibitions of the Stark law and
    associated fraud and abuse laws for physicians seeking to
    develop and operate APMs, as was provided for ACOs in the
    Affordable Care Act; remove the volume or value prohibition in
    the Stark law, so that physician practices can incentivize
    physicians to abide by best practices and succeed in the new
    value-based alternative payment models. This protection would
    apply to physician practices that are developing or operating
    an alternative payment model, including the advanced APMs, APMs
    approved by the physician-focused payment model, the Technical
    Advisory Committee, MIPS APMs and other APMs specified by the
    Secretary; and finally, ensure that CMS's use of current
    administrative authority promotes care coordination, quality
    improvement, and resource conservation.
        I guess I will ask the question of everyone. How do you
    think changes to the Stark law would help physicians coordinate
    and improve care and help MACRA succeed? And how important do
    you think that would be in the overall success of what we are
    trying to do with the MACRA legislation and, also, as you have
    noted, transition to an outcome-based, patient-centered-based
    way to reimburse providers?
        I will just start that. If any of you aren't aware of what
    we have done, that is OK. But we can start with the surgeons.
        Dr. Opelka. Thank you very much.
        First of all, yes, we are in strong support of this effort.
    Specifically, the way that Stark is written, you can be held
    accountable without intent, and that is a problem. So, when we
    have alternative payment models with shared savings
    opportunities between all the parties, legal counsel, when they
    review these contracts, become extremely worried about how
    clean are these waivers or exemptions from Stark. They have got
    to be bulletproof because Stark is so broad and overreaching,
    it is easy for a court to interpret things different than your
    own counsel interpreted them.
        For that reason, when we go to these alternative payment
    models where there are parties that will be involved in shared
    savings, or whatever different payment models are applied, we
    need to be sure that there is clean, crisp lines that exempt or
    waivers that are provided for Stark, so the parties can come
    together. That is really what we see. When we put our own APM
    forward to PTAC, we included the need for Stark waivers and the
    exemptions. But we agree with you and fully support what you
    are doing.
        Dr. Ransohoff. In order to have an ACO, particularly an ACO
    like this that requires risk-taking and risk-sharing, you need
    to get a group of physicians together who are willing to work
    together and share the risk and, also, generally, a hospital.
    So, you need all of those parties to do that. Then, these laws
    become a serious impediment to doing that. Just the legal
    expenses of trying to make sure it is even OK to have a meeting
    become daunting. So, I think if you are going to encourage
    doctors and hospitals to try to take risks together in a fee-
    for-service world, you do need to look at the regulatory
    barriers that exist.
        Mr. Bucshon. All right. Thank you.
        Beg your indulgence, Mr. Chairman.
        Anyone else have any comments quickly? Anyone else? Yes?
        Dr. Rai. Stark made sense in a fee-for-service environment,
    but if we are truly going to move to value, we need regulatory
    relief, as explained by my colleagues.
        Mr. Bucshon. OK. Thank you. I appreciate that.
        Thanks, Mr. Chairman. I yield back.
        Mr. Guthrie. Thank you. The gentleman yields back.
        The Chair now recognizes Mr. Griffith of Virginia, 5
    minutes for questions.
        Mr. Griffith. Thank you very much, Mr. Chairman. I
    appreciate it.
        I appreciate you all being here. With two votes series
    disrupting the committee, it is tough as witnesses, and I do
    appreciate your patience.
        Let me echo what my colleague just said about the Stark
    Act. I think it is outdated probably in more ways than most
    people do. And I find it inhibits some collaboration in rural
    areas where we are underserved already. And why would we put
    barriers up?
        Does anybody disagree with that statement? I am looking at
    the entire panel. Just for the record, none of them disagrees
    with that statement.
        All right. Let's see. Given that, now I have got a question
    that we want to get on the record. On June 29th, CMS allowed
    MIPS participants to see their performance score based on 2017
    reporting. Would each of you please share what your scores
    were?
        Dr. Rai. I would be happy to start since I brought mine
    with me.
        Mr. Griffith. All right. That would be fine.
        Dr. Rai. We bill under four Tax ID Numbers because of how
    we are regionally divided. Three, we scored 100, and on the
    fourth one we had a 97.
        Mr. Griffith. OK. Anybody else weigh in who knows? Yes,
    sir?
        Dr. Parekh. I like your question because it also relates to
    the previous issue of physician participation. I was in a big
    group practice and I decided to start my own practice. And so,
    it was the end of 2015 and into 2016 that I was doing that. The
    2017 measurement, what you are asking about, is based on your
    surgical volume or your volume at the end of 2016, but that is
    when I was starting my practice.
        I knew, of course, about our Academy's IRIS registry. I
    knew myself. I knew that I could do a good job on those
    measures, but there was no opportunity for me to participate. I
    couldn't opt in. I couldn't believe that I couldn't opt in. So,
    I asked multiple people. I am like, ``Are you sure I can't opt-
    in? I would love to do this. This is great. That is a good
    measure.'' Multiple people assured me I could not.
        Mr. Griffith. OK.
        Dr. Parekh. So, unfortunately, I was not eligible, even
    though I wanted to be.
        Mr. Griffith. All right.
        Dr. Ransohoff. As I have said before, we bill under a
    single Tax ID Number, and we did get 100.
        Mr. Griffith. OK. And last, but not least.
        Dr. Opelka. I am retired from practice.
        Mr. Griffith. Yes? So, no data? All right. I appreciate
    that. Thank you so much.
        My concern, of course, is rural areas, as I mentioned
    before, when I was talking about the Stark Act. So, when we are
    looking at rural areas, can you describe or can any of you
    illuminate us on the challenges of physicians practicing in the
    rural areas and the pressures they face to remain in practice?
    And how do the legacy programs add to those burdens? I know a
    lot of the burdens they have already. But how do the legacy
    programs add to those burdens, and has MIPS eased those
    burdens? And even if it has eased them a little bit, what else
    can we be doing to help our rural friends?
        Dr. Barbe?
        Dr. Barbe. Maybe I will weigh in on that first. So, I was
    amazed when MACRA passed and we were looking at MIPS, and we
    had a lot of physicians come out of the woodwork and say, ``Oh,
    my gosh, how are we going to comply with MIPS?'' And I thought
    in my mind, well, have they not been doing the legacy programs
    already? And the answer is, no, they hadn't. Hundreds of
    thousands of physicians didn't participate in all three or
    didn't participate successfully. So, there are a lot of
    physicians that are now working to make this transition.
        Specifically, with regard to rural, Dr. Opelka said it very
    well. We need meaningful measures that relate to that
    individual physician's practice. We need to make them easy to
    capture, and we need to make them, if you will, activities that
    are applicable across more than one of those dimensions of
    MIPS. If you have got a diabetic patient and you are changing
    your processes and you are improving care, and you are using an
    electric record, why don't you get credit across all three
    domains?
        Mr. Griffith. All right. Yes, sir?
        Dr. Opelka. Very quickly, the trauma program is a classic
    example where we have Level I, II, and III levels of service.
    Typically, in the rural environment we are dealing with a Level
    III. The number of standards they need to meet are
    significantly less than the 200-plus standards for a Level I.
    So, you need to tailor measurement down to the point of care
    and the care model that that environment has. The MIPS program
    does not do that. It is a one-size-fits-all program. So, the
    rural element is no different than, in surgery, it is no
    different than in the city. They are not meaningful and fit for
    purpose. And therefore, the surgeons pay attention to it for
    purposes of payment, but not for the purposes of quality of
    care.
        Mr. Griffith. OK. Anybody else? Yes?
        Dr. Rai. We operate many rural clinics, but because they
    are part of a larger multi-specialty group, we are able to
    spread our infrastructure more efficiently to them.
        And to your other question about was it easier under MACRA
    to submit versus the legacy programs, I have talked to our
    quality department. It was slightly easier this year to submit
    to CMS. The mechanism of submitting all three at once was
    easier than the previous legacy format.
        Mr. Griffith. So, it was a little bit better?
        Dr. Rai. A little bit better, yes, sir.
        Dr. Parekh. I would echo all these comments. Understand
    that rural medicine is very different than urban/suburban. And
    I know in Washington oftentimes people talk about a bubble in
    Washington, but coming from central Pennsylvania, it is a very
    different environment here. Let me tell you, there are
    hospitals where I can't get internet service. Just think about
    that statement. And my EMR, of course, is a cloud-based EMR.
    This is a true issue. But, again, I think MACRA has certainly
    helped, to answer the second part of your question.
        Mr. Griffith. Other parts of our committee are trying to
    work on those internet issues.
        Dr. Ransohoff?
        Dr. Ransohoff. Technically, right now for someone who had
    just done nothing, MIPS is actually better, just by the algebra
    of it initially, because the cut would have been less.
        But I agree with my colleagues, and I have said previously
    I think for small practices in rural areas they just need a
    different--they need relevant standards that resonate with
    their practice, but they probably need to have a different
    test, so that they can participate. Fewer measures I think
    would be a very reasonable approach.
        Mr. Griffith. All right. Thank you very much. I appreciate
    it.
        And my time is up and I yield back.
        Mr. Guthrie. Thank you. The gentleman yields back.
        The Chair now recognizes Mr. Carter from Georgia for 5
    minutes for questions.
        Mr. Carter. Thank you, Mr. Chairman.
        And thank all of you for being here.
        Before I begin my questions, I have to say this. Earlier in
    the hearing there was a conversation about doctors'
    handwriting. And I just want to say, I want to represent my
    profession as a practicing pharmacist for over 30 years. So,
    you get it? You understand what I am saying.
        [Laughter.]
        Anyway, I couldn't resist that and I apologize. Too many
    times have I struggled to understand what a doctor was writing.
        I wanted to talk to Dr. Rai. OK, I am sorry. I know I
    butchered that.
        But, nevertheless, as a pharmacist, I am a member of the
    Doctors Caucus. We had sent a letter to CMS earlier this month
    about MACRA and MIPS implementation and the $500 million that
    had been authorized to ensure positive payment adjustments. But
    one of the things that we have run into is that we just don't
    have enough physicians who are participating. And I just wanted
    to ask you. CMS estimates that it is over 60 percent that
    aren't participating. What are the obstacles? What are some of
    the obstacles that are preventing or prohibiting providers from
    switching to this?
         Dr. Rai. I think some of the obstacles are inherent to how
    they have been practicing medicine and how their own structures
    have been developed over time. Some may say they have not
    followed the legacy programs, as was mentioned earlier. So,
    they have not actually implemented the EMR or using it in a
    meaningful way. They have not developed patient-centered
    medical homes or have the ability to tap into registries. There
    are a variety of reasons why people are not participating.
        But for us to truly move to value, we need everybody to
    participate. MACRA was written to be a carrot-and-a-stick
    program. So, for it to work, everybody has to be in.
        Mr. Carter. I suspect that I would be correct to say that
    it is worse in rural areas than it is in urban areas. Is that
    correct?
        Dr. Rai. I haven't seen CMS's distribution of who is not
    participating, but I think it is across the board. I think you
    will see it in small single specialty in a very urban area.
    But, yes, you will probably see it a lot in urban areas that
    don't have a system infrastructure supporting them.
        Mr. Carter. OK. Can you describe very briefly about some of
    the investments that your organization has made in order to
    participate in this?
        Dr. Rai. I can break the investments into three categories,
    the first being people. The most important category in
    healthcare is continuously investing in people. Team-based care
    is not inexpensive--nurse care managers, extra medical
    assistance, making sure the physician or the provider is
    surrounded by the best people to take care of their population,
    not just the patient that is in front of them that day.
        The next area is, like I mentioned, an EMR is only as good
    as you can draw the data out of. So, our largest area of
    investment in the EMR is not really the EMR anymore. It is
    digital platforms to draw the data out, to analyze it, to
    hopefully someday get access to claims data, which we need, to
    be able to look at a risk population and predict what is going
    to happen to a patient before it happens to them.
        And the third area of investment is that digital platform
    that is patient-facing. Our patients want access to their
    record. It is not our medical record; it is their medical
    record. It is creating environments for them to interact with
    us in virtual care, like we launched this year, where they
    don't have to come into the office.
        Those have been the three categories of investments that we
    personally made to make sure we are successful not only with
    MACRA, but with value down the line.
        Mr. Carter. Right. Thank you.
        Dr. Parekh, I wanted to ask you, in your testimony you had
    mentioned that MedPAC had made the recommendation that MIPS
    should be replaced with a voluntary value program that might be
    phased in over time. And I just wanted to ask you--and in full
    disclosure, I agree with you; I don't agree with MedPAC. I
    think that would be the wrong route for us to go. I think we
    are headed in the right direction with this. We ought to figure
    out a way, I think, if not to incentivize, then to require
    physicians to do this. And I don't like that. I don't like the
    heavy-handed government, particularly in healthcare. But, at
    the same time, I am convinced we are moving in the right
    direction.
        I just wanted to ask you, what are some of the challenges
    to developing outcome measures in the practice of medicine?
        Dr. Parekh. It is just hard. It is hard to do. You have to
    have a clean measurement. You don't want all these other
    comorbidities that are ``messing up your outcomes''. So, let's
    take cataract surgery, for example. If I have a patient who has
    got severe blinding macular degeneration at baseline, and then,
    they have developed a cataract on top of that, as bad as it
    originally was, now it is worse. So, I take their cataract out
    and I get them maybe to 2400, which is the big ``E'', legal
    blindness still. They are ecstatic, but my measure might look
    bad because, ``Oh, Dr. Parekh, this patient, you operated on
    them and they are legally blind.'' So, things like that, those
    subtleties, the devil is in the details.
        Mr. Carter. Right.
        Dr. Parekh. Those subtleties make all the difference. So,
    coming up with those kind of clean outcomes is very hard to do.
        Mr. Carter. Right.
        Dr. Parekh. And so, there are certain surgeries that lend
    themselves to that, but others that don't.
        Mr. Carter. I am out of time. But I want to thank all of
    you for your efforts in moving this forward, because I do
    believe it is we are headed in the right direction with this.
        And I yield back.
        Mr. Guthrie. Thank you. The gentleman yields back.
        Seeing there are no further members wishing to ask
    questions, I would like to thank you all for being here today.
    As somebody mentioned earlier, you are missing a lot of
    patients today to be here to inform us, but it is important
    that you do.
        And I would like to submit the following documents for the
    record: American Academy of Dermatology Association, letters
    from the American Academy of Family Physicians, the American
    College of Physicians, Connected Health, American Society of
    Clinical Oncology, Infectious Disease Society of America, and
    Medical Group Management Association.
        Mr. Green. No objection, Mr. Chairman.
        Mr. Guthrie. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Guthrie. Pursuant to committee rules, I remind members
    that they have 10 business days to submit additional questions
    for the record, and I ask that witnesses submit their response
    within 10 business days of receipt of the questions.
        Mr. Green. Without objection. Mr. Chairman, I would just
    like to recognize a family from my district, the Garcia family.
    We spend a whole lot of time in these committee meetings. But I
    thank them for coming here.
        Mr. Guthrie. Welcome. Welcome to Washington. Thanks for
    being here.
        So, without objection, the subcommittee is adjourned.
        [Whereupon, at 12:13 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        We're meeting today to discuss one of the great bipartisan
    success stories of this Committee, the Medicare Access and CHIP
    Reauthorization Act of 2015, or MACRA. MACRA built upon the
    successes of the Affordable Care Act to improve the quality and
    efficiency of the Medicare program, and of our health care
    system more broadly.
        The ACA took major steps towards improving the quality of
    our health care system by creating new models of health care
    delivery within the Medicare program. These new payment and
    delivery models focused on transforming clinical care and
    shifting from a volume- to a valuebased care model, such as
    Accountable Care Organizations (ACOs) and Patient Centered
    Medical Homes (PCMHs).
        With MACRA, we are entering the next phase of delivery
    system reform. MACRA builds on reform efforts by offering
    opportunities and financial incentives for physicians to
    transition to new payment models known as Advanced Alternative
    Payment Models, or AAPMs. AAPMs must meet a number of criteria,
    and requires clinicians to accept some financial risk for the
    quality and cost outcomes of their patients. Physicians can
    join existing and successful models that qualify as AAPMs, such
    as ACOs and the Comprehensive Primary Care Plus (CPC+) model,
    which we will hear about today. They can also develop their own
    models, known as Physician-Focused Payment Models.
        MACRA also created the Merit-Based Incentive Payment
    System, or MIPS. This is an alternative path for clinicians to
    make the shift away from a volume-based system to a valuebased
    system. It focuses on quality, value, and accountability.
        Our witnesses practice in a variety of settings across the
    country and represent diverse expertise and training. They each
    have a unique perspective to share with us regarding the
    implementation of MACRA. I know that some of our witnesses have
    concerns about how MIPS has been implemented by CMS, in
    particular the decision by the agency to exclude 58 percent of
    providers from MIPS requirements through the low-volume
    adjustment. I share these concerns and want to learn more about
    how CMS's decisions may impact successful MACRA implementation
    going forward.
        I want to thank you all for your commitment to delivery
    system reform-it is only through the sustained commitment of
    the leading physician organizations and clinicians such as
    yourselves that we can hope to bend the cost curve and create a
    system that truly rewards high value care. I hope that after
    hearing from our panelists today, we will all have a better
    understanding of the opportunities and challenges faced by
    physicians in the MIPS program.
        Thank you, I yield back the remainder of my time.
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