[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                     
          
--------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].                               
                    
                    
                    
                    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.
                              ----------                              

[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                                 [all]