[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
OPPORTUNITIES TO IMPROVE HEALTH CARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 5, 2018
__________
Serial No. 115-161
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
----------
Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Prepared statement........................................... 5
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 7
Prepared statement........................................... 8
Witnesses
Hugh M. Chancy, RPH, Owner, Chancy Drugs, Hahira, Georgia, and
Member, Board of Directors, National Community Pharmacists
Association.................................................... 10
Prepared statement........................................... 13
Answers to submitted questions............................... 208
Curtis Cunningham, Vice President, National Association of States
United for Aging and Disabilities (NASUAD), and Assistant
Administrator, Long-Term Care Benefits And Programs, Division
of Medicaid Services, Department of Health Services, State of
Wisconsin...................................................... 18
Prepared statement........................................... 21
Matt Salo, Executive Director, National Association of Medicaid
Directors...................................................... 27
Prepared statement........................................... 29
Rick Merrill, President and CEO, Cook Children's Health Care
System, Fort Worth, Texas...................................... 37
Prepared statement........................................... 40
Derek Schmidt, J.D., Attorney General, State of Kansas........... 49
Prepared statement........................................... 51
Answers to submitted questions............................... 211
David Yoder, Pharm.D., M.B.A., Executive Director of Member Care
and Benefits, Blue Cross Blue Shield Association's Federal
Employee Plan.................................................. 73
Prepared statement........................................... 75
Submitted Material
Documents submitted by Mr. Barton
Statement of the Association of American Medical Colleges.... 75
Statement of various heart associations...................... 122
Statement of the American Academy of Pediatrics.............. 124
Statement of the American Board of Pediatrics................ 125
Statement of the American College of Cardiology.............. 126
Statement of the Association of Medical School Pediatric
Department Chairs.......................................... 127
Statement of the Autism Society of America................... 129
Statement of Autism Speaks................................... 130
Statement of the California Children's Hospital Association.. 132
Statement of ChildServe...................................... 133
Statement of the Foundation to Eradicate Duchenne............ 135
Statement of the International Pediatric Rehabilitation
Collaborative.............................................. 137
Statement of the March of Dimes.............................. 139
Statement of the National Association for Children's
Behavioral Health.......................................... 140
Statement of the National Association of Pediatric Nurse
Practitioners.............................................. 141
Statement of the National Down Syndrome Society.............. 143
Statement of the Tricare for Kids Coalition.................. 145
Statement of Vizient, Inc.................................... 147
Documents submitted by Mr. Green
Statement of the Medicare Payment Advisory Commission........ 148
Statement of the Medicaid and CHIP Payment and Access
Commission................................................. 151
Statement of St. Joseph's Children's Hospital, submitted by Ms.
Castor......................................................... 153
Documents submitted by Mr. Walberg
Statement of the National Association of Attorneys Generals.. 163
Statement of Families USA.................................... 168
Statement of the Partnership for Medicaid Home Based Care.... 169
Documents submitted by Mrs. Dingell
Statement of the Area Agencies of Aging Association of
Michigan................................................... 171
Statement of the National Association of Medicaid Directors,
the National Association of State Directors of
Developmental Disability Services, the National Association
of States United for Aging and Disabilities................ 172
Statement of dozens of health and aging organizations........ 175
Documents submitted by Mr. Burgess
Statement of PillPack, Inc................................... 197
Statement of LeadingAge...................................... 198
Statement of Medicaid Health Plans of America................ 200
Statement of the American Association of Medical Colleges.... 206
OPPORTUNITIES TO IMPROVE HEALTH CARE
----------
WEDNESDAY, SEPTEMBER 5, 2018
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:04 a.m., in
room 2123, Rayburn House Office Building, Hon. Michael Burgess,
M.D. (chairman of the subcommittee) presiding.
Present: Representatives Burgess, Guthrie, Barton, Shimkus,
Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks,
Mullin, Hudson, Carter, Walden (ex officio), Green, Engel,
Schakowsky, Matsui, Castor, Sarbanes, Schrader, Kennedy,
Cardenas, and Degette.
Also Present: Representatives Walberg, Welch, and Dingell.
Staff Present: Mike Bloomquist, Staff Director; Samantha
Bopp, Staff Assistant; Adam Buckalew, Professional Staff
Member, Health; Daniel Butler, Legislative Clerk, Health; Karen
Christian, General Counsel; Jordan Davis, Senior Advisor;
Melissa Froelich, Chief Counsel, DCCP; Adam Fromm, Director of
Outreach and Coalitions; Ali Fulling, Legislative Clerk, O&I,
DCCP; Theresa Gambo, Human Resources/Office Administrator;
Caleb Graff, Professional Staff Member, Health; Jay Gulshen,
Legislative Associate, Health; Ed Kim, Policy Coordinator,
Health; Ryan Long, Deputy Staff Director; James Paluskiewicz,
Professional Staff, Health; Kristen Shatynski, Professional
Staff Member, Health; Jennifer Sherman, Press Secretary; Austin
Stonebraker, Press Assistant; Josh Trent, Chief Health Counsel,
Health; Jacquelyn Bolen, Minority Professional Staff; Tiffany
Guarascio, Minority Deputy Staff Director and Chief Health
Advisor; Una Lee, Minority Senior Health Counsel; Rachel Pryor,
Minority Senior Health Policy Advisor; and Samantha Satchell,
Minority Senior Policy Analyst.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. I call the Subcommittee on Health to order. I
am going to ask our guests to please take their seats. And,
again, welcome to everyone for the first September hearing of
the Health Subcommittee of the Energy and Commerce Committee,
the most productive subcommittee in the United States House of
Representatives.
So today we are joined by a panel of witnesses. I will
recognize myself for 5 minutes for an opening statement. We are
joined by a panel of witnesses who are going to provide us
testimony on a variety of topics and legislative ideas, ranging
from initiatives to address drug pricing to reducing fraud at
the Centers for Medicare and Medicaid Services to improving the
care of children with complex medical conditions.
These bills cover different topics within healthcare, but
there is a common thread that connects all. All of the bills in
discussion drafts before us today have the aim to improve the
access and the quality of care for America's patients and their
families.
So, first, I would like to commend Representative Buddy
Carter of Georgia for his hard work on legislation to prohibit
gag clauses in Medicare and private health insurance plans. Gag
clauses prohibit pharmacists from informing patients that
paying in cash will result in lower out-of-pocket costs than
the insurer's cost-sharing arrangement unless the patient
directly requests such information. The draft bill being
discussed today is essential in both lowering drug costs for
individuals and freeing the pharmacists to do what many
consider would be the right thing, in fact, freeing the
pharmacist to simply do their job. It would ban an employer and
individual health insurance plans, in addition to Medicare
Advantage and Medicare part D plans, from using gag clauses.
This bipartisan policy has been a shared priority for Mr.
Carter and others on the committee for quite some time, and it
was brought further to the forefront by the administration's
drug pricing blueprint that many of us attended a Rose Garden
ceremony in May. While the gag clauses are already prohibited
in Medicare, it is important that we protect consumers by
putting this in statute and sending this bill to the
President's desk as soon as possible.
Today, we are also considering several Medicaid bills and
discussion drafts that will further prevent and investigate
fraud and abuse in addition to increasing access for certain
beneficiaries.
H.R. 3891, introduced by Representatives Walberg and Welch,
will improve the authority of the State Medicaid Fraud Units,
which currently investigate provider fraud and patient abuse
only in healthcare facilities and care facilities. According to
the Health and Human Service Office of the Inspector General,
Medicaid Fraud Control Units recovered almost $2 billion in
fiscal year 2017. This legislation builds upon the success of
these Fraud Control Units by broadening their authority to
investigate and prosecute abuse and neglect of beneficiaries in
noninstitutional or other settings. Another discussion draft
before us today will codify the Health Fraud Prevention
Partnership, which will further enable our public and private
institutions to combat fraud within the healthcare system.
Health Subcommittee Vice Chairman Guthrie and
Representative Dingell have introduced the EMPOWER Care Act,
which will extend the Money Follows the Person Demonstration
for an additional 5 years. This Medicaid demonstration, which
was established in 2005, has enabled eligible individuals in
States across our Nation, including Texas, to receive long-term
care services in their homes or other community settings rather
than in institutions such as nursing homes. Not only does this
increase the comfort and quality of life for many Medicaid
beneficiaries, but it has reduced hospital readmissions and
saved money within the Medicaid program.
The final Medicaid discussion draft, the ACE Kids Act, is
introduced by full committee Vice Chairman Barton and
Representative Castor of Florida and has received substantial
feedback from stakeholders and has been revised to reflect this
increased input. The goal of this legislation is to improve
comprehensive care for medically complex children through a
State option to create a Medicaid health home specific for
children. The bill will also increase data collection and add a
requirement for the Department of Health and Human Services to
issue guidance on best practices for providing care for this
unique and complex pediatric population.
I do want to thank the members whose legislation we are
considering today. They have put in a lot of time and effort
and certainly as has their staff. They put this into the
development and fine-tuning of the language. I look forward to
hearing from our witnesses and having a productive discussion
on these important public health initiatives.
And now I yield back my time, and I want to recognize the
ranking member of the subcommittee, Mr. Green of Texas, 5
minutes for an opening statement, please.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Good morning, everyone. Today, we are joined by a panel of
witnesses who are here to testify on a variety of topics and
legislative ideas, ranging from initiatives to address drug
pricing to reducing fraud at the Centers for Medicare and
Medicaid Services, to improving the care of children with
complex medical conditions.
While these bills cover different topics within health
care, there is one common thread that connects them. All of the
bills and discussion drafts before us today aim to improve the
access to and quality of health care for American patients and
their families.
First, I would like to commend Representative Buddy Carter
of Georgia for his hard work on legislation to prohibit gag
clauses in Medicare and private health insurance plans. Gag
clauses prohibit pharmacists from informing patients that
paying in cash will result in lower out of pocket costs than
the insurer's cost-sharing arrangement, unless the patient
directly asks. The draft bill being discussed today is
essential in both lowering drug costs for individuals and in
freeing pharmacists to do what many consider to be the right
thing. It would ban employer and individual health insurance
plans, in addition to Medicare Advantage and Medicare Part D
Plans, from using gag clauses.
This bipartisan policy has been a shared priority for Mr.
Carter and others on the committee for quite some time and was
brought further to the forefront by the Administration's drug
pricing blueprint in May. While gag clauses are already
prohibited in Medicare, it is important that we protect
consumers by putting this in statute and sending this bill to
the President's desk as soon as possible.
Today we are also considering several Medicaid bills and
discussion drafts that will further prevent and investigate
fraud and abuse, in addition to increasing access to care for
certain beneficiaries.
H.R. 3891, introduced by Representatives Walberg and Welch
will improve the authority of State Medicaid Fraud Control
Units, which currently investigate provider fraud and patient
abuse only in health care facilities and board and care
facilities. According to the Health and Human Services Office
of the Inspector General, Medicaid Fraud Control Units
recovered $1.8 billion dollars in fiscal year 2017. This
legislation builds upon the success of these fraud control
units by broadening their authority to investigate and
prosecute abuse and neglect of beneficiaries in non-
institutional or other setting. Another discussion draft before
us today will codify the Healthcare Fraud Prevention
Partnership, which will further enable our public and private
institutions to combat fraud within our health care system.
Health Subcommittee Vice Chairman Guthrie and
Representative Dingell have introduced the EMPOWER Care Act,
which will extend the Money Follows the Person Demonstration
for five additional years. This Medicaid demonstration, which
was established in 2005, has enabled eligible individuals in
states across our nation, including Texas, to receive long-term
care services in their homes or other community settings,
rather than in institutions such as nursing homes. Not only
does this increase the comfort and quality of life for many
Medicaid beneficiaries, but it has reduced hospital
readmissions, and saved money within the Medicaid program.
The final Medicaid discussion draft, the ACE Kids Act,
introduced by full committee Vice Chairman Barton and
Representative Castor, has received substantial feedback from
stakeholders and has been revised to reflect their input. The
goal of this legislation is to improve comprehensive care for
medically complex children through a state option to create a
Medicaid health home specific to children. The bill will also
increase data collection and add a requirement for the
Department of Health and Human Services to issue guidance on
best practices for providing care for this unique and complex
pediatric population.
I would like to thank the members whose legislation we are
considering today for the time, effort, and thought that they
have put into the development and fine-tuning of the language.
I look forward to hearing from our witnesses and having a
productive discussion on these important public health
initiatives.
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 these bipartisan drafts and legislation to improve
the delivery cost of healthcare in our country. In particular,
I am happy to see that our committee will be considering H.R.
3325, the Advancing Care for Exceptional Kids, or ACE Kids Act.
I am grateful to Representatives Barton and Castor for their
commitment to the children with complex medical needs and their
quest to improve the system of care provided to our nation's
most vulnerable population.
I am also proud to be a cosponsor of the ACE Kids Act. The
ACE Kids Act aims to improve the delivery care for children
with complex medical conditions served by Medicaid. It presents
a great opportunity for us to implement better care delivery
and payment models to support children and their families.
The current discussion draft will establish a Medicaid
health home State option, specifically targeting children with
medically complex conditions, and require the Department of
Health and Human Services to issue guidance regarding the best
practices for using out-of-State providers for children with
medically complex conditions. States who accept this new home
health option for children with medically complex conditions
will receive an enhancement 90 percent Federal medical
assistance percentage, FMAP, for the first eight fiscal year
quarters after the option is adopted.
The discussion draft seeks to achieve three primary goals:
improve the coordination of care for children; address the
problems of fragmented access, especially when the necessary
care is only available out of State; gather national data to
help researchers improve services and treatments for children
with complex medical conditions.
I also want to thank our stakeholders in my area in
Houston, Texas, Children's Hospital--I am glad to have Dr. Cook
on the panel I think today, no, anyway--and my colleagues for
moving this important legislation.
Children with medically complex conditions require a lot of
healthcare and generate significant cost. One study found that
children with complex medical conditions who account for just
over 5 percent of all children in Medicaid account for 34
percent of all Medicaid spending for children.
While the data is compelling, it is important not to reduce
these children and their families to statistics. We must do a
better job to ensure that all of these exceptional children get
the care they need.
Children with medically complex conditions often have
multiple illnesses and disabilities and commonly need to see a
number of physicians and specialists. The necessary care often
requires these special children to travel across State lines to
see one of the small number of pediatric specialists for their
conditions.
Under our current system, parents of kids with complex
conditions struggle to coordinate the intricate multistate care
of their children. We need this legislation to make sure that
this care is more coordinated and seamless for families. The
discussion draft is an important step forward.
We must ensure that final legislation is robust and
meaningful in accomplishing our shared goals of improving care
and removing barriers for children with complex medical
conditions. The ACE Kids Act now has 99 cosponsors, evidence
that the health of our children is an issue above partisanship
and brings us all together. I look forward to working with my
colleagues to move the legislation forward and give our
children the bright futures they deserve.
I support the other four bills in discussion draft being
considered today. Many of these bills, including H.R. 3891,
will expand the authority of State Medicaid Fraud Control Units
to investigate and prosecute Medicaid fraud and abuse at
noninstitutional settings, and the discussion draft to codify
the Health Fraud Prevention Partnership are comments and
changes to current law and should receive wide bipartisan
support.
I also support the discussion draft to prohibit the use of
the so-called gag clauses in Medicare and private health plans
that prohibit pharmacists from informing consumers that their
prescription can be purchased at a lower price. While I support
the gag clause discussion draft, I hope the committee will
consider a deeper examination for rising costs of prescription
drugs and consider what Congress can do to help seniors
struggling to afford their medication.
And like you, Mr. Chairman, I want to thank our colleague
from Georgia for bringing this up. This is a major issue with
the seniors in my district in Houston and Harris County, Texas.
I thank our witnesses for joining us today and look forward to
hearing their testimony. Again, Mr. Chairman, thank you, and I
yield back the remainder of my time.
[The prepared statement of Mr. Green follows:]
Prepared statement of Hon. Gene Green
Thank you, Mr. Chairman, for holding today's hearing on
bipartisan legislation to improve the delivery and cost of
health care in our country.
In particular, I am happy to see that our committee will be
considering H.R. 3325, the Advancing Care for Exception Kids or
``ACE'' Kids Act.
I am grateful to Representatives Barton and Castor for
their commitment to children with complex medical needs and
their quest to improve the system of care provided to our
nation's most vulnerable population.
I am a proud original co-sponsor of the ACE Kids Act.
The ACE Kids Act aims to improve the delivery of care for
children with complex medical conditions served by Medicaid.
It presents a great opportunity for us to implement better
care delivery and payment models to support children and their
families.
The current discussion draft would establish a Medicaid
health home state option specifically targeted for children
with medically complex conditions and require the Department of
Health and Human Services to issue guidance regarding best
practices for using out-of-state providers for children with
medically complex conditions.
States that accept this new home health option for children
with medically complex conditions will receive an enhanced 90
percent Federal Medical Assistance Percentage (FMAP) for the
first eight fiscal year quarters after the option is adopted.
The discussion draft seeks to achieve three primary goals:
Improve the coordination of care for children;
Address problems with fragmented access,
especially when the necessary care is only available out-of-
state;
Gather national data to help researchers improve
services and treatments for children with complex medical
conditions.
I want to thank our stakeholders, Texas Children's Hospital
in particular, and my colleagues for moving this important
legislation forward.
Children with medically complex conditions require a lot of
health care and generate significant costs. One study found
that children with complex medical conditions, who count for
just over 5 percent of all children in Medicaid, account for 34
percent of all Medicaid spending for children.
While the data is compelling, it is important not to reduce
these children and their families to statistics. We must do a
better job to ensure that all of these exceptional kids get the
care they need. Children with medically complex conditions
often have multiple illness and disabilities, and commonly need
to see a number of specialists and physicians. The necessary
care often requires these special children to travel across
state lines to see one of the small number of pediatric
specialists for their conditions.
Under the current system, parents of kids with complex
conditions struggle to coordinate the intricate, multi-state
care of their children.
We need this legislation to make this care more coordinate
and seamless for families.
This discussion draft is an important step forward.
We must ensure that the final legislation is robust and
meaningful to accomplish our shared goals of improving care and
removing barriers for children with complex medical conditions.
The ACE Kids Act now has 99 cosponsors, evidence that the
health of our children is an issue that is above partisanship
and brings us all together.
I look forward to working with my colleagues to move this
legislation forward and give our children the bright futures
they deserve.
I support the other four bills and discussion drafts being
considered today.
Many of these bills, including H.R. 3891, which would
expand the authority of state Medicaid Fraud Control Units to
investigate and prosecute Medicaid fraud and abuse in non-
institutional settings, and the discussion draft to codify the
Health Fraud Prevention Partnership (HFPP), are commonsense
changes to current law and should receive wide bipartisan
support.
I also support the discussion draft to prohibit the use of
so-called ``Gag Clauses'' in Medicare and private health
insurance plans that prohibit pharmacists from informing
consumers that their prescription can be purchased for a lower
price out-of-pocket.
While I support the ``gag clause'' discussion draft, I hope
that the committee while consider a deeper examination on the
rising costs of prescription drugs and consider what Congress
can do to help seniors struggling to afford their medication.
This is a major issue for seniors in my district in Houston
and Harris County.
I thank our witnesses for joining us today and look forward
to hearing their testimony.
Thank you again, Mr. Chairman, and I yield the remainder of
my time.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from Oregon, the
chairman of the full committee, Mr. Walden, 5 minutes for an
opening statement, please.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Well, thank you, Mr. Chairman, and thanks for
all your great work in this subcommittee, that and the members.
Again, today we are taking up bipartisan issues that really
matter for people's health and the cost of healthcare. So I
think it is a real another step forward.
So I traveled across Oregon over the last 5 weeks, covering
2,000 miles, 39 meetings, and 12 counties. These issues come
up, especially about healthcare, the cost, the quality.
Accessing affordable healthcare is a real important issue, and
it is one we consistently try to tackle in this committee.
Today, we hope to build on the bipartisan achievements of
the committee under the leadership of Chairman Burgess and
Ranking Member Green and review yet another slate of bills that
can help improve our overall healthcare system.
Now, among those we will examine is the one we have heard
about already pertaining to gag clauses, which have been front
and center in the national debate on drug prices. Many patients
who are struggling to afford costly prescription drug prices
may not know that actually paying for their medications with
cash is sometimes cheaper than using their health insurance.
And with the high deductibles right now, you ought to be
informed as a consumer. What is worse is some contracts
prohibit pharmacists from telling their customers when this is
the case.
So banning these so-called ``gag clauses'' has gained
tremendous bipartisan support, rightly so, with these bills in
both the Senate Finance and Senate Health Committees advancing
without objection. We will review the draft legislation banning
group health plans offered by employers and individual health
plans as well as Medicare Advantage and Medicare part D plans
from limiting a pharmacist's ability to inform a consumer about
the lower cost out-of-pocket price for their prescription.
Now, another practical bill will give the administration
additional authority to better detect and stop fraud and abuse
in the healthcare system. This has been an area of interest for
both the Obama and Trump administrations, and it is supported
by the committee's ranking member, Mr. Pallone, as well as
myself. I look forward to our continued bipartisan work in this
space.
We will also consider three bills in the Medicaid space
that will help ensure the beneficiaries who are receiving the
support and care they deserve in the setting that works best
for them. Mr. Guthrie and Ms. Dingell's bill, H.R. 5306, for
example, extend funding for the Money Follows the Person
Demonstration Program, that is MFP Demonstration, in Medicaid.
The MFP Demonstration provides additional resources for State
Medicaid programs to help ensure Medicaid patients needing
long-term care are served in their communities or in their
homes instead of at institutions. By many measures, the MFP
Demonstration has been successful.
We will also consider a bill offered by Mr. Walberg and Mr.
Welch, H.R. 3891, that will help improve the authority of State
Medicaid Fraud Control Units, or MFCUs. Currently, MFCUs are
only allowed to investigate cases of provider fraud and patient
abuse in healthcare facilities or board and care facilities.
This legislation would broaden that authority so that these
units could investigate and prosecute abuse and neglect of
Medicaid beneficiaries in noninstitutional or other settings.
Practically speaking, this bill will improve the ability of
MFCUs to help protect vulnerable Medicaid patients from harm,
while reducing the program's resources diverted by fraud.
And, finally, we will consider an amendment in the nature
of a substitute to a familiar bill authored by our full
committee vice chair, Mr. Barton, and Representative Castor.
That is H.R. 3325. Under current law, a health home State plan
amendment cannot target by age or be limited to individuals in
a specific age range. The Centers for Medicare and Medicaid
Services has reported that States have identified this
inability to target health home services as an operational
challenge. This bipartisan bill seeks to address that challenge
by giving States a new option through the existing health home
model to coordinate care for children with medically complex
conditions.
So further discussion of this report and bill, I would
yield the balance of my time to full committee vice chair, Mr.
Barton, and thank our witnesses for joining us today.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Today's hearing is another step forward to improve patient
health care. As I traveled across Oregon over the last 5 weeks,
I continued to hear from constituents about health care,
particularly regarding the cost and quality of care. Today we
hope to build on the bipartisan achievements of this
subcommittee, under the leadership of Chairman Burgess and
Ranking Member Green, and review yet another slate of bills
that can help improve our health care system.
Among the bills we will examine today is one pertaining to
gag clauses, which have been front and center in the national
debate on drug prices. Many patients who are struggling to
afford costly prescription drug prices may not know that paying
for their medications with cash can sometimes be cheaper than
using their health insurance. What's worse is some contracts
prohibit pharmacists from telling their customers when this is
the case.
Banning these so-called ``gag clauses'' has gained
tremendous bipartisan support, with bills in both the Senate
Finance and Senate HELP committees advancing without objection.
We'll review draft legislation banning group health plans
offered by employers and individual health insurance plans--as
well as Medicare Advantage and Medicare Part D plans--from
limiting a pharmacist's ability to inform a customer about the
lower cost, out-of-pocket price of their prescription.
Another practical bill will give the administration
additional authority to better detect and stop fraud and abuse
in the health care system. This has been an area of interest
for both the Obama and Trump administrations, and it's
supported by the committee's Ranking Member, Mr. Pallone, as
well as myself. I look forward to our continued bipartisan work
in this space.
We will also consider three bills in the Medicaid space
that will help ensure that beneficiaries are receiving the
support and care they deserve in the setting that works best
for them. Mr. Guthrie and Ms. Dingell's bill, H.R. 5306 for
example, will extend funding for the Money Follows the Person
Demonstration Program (MFP demonstration) in Medicaid. The MFP
demonstration provides additional resources for state Medicaid
programs to help ensure Medicaid patients needing long-term
care are served in their communities or in their homes, instead
of at institutions. By many measures, the MFP demonstration has
been successful.
We will also consider a bill authored by Mr. Walberg and
Mr. Welch, H.R 3891, that will improve the authority of state
Medicaid Fraud Control Units--or MFCUs. Currently, MFCUs are
only allowed to investigate cases of provider fraud and patient
abuse in health care facilities or board and care facilities.
This legislation would broaden the authority of these units to
investigate and prosecute abuse and neglect of Medicaid
beneficiaries in non-institutional or other settings.
Practically speaking, this bill will improve the ability of
MFCUs to help protect vulnerable Medicaid patients from harm,
while reducing the program resources diverted by fraud.
Finally, we will consider an Amendment in the Nature of a
Substitute to a familiar bill authored by our full committee
Vice Chairman Barton and Rep. Castor bill, H.R. 3325. Under
current law, a Health Home state plan amendment cannot target
by age or be limited to individuals in specific age range. The
Centers for Medicare and Medicaid Services (CMS) has reported
that states have identified this inability to target Health
Home services as an operational challenge. This bipartisan bill
seeks to address that challenge by giving states a new option
through the existing Health Home model to coordinate care for
children with medically complex conditions.
To further discuss this important bill, I would like to
yield the remainder of my time to the Vice Chairman of the Full
Committee, Mr. Barton, and thank our witnesses for joining us
here today.
Mr. Barton. Well, thank you, Mr. Chairman. Every now and
then, we have a day when it reminds us why we ran for Congress.
Today is one of those days. As Mr. Green in his opening
statement just itemized, the ACE Kids Act, all the good things
that it will do. So I don't need to go through that.
But we are going to have a hearing on that bill today among
the other four bills, and hopefully, on Friday, we are going to
mark it up. ACE Kids is a bill that has been in some shape or
form before this subcommittee for about 6 years. The bill, the
draft discussion today, is one of those rare things. It is
totally bipartisan. Half of the cosponsors are Republican; half
are Democrat. On this subcommittee, Mr. Latta, Mr. Lance, Mr.
Guthrie, Mr. Bilirakis, Mr. Long, and Mr. Carter are Republican
cosponsors. Mr. Green, Ms. Eshoo, Mrs. Dingell, Ms. DeGette,
Ms. Castor, Mr. Kennedy, and Mr. Cardenas are Democratic
cosponsors. We have half the subcommittee cosponsor this bill.
It doesn't expand coverage; it doesn't increase spending. It
makes it better, Mr. Chairman. It allows families to choose. It
allows the care providers to coordinate, and you can go across
State lines.
This is a really, really good bill. I hope we have a great
hearing. I want to thank Rick Merrill from Fort Worth, Texas,
for testifying in its favor, and I look forward to the
discussion and the questions.
With that, I yield back, Mr. Chairman.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The ranking member of the full committee has not yet
arrived, so we will delay his opening statement until his
arrival.
But I do want to welcome and thank our witnesses for being
here and taking time to testify before the subcommittee on
these pending pieces of legislation. Each witness will have the
opportunity to give an opening statement, and this will be
followed by questions from members.
So, today, in order, we are going to hear from Mr. Hugh
Chancy, Owner, Chancy Drugs, and Member of the Board of
Directors of the National Community Pharmacists Association;
and Mr. Curtis Cunningham, Vice President, National Association
of States United for Aging and Disabilities, and Assistant
Administrator, Long-Term Care Benefits and Programs, Division
of Medicaid Services, Department of Health Services from the
State of Wisconsin; Mr. Matt Salo, the Executive Director of
the National Association of Medicaid Directors; Mr. Rick
Merrill--always have to have a Texan on the panel, so welcome
and thank you for joining us today--Mr. Rick Merrill, who is
the President and CEO of Cook Children's Health Care System in
beautiful downtown Fort Worth, Texas; Mr. Derek Schmidt, the
Attorney General for the State of Kansas; and Dr. David Yoder,
Executive Director of Member Care and Benefits, Blue Cross Blue
Shield Association's Federal Employee Plan.
Again, thanks to all of you. We appreciate you giving of
your time today to testify. Mr. Chancy, you are now recognized
5 minutes to summarize your opening statement, please.
STATEMENTS OF HUGH M. CHANCY, RPH, OWNER, CHANCY DRUGS, HAHIRA,
GEORGIA, AND MEMBER, BOARD OF DIRECTORS, NATIONAL COMMUNITY
PHARMACISTS ASSOCIATION; CURTIS CUNNINGHAM, VICE PRESIDENT,
NATIONAL ASSOCIATION OF STATES UNITED FOR AGING AND
DISABILITIES (NASUAD), AND ASSISTANT ADMINISTRATOR, LONG-TERM
CARE BENEFITS AND PROGRAMS, DIVISION OF MEDICAID SERVICES,
DEPARTMENT OF HEALTH SERVICES, STATE OF WISCONSIN; MATT SALO,
EXECUTIVE DIRECTOR, NATIONAL ASSOCIATION OF MEDICAID DIRECTORS;
RICK MERRILL, PRESIDENT AND CEO, COOK CHILDREN'S HEALTH CARE
SYSTEM, FORT WORTH, TEXAS; DEREK SCHMIDT, J.D., ATTORNEY
GENERAL, STATE OF KANSAS; AND DAVID YODER, PHARM.D., M.B.A.,
EXECUTIVE DIRECTOR OF MEMBER CARE AND BENEFITS, BLUE CROSS BLUE
SHIELD ASSOCIATION'S FEDERAL EMPLOYEE PLAN
STATEMENT OF HUGH M. CHANCY, RPH
Mr. Chancy. Chairman Burgess, Ranking Member Green, members
of the subcommittee, thank you for conducting this hearing. My
name is Hugh Chancy. I have been practicing community pharmacy
since 1988. I am currently an owner of five community
pharmacies in the southern part of Georgia, and I am here on
behalf of the National Community Pharmacy Association. I
currently serve as NCPA board of directors. NCPA represents
America's community pharmacists, including owners of more than
22,000 independent community pharmacies. I am here today as a
healthcare provider and a small business owner to present my
experience with restrictive contractual language, often called
gag clauses, that may result in patients being charged inflated
prices for their medications.
My first experience with so-called gag clauses occurred in
2015, when one of my pharmacies served several patients on the
city's employment-sponsored insurance, including the city
mayor. The city had just changed insurance providers, and many
of my patients experienced a rise in their prescription copays.
Specifically, the mayor's copay of his medication went from
roughly $7 to $26.
When I noticed this difference, I informed the mayor that
it would be cheaper if he paid cash for his prescription or off
of his insurance. The mayor was fortunate to have the political
wherewithal to contact the right people in charge of the city's
insurance plan and to complain about the changes and the
oddities of paying more for the prescription on insurance than
off. It goes without saying that many of the patients do not
have similar avenues to voice their concerns about prescription
drug coverage.
After the mayor contacted the plan, the plan consulted with
their PBM, who issued us a verbal warning to my pharmacy for
talking to the patient about the drug cost. The PBM stated that
we are in violation of our contract for disparaging the plan
when we discuss the cost of the drug off insurance. We were
told that if our pharmacy were to do so again, there would be
consequences and possibly exclusion from the PBM's network.
The common denominator in all community pharmacies'
experiences with gag clauses is a strained relationship with
PBMs. When a patient comes to the pharmacy and presents
insurance, the pharmacy is bound by the terms of the patient's
insurance and the PBM's rules. Put simply, pharmacists do not
play a role in determining the patient's financial
responsibility for prescription medications that they access
through any prescription drug coverage.
If a patient does not present insurance or if a patient
inquires directly, however, pharmacies can tell the patient
alternative means to purchase a drug. When a PBM is involved,
however, communication with the patient becomes murky, because
pharmacies are contractually required to charge the patient
what the PBMs say when the prescription is processed.
I am often asked what gag clauses look like in contracts,
but the answer to that question is not as simple as it may
seem. The expression ``gag clauses'' is a misnomer, because
what is most often being referred to are multiple contract
provisions or requirements embedded in lengthy PBM provider
manuals that include overly broad confidentiality requirements
and nondisparagement clauses. Some PBMs have even included
provisions that can be interpreted as prohibiting communication
with news media, policymakers, and even elected officials.
Ultimately, these provisions have the effect of chilling a
range of pharmacist communications with patients for fear of
retaliation by the PBM. For this reason, the gag clause issue
goes well beyond drug price disclosures. Further, community
pharmacies like mine have very little negotiating power to
strip these provisions out of their contracts.
As a solution to this problem, community pharmacies need a
place to point into law that will allow for the free flow of
information between them and the patients. NCPA supports the
discussion draft that is the focus of this hearing. The draft
is legislation to prohibit gag clauses in Medicare and private
insurance by banning health plans from restricting a pharmacy's
ability to inform customers about the lower cost, the out-of-
pocket price for their prescription.
Additionally, NCPA appreciates the work that Congressmen
Buddy Carter and Peter Welch have done in introducing
legislation that would also meaningfully address contract
provisions that prohibit or penalize a pharmacist from
communicating different cost options to their patients.
Also, I was pleased to hear that CMS recently sent a letter
to plan sponsors and Medicare explaining that any form of gag
clauses in contracts is unacceptable. In addition, 25 States
have passed legislation prohibiting gag clauses. These actions
give pharmacists the ability to point to laws and rules that
prevent PBMs from restricting free flow of information.
In conclusion, as Congress demands increased transparency
in the prescription drug marketplace, this committee can
provide a much needed stake in the ground to allow pharmacists
to freely discuss drug costs with their patients. Providing the
free flow of this kind of information is a step in the right
direction to meaningfully addressing drug costs for Americans.
Thank you.
[The prepared statement of Mr. Chancy follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Chancy. Thanks for sharing your
testimony with us.
Mr. Cunningham, you are recognized for 5 minutes to
summarize your opening statement, please.
STATEMENT OF CURTIS CUNNINGHAM
Mr. Cunningham. Thank you. Chairman Burgess, Ranking Member
Green, and members of the subcommittee, thank you for the
opportunity to discuss Money Follows the Person Program.
In addition to serving as Assistant Administrator for Long-
Term Care Benefits and Programs in Wisconsin, I am also the
Vice President of the National Association of States United for
Aging and Disabilities, known as NASUAD, which is a nonpartisan
association that represents administrators of aging,
disability, and long-term supports and services in all 50
States, District of Columbia, and territories.
I am also designated as the Wisconsin disability director
and serve on the National Policy Work Group for the National
Association of State Directors of Developmental Disability
Services.
I am honored to be here today to represent NASUAD and speak
about Money Follows the Person and its impact on individuals
that require long-term supports and services.
The MFP program, as it is frequently called, was first
created by the Deficit Reduction Act of 2005 as a way to
provide States with increased resources and flexibilities that
assist in the transition of individuals from institutional
long-term care settings to home and community-based services.
The creation of MFP gave States crucial tools to increase
choices or options for individuals who receive long-term
services and supports in accordance with the landmark Olmstead
decision that mandates that States ensure that participants
receive services in the most integrated setting based on their
needs and their preferences. States began operating MFP in
2007, and between 2007 and 2017, 43 States transitioned over
75,000 individuals into the community.
MFP also results in significant cost savings. According to
the national MFP evaluation, the average annual person's
spending during the first year following the transition into
the community declined by over $20,000 for older adults and
people with disabilities and by over $48,000 for individuals
with intellectual and developmental disabilities. All told,
this has resulted in $1 billion in savings during the first
year of transition alone for these individuals.
The evaluation also estimated that 17 States evaluated,
roughly one-quarter of the older adults and one-half of the
individuals with intellectual and developmental disabilities
would not have transitioned without the support of MFP.
One of the reasons MFP provides an opportunity for
deinstitutionalization for individuals who would not otherwise
move into the community is due to the flexible services that
this program provides.
MFP allows for supplemental services that are not covered
through the standard Medicaid long-term services and supports,
and provides opportunities for innovation to address some of
the common barriers to community transitions. Some examples
include, in Wisconsin, we funded community living specialists
who review nursing home diagnostic data to identify people who
indicate they would like to move into the community, and these
community specialists assist them in that movement.
Nearly every State has identified lack of accessible
affordable housing as a significant challenge that can prevent
community placements. In Tennessee, MFP funded a housing
counseling and a pilot program to support bridge subsidies for
individuals leaving institutions. Many States also use MFP
funding to support programs that help beneficiaries gain and
maintain employment, provide behavioral supports, provide
outreach consultation with nursing facilities, and then also
provide grants to Tribal entities to develop their own
community relocation initiatives.
Critically, in Wisconsin, many other States use MFP funds
to address waiting lists through diversion initiatives and
expand available slots for their community-based waivers.
States also use MFP to support Aging and Disability Resource
Centers, which provide comprehensive information and referral
services to keep people in the community. Finally, MFP also
serves several States in their person-centered thinking and
organizational thinking.
Finally, it is important to remember that, behind each of
these statistics, there are real people. I would like to share
one of those stories. In Delaware, MFP changed the life of a
young mother of three who was a victim of a violent crime. She
found herself in a nursing home due to her injuries, which left
her paralyzed from the waist down. Prior to the crime, she was
working, supporting her family; and while in the facility, she
had no income. Being in the nursing facility was difficult for
her and her children. While they could visit her in the
facility, she was not at home to be part of their daily lives
or put them to bed at night.
MFP was able to transition her home with her children and
her mother as their caretaker after spending 8 months in the
facility away from her children. After the transition, she
continued to improve the quality of life. She is learning how
to drive an adapted vehicle. Her intention is now to attend
vocational rehab so that she can return to work to support
herself and her children.
As you can see, these unique programs provide benefits to a
wide range of people. Not only is it valuable to States. It is
fiscally responsible and results in savings for the Federal
Medicaid program. Lastly and most importantly, it improves the
lives for the individuals we serve.
Although significant progress and success has been made in
rebalancing HCBS, there is still a lot of work that can be
done. Almost 60 percent of all Medicaid expenditures for long-
term services and supports are delivered to older adults and
people with physical disabilities or for institutional care.
On behalf of NASUAD, I therefore encourage Congress to
continue this important program. Our members across the country
have seen great value in the program, and the interventions
have become more effective as the States experimented with and
learned from innovative ways to provide these supports.
We encourage Congress to continue to work with NASUAD, our
membership, and the broader aging and disability community to
demonstrate the financial and human benefits of a program in
order to secure the extension of MFP. Thank you for the
opportunity to comment, and I would be happy to answer any
questions you may have.
[The prepared statement of Mr. Cunningham follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Cunningham.
The chair now recognizes Mr. Matt Salo for 5 minutes to
summarize your opening statement, please.
STATEMENT OF MATT SALO
Mr. Salo. Thank you so much, Chairman Burgess, Ranking
Member Green, members of the subcommittee. My name is Matt
Salo, and I represent the National Association of Medicaid
Directors. These are the folks in each of the 56 States and
U.S. territories who run the Medicaid program.
I want to briefly just frame Medicaid and what my members
do before touching briefly on three of the bills that you are
currently considering. I think it is important to recognize
just how big, complex, and important Medicaid is. Medicaid
covers more than 70 million Americans. We spent more than $550
billion last year, and it is roughly 30 percent of the average
State budget and 3 percent of the Nation's GDP.
Medicaid is the backbone of the U.S. healthcare system, and
in many ways and for many of the populations that we are
talking about today, it is the backbone of America. And I think
that it is important, despite the complexity of all the things
we are talking about--we are talking about some very, very
different components of Medicaid today--it is important to keep
in mind the importance and the breadth of the things that we
try to achieve. And arguably, I think Medicaid is clearly the
largest and most important healthcare program, not only in this
country but arguably in the world.
One way that I think it is important to also frame it is,
similar to the parable of the six blind men trying to describe
an elephant and sort of only looking at what they can see and
touch, if you look at any of the pieces today, you might think,
oh, well, Medicaid's a program for medically complex kids or
Medicaid's a program for frail seniors or adults with
disabilities. It is all of those things and many, many more.
My members, the State Medicaid directors, their job, no
matter what State they are in, is to try to improve the
healthcare system to deliver a better healthcare experience to
the people that we serve while being responsible stewards of
both State and Federal taxpayer dollars, and to do so in ways
that are meaningful and relevant in the State and in the
cultural community that they reside.
My members are driving significant complicated healthcare
reforms to the delivery system of Medicaid and the broader U.S.
healthcare system. We are driving sustainable payment reforms
to try to bring Medicaid from a fee-for-service system into a
value-based system. This is complicated. This is multisector.
This is multiyear. This is difficult work, but it is critically
important.
Three of the bills I want to touch on real briefly. We have
talked a lot about the ACE Kids Act. This has been a very
complex, a very fluid piece of legislation. As Chairman Barton
has referenced, it has been around for at least 6 years now. I
would hope that the message that we give is that if we want
something like this to be successful, look to the example of
CHIP.
CHIP was a program created in 1997 that sought to improve
coverage and care for kids in this country. And the way that it
evolved and the way that it was created and the way that it
ultimately has become one of the most bipartisan and most
successful programs that this committee has worked on is that
it embraced two concepts, one of which is that if we want
States to make significant progress in areas like this, it has
got to embody two principles: one, enhanced Federal support;
and, two, increased State flexibility. Because no matter what
we are looking at, the ways that States, from New York to Texas
to California and everything in between, their healthcare
cultures, their healthcare systems are different, and it has to
be cognizant and respectful of those differences as we are
trying to provide the best possible healthcare, not to just to
those kids but to everybody else that we serve. So, if we want
this to be successful, we have to ensure that it is flexible,
ensure that there is strong sustained Federal support, and I
believe that we can get there.
Second, very, very briefly, Money Follows the Person. I can
be very brief on this, because there is no question that this
works. There is no question this is highly successful. There is
no question this is incredibly important to continue not just
for the short-term but for the long-term. I think we should be
talking about how long can we reauthorize this for. Can we make
this permanent? And that is one of the things that we always
talk about is, if we find something that works, let's make it
permanent. And I think clearly this works, and clearly this is
an important part of our conversation.
The final piece on the Medicaid Fraud Control Units. Very
important conversation, especially in light of increased
movement from institutional to noninstitutional. But I would
urge you also to think more broadly about how we are
approaching program integrity. Program integrity is not just
fraud or abuse or safety. It is those things, but it is more.
The Fraud Control Units exist within the Attorney General's
Office, not within Medicaid. We have to make sure that if we
are going to invest in targeted areas like this, which we
should, we have to make sure that we are coordinating the
efforts across the system. And I have got a couple of other
ideas, in terms of things that we could do to improve this.
And then, just finally, I will say I would be happy to also
talk about some of the other possible reforms in Medicaid that
my members would love to see to help them in their efforts to
improve the Medicaid program for taxpayers, for beneficiaries,
for providers, and for all of us. So I would be happy to answer
questions at the end, and thank you for having me.
[The prepared statement of Mr. Salo follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Salo. Thanks. Just a historical
note since two of you now have brought up the Deficit Reduction
Act of 2005. It was late in December of 2005 when this
committee passed the Deficit Reduction Act. Mr. Barton was
chairman at the time. And now all these many years later to
hear about an enduring part of that that actually did perform
as indicated, it is gratifying. It was a big bill with a lot of
moving parts, but I am grateful that that one did deliver.
Mr. Merrill, we are grateful to have your presence on the
subcommittee dais today. You are recognized for 5 minutes to
summarize your opening statement.
STATEMENT OF RICK MERRILL
Mr. Merrill. Thank you very much. I thank Congressman
Barton, Chairman Barton, Chairman Burgess, and Ranking Member
Green. You guys did such a great job describing ACE Kids and
the importance of it and the benefits of it. I am not sure I
could top that, but I will do my best to equal this today.
Chairman Burgess, Ranking Member Green, and members of the
subcommittee, I am Rick Merrill, the President and CEO of Cook
Children's Health Care System in Fort Worth, Texas, and I am
Chair of the Children's Hospital Association Board of Trustees.
On behalf of my hospital system, our CHA member institutions
and the patients and families we serve, thank you for the
opportunity to speak in strong support of H.R. 3325, the
Advancing Care for Exceptional Kids Act of 2017, or ACE Kids,
as we refer to it.
We are extremely grateful to Representatives Barton and
Castor for their leadership on behalf of children, as the
original cosponsors of this bipartisan legislation, and to the
nearly 100 additional House Members who have joined them as
cosponsors. We also wish to thank the leadership of the Energy
and Commerce Committee and the Health Subcommittee for devoting
considerable time and resources to working toward solutions in
this important area.
In addition, we want to recognize Chairman Burgess and
Ranking Member Green for their longstanding leadership and
support of the Children's Health Insurance Program and the
recent reauthorization of the Children's Hospital Graduate
Medical Education Program, which was passed by the Senate last
evening. Thank you for that.
Last year, Cook Children's treated children from more than
35 States, recorded nearly half a million child visits in our
60 pediatric specialty clinics, 240 visits in our Mercy
Department and Urgent Care Center, and registered over 11,000
inpatient admissions. With over 1.5 million patient encounters
a year, Cook Children's provides comprehensive and coordinated
care across our fully integrated system, including home health
services and a health plan which enrolls over 100,000 Medicaid
children, many of whom have serious disabilities.
For many years now, we have taken care of some very sick
kids, and I think we have done a good job in our part of Texas,
but I am here today to tell you that we could and should do
better. Medicaid covers over 37 million children. A small
percentage of these kids have complex medical conditions
requiring ongoing and specialized care. These children have
diagnoses that are multiple and varied, from cerebral palsy to
cystic fibrosis to congenital heart disease and even childhood
cancers. They typically are under the continuous care of
multiple pediatric specialists and require access to
specialized care and additional services, often from outside
their home State. Additionally, their care accounts for a
drastically disproportionate percentage of Medicaid spending on
children.
Behind each of these data points is a real child and
family, families like the Beckwiths. Alex and Maddy Beckwith of
Keller, Texas, are some of the most remarkable, kindest 14- and
4-year-olds that you could hope to meet, but they both also
suffer from mitochondrial disease, along with other health
issues. Mitochondrial disease is a serious condition without a
cure. It requires lifelong medication and therapy.
Due to their conditions, Alex and Maddy, their care is
complex and ongoing. And so they actually have become like
family members to the staff at Cook Children's. They see 15
specialists between them and require major interventions to
remain medically stable. The ACE Kids Act is about improving
care for children like Alex and Maddy by expanding access to
patient-centered pediatric-focused coordinated care tailored to
their unique needs. The ACE Kids Act would modify Medicaid's
existing health home option to give States the ability to
implement health home specifically targeting children with
complex medical conditions.
These new pediatric health homes would follow national
guidelines in implementing a care plan for the medically
complex child, coordinating care from providers, such as
physicians, children's hospitals, specialized hospitals,
nonphysician professionals, and home health and behavioral
health providers. These homes will help families manage the
challenges associated with their child's care while improving
quality of care for the children enrolled.
Participation will be completely voluntary for these
children. Families, healthcare providers, and the pediatric
health homes will work within the existing State's Medicaid
program, including those States with Medicaid managed care. The
focus of ACE Kids is creating opportunities for providers,
plans, and States to collaborate to provide the best quality of
care for these children.
The ACE Kids Act is also about using existing Medicaid
resources more efficiently. A large and growing body of
research shows that coordinating care for people with chronic
conditions can, indeed, reduce spending. The potential cost
savings the ACE Kids model could produce have been demonstrated
through projects supported by the Center for Medicare and
Medicaid Innovation. The CMMI Coordinating All Resources
Effectively Award, that is the CARE Award, implemented care
coordination programs serving 8,000 children with medical
complexity. Collectively, the 10 hospitals participating in the
CARE Award, including Cook Children's, reduced emergency
department visits by 26 percent, reduced inpatient stays by 32
percent, and in just the full year of operation coordinating
care for these children, care ultimately reduced overall
Medicaid costs for these children 2.6 percent. Additionally,
prior independent analysis of the ACE Kids Act conducted shows
substantial potential long-term savings in the Medicaid
program.
The ACE Kids Act will create a data and quality framework
to drive improvement in care and further reduce cost. The bill
outlines a definition of children with medically complex
conditions who will be eligible to participate in the program
and includes standardized data reporting requirements related
to their care. This information and sharing does not exist in
Medicaid today. There is currently no national data available
to inform our policies for children with medical complexity.
Since its original introduction in the 113th Congress, the
ACE Kids concept has continued to evolve, based on extensive
stakeholder feedback. This bill reflects the results of this
collaborative process and has received support from many
organizations dedicated to children's health.
In closing, the ACE Kids Act will have an opportunity to
help children and their families who face some of the most
significant health challenges. On behalf of children's
hospitals nationwide and the thousands of children and families
that we care for at Cook Children's, we look forward to working
with Congress to pass ACE Kids this year and advance solutions
that improve care for all kids. Thank you.
[The prepared statement of Mr. Merrill follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you, Mr. Merrill.
Mr. Schmidt, you are recognized for 5 minutes to summarize
your opening statement, please.
STATEMENT OF DEREK SCHMIDT, J.D.
Mr. Schmidt. Thank you, Mr. Chairman, Ranking Member Green,
thank you all very much for conducting this hearing today. I
want to particularly thank Representative Walberg and
Representative Welch for their leadership in bringing forward
H.R. 3891.
It is a bipartisan bill not only on your side but on ours,
and I testify today wearing two hats: first, as the immediate
past president of the National Association of Attorneys
General, the nationwide organization of all 56 State,
territory, and District of Columbia attorneys general, a
nonpartisan organization. To the extent my testimony conveys
information that is in the two National Association letters
submitted with my testimony, it is testimony on behalf of the
organization. To the extent I may testify on other matters, for
example, illustrate points with experiences from Kansas, it is
my testimony as the State of Kansas attorney general.
I would slip into the jargon, Mr. Chairman, the MFCUs, the
Fraud Control Units, but we tend to call them MFCUs. Title 19
of the Social Security Act, of course, requires every State to
have one or obtain a waiver. Forty-nine States, North Dakota
being the exception, have a MFCU, as does the District of
Columbia. None of the territories does.
So there are 50 of them nationwide. Of those 50, 44 are
housed within the Office of the Attorney General. The other six
are housed at another location in State government, but, of
course, none can be housed, by law, within the Medicaid program
itself. The whole point in Congress' enactment is to have an
outside entity watching, the fraud fighters, the abuse fighters
outside connected with, coordinated with, communicating with,
but separate from the program itself.
Kansas is one of those States where the MFCU is housed in
the Attorney General's Office. These are valuable programs from
a State perspective because, like the Medicaid program itself,
the cost is shared. The ratios are slightly different. It is a
75-percent Federal/25-percent State mix on the cost. That is a
tremendous value-added proposition from the standpoint of being
able to detect, investigate, and prosecute Medicaid fraud or
the abuse of Medicaid beneficiaries. And so they are very
attractive and, therefore, robustly used among the States,
including in Kansas.
HHS OIG data shows that in fiscal 2017, the total
recoveries nationwide from the MFCUs were about $1.8 billion, a
little under $2 billion, and the total number of criminal
convictions were about 1,500, give or take. Of that number,
about 370 of those 1,500 criminal convictions were patient
abuse convictions as opposed to fraud against the program
convictions. And it is that distinction between fraud and abuse
investigations, prosecutions, and efforts to detect that is the
subject of H.R. 3891.
The distinction is important. I don't know the historical
reasons for it. I suspect staff does. But for whatever reason,
when Congress enacted the provisions in title 19, it drew a
jurisdictional distinction between the ability of a Medicaid
fraud control unit to address fraud, an effort to steal public
money from the Medicaid program, and the authority of a MFCU to
address the abuse of patients, whether it is physical or
financial or sexual or whatever sort of abuse it might be.
And to boil it all down, the net is cast wider statutorily
in terms of our ability to go after fraud than it is in terms
of our ability to go after patient abuse. In a phrase, we can
essentially go after fraud wherever we find it, but with
respect to patient abuse, we can only go after it when we find
it in what the statute calls a healthcare facility or in some
States, at a statutory option, a board and care facility, in
other words, in an institutional setting.
We cannot use those MFCU assets to detect, investigate,
prosecute patient abuse cases in a noninstitutional setting.
And obviously, when you lay that alongside the tremendous
growth in HCBS services, home healthcare delivery services
outside of an institution, that disconnect, the problem with
that becomes obvious.
So consider, for example, our folks, for example, in Kansas
investigating a home healthcare fraud, a PCA fraud sort of
circumstance, and we are at a nonresidential or
noninstitutional, in a residential setting for the purpose of
figuring out where the money went, and we discover evidence of
abuse or neglect of the patient. We can no longer use those
MFCU assets to pursue the investigation and prosecution of the
patient abuse or neglect, even though we can continue to pursue
the investigation and prosecution of the financial fraud. We
don't think that makes any sense. And that is precisely what
H.R. 3891 is designed to collapse, to allow us the broader
scope with respect to both.
This is not just an academic point. In my written
testimony, I highlight some cases from Kansas, where we have
prosecuted serious physical or other abuse against patients in
an institutional setting. We have cases where we have not been
able to proceed because we are in a noninstitutional setting.
We functionally, in Kansas at least, we go beg, borrow, and
plead for a local police department to please take up the
cause, or a local prosecutor. And we just don't think that
makes any sense from a policy standpoint in today's healthcare
delivery method.
So we would encourage the enactment of H.R. 3891, both as
our association and as myself. I would be delighted to answer
any questions. And I would just end where I started. From our
vantage point, like you, most of our members, not all of our
members but most of our members are elected officials. We are
Republicans, Democrats, and sometimes other, and there is no
daylight on this issue among our members.
The first of the two letters that reflect NAAG policy had
38 signers. It was led by Attorney General Jepsen from
Connecticut and myself, a Democrat and a Republican. The second
had 49 of our 56 members. And remember, there are only 50
MFCUs. Forty-nine signed on, and it was led by Attorney General
Jepsen and myself, Attorney General Donovan from Vermont, a
Democrat from Vermont, and Attorney General Hunter, a
Republican from Oklahoma. So we are all behind this, and we are
grateful for your time.
[The prepared statement of Mr. Schmidt follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Great. Thank you, Mr. Schmidt.
Dr. Yoder, you are recognized for 5 minutes to summarize
your opening statement, please.
STATEMENT OF DAVID YODER, PHARM.D.
Dr. Yoder. All right. Thank you, Mr. Chairman. First, I
would like to thank both Chairman Burgess and the Ranking
Member Green for their leadership in holding today's hearing
and providing an opportunity to discuss key ways to improve
healthcare.
My name is David Yoder. I am the Executive Director, Member
Care and Benefits at the Blue Cross Blue Shield's Federal
Employee Program. BCBSA is a national federation of 36
independent community-based and locally operated Blue Cross and
Blue Shield companies that collectively provide healthcare
coverage for one in three Americans.
Blue Cross and Blue Shield companies offer quality
healthcare coverage in all markets across America and
participate in all Federal insurance programs. BCBSA, through
the FEP, administers health insurance to approximately 5.4
million Federal employees, retirees, and their families. We are
committed to high-quality affordable coverage for all,
regardless of preexisting conditions.
Today I am going to address a couple areas. One is how
BCBSA and its member companies are working to reduce fraud and
abuse and the need to eliminate gag clauses related to
prescription drugs. Fraud and abuse is an essential step to
ensure the affordability of healthcare and addressing,
reducing, and, to the extent possible, preventing the
opportunity for fraud and abuse.
BCBS companies are diligent in working to stay ahead of
fraud and abuse. The BCBSA National Antifraud Department is
dedicated to the support and promotion of BCBSA's antifraud
efforts nationwide, including for the FEHBP program. This
effort includes direct investigative support of local Blue
Cross Blue Shield special investigative units, coordination of
multiplan investigations, working with Federal and State law
enforcement, and providing subject-matter experts to BCBSA's
Office of Policy and Representation, the media, and the
government entities.
Among various governmental efforts, the Federal Government
established the Healthcare Fraud Prevention Partnership, HFPP,
to improve the detection and prevention of healthcare fraud.
BCBSA and several of our member companies are active
participants in the HFPP. We support the HFPP and Congress'
desire to establish explicit authority for HFPP and its
activities. As Congress takes steps to codify the HFPP charter,
we recommend improvements to help the partnership fulfill its
objectives, which were in my submitted written testimony.
Turning to gag clauses, BCBSA does not support the use of
gag clauses and is unaware of any Blue Cross and Blue Shield
company or contracted pharmacy benefit managers to have gag
clauses in place with pharmacies. We commend CMS for taking a
tougher position on gag clauses and support legislation to ban
gag clauses and any prohibitions on allowing pharmacists to
make information and cost savings known to the member at the
point of sale.
To the extent that some of the industry includes such
clauses in their contracts, consumers may be deprived of
information that will help them make prudent decisions when
paying for prescription drugs. With this in mind, we would also
encourage pharmacists to advise patients on generic
substitution and alternative medications, so long as this is
done in direct communication with the dispensing physician.
Full transparency is critical for consumers to have the
necessary information to make choices that work best for them.
It is also important that pharmacists advise consumers to
consider the impact of not using insurance coverage to pay for
their prescriptions. While certain beneficiaries might pay
lower out-of-pocket costs on a given prescription, drugs
purchased outside the insurance benefit in most cases will not
count toward the beneficiary's deductible or maximum out-of-
pocket limits, which may reduce the value of their insurance
coverage.
That is why we support elimination of gag clauses. We
believe that pharmacists should also inform consumers about the
potential risks of not using their drug coverage so they can
make more informed decisions.
In closing, BCBSA applauds the committee for taking on
these important issues as it is critical that all stakeholders
work together to ensure the affordability of healthcare for all
Americans. We support these efforts to drive the healthcare
system to higher quality, lower costs, and improve access to
care for everyone.
In line with these goals, we urge Congress to continue its
efforts to ensure that people have timely access to safe,
effective, and affordable cutting-edge prescription medications
when they need them. Achieving this important goal will require
the public and private sectors to collaborate to develop
solutions that benefit patients and the entire healthcare
system. Thank you for the opportunity to testify today and your
leadership in seeking opportunities to improve healthcare. And
I look forward to taking any questions. Thank you.
[The prepared statement of Dr. Yoder follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you.
Thank you, Dr. Yoder, and thanks to all of our witnesses
for your testimony. So we will move into the question-and-
answer portion of the hearing. And I would actually like to
defer my questions until later in the hearing and recognize the
vice chair of the full committee, Mr. Barton of Texas, 5
minutes for questions, please.
Mr. Barton. Thank you, Mr. Chairman, I am very honored and
flattered to take your question time at this time. I sincerely
mean that.
First, I want to ask unanimous consent, Mr. Chairman, to
place into the record statements of support for the ACE Kids
Act. We have almost two dozen national groups that are
supporting the draft bill in its current form, and I would like
to put that in the official record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Barton. Thank you, Mr. Chairman.
Mr. Merrill, I want to thank you for coming up from Fort
Worth for your testimony. I want to thank you for all the years
you and your national group that you are the president of this
year have supported us and helped us to refine the bill. Can
you tell the subcommittee--and I don't think you said this in
your opening statement--what percent of Medicaid-eligible
children meet the eligibility requirements of the ACE Kids Act?
Mr. Merrill. I would have to probably get that specific
number for you or percentage for you. It is definitely a small
percent.
Mr. Barton. I am told it is around 1 or 2 percent.
Mr. Merrill. That is close to the number. I just wanted to
make sure I stated an accurate number.
Mr. Barton. All right. This is a friendly hearing. We don't
require total specificity.
Mr. Merrill. Just want to answer it as best I can and
correctly.
Mr. Barton. All right. Now, to the best of your knowledge,
this small percentage of Medicaid-eligible children that would
qualify for ACE Kids, what is a seat-of-the-pants estimate
about the cost to Medicaid by that 1 or 2 percent?
Mr. Merrill. Yes, again, I would have to get the number for
you. I don't have the number off----
Mr. Barton. If I were to throw out 30 percent, would you
strongly disagree with that?
Mr. Merrill. Percentagewise, I think it is up close to 40
percent.
Mr. Barton. Forty percent.
Mr. Merrill. In terms of an actual dollar amount, I would
have to get that number.
Mr. Barton. So here we have a situation where, thankfully,
of the 37 million eligible Medicaid children, there are not
very many that have these complex medical conditions. But for
those that do, they take a hugely disproportionate share of the
cost.
Mr. Merrill. That is correct.
Mr. Barton. So, if we can do something that provides better
care, more comprehensive care, and actually saves money, that
is a win-win. Would you agree with that?
Mr. Merrill. I would absolutely agree with that. I think
everyone does win. I would say all in, all win, frankly, on ACE
Kids. I think that will matter greatly for these families,
these children. It will matter to the State programs in saving
Medicaid dollars and improving care and outcomes for these
kids, and, as I said, all in, all win.
Mr. Barton. Are you aware of any provider organization that
actually provides services, whether it be doctors, therapists,
hospitals, anybody in this country, that opposes the ACE Kids
Act?
Mr. Merrill. I am sorry?
Mr. Barton. Are you aware of anyone that is actually
providing services to these eligible children that opposes this
bill?
Mr. Merrill. I think that any time a new bill or approach
to care is introduced, organizations will have concern: What
does it mean for me?
And based upon the original draft of 3 years ago and all of
the work that has gone to try and address some of those
concerns, the current bill, as it is reflected, I do believe,
addresses most, if not all, of those concerns from those who
might not originally have been fully in support of.
Mr. Barton. You can tell that you have been president of a
national organization. I am throwing you softballs, and you are
being very ecumenical. The answer is no, there is no national
organization that provides care--now, there are some opponents
but not of the people that are providing the care. To my
knowledge, there are none.
Mr. Merrill. Fair enough.
Mr. Barton. Now, I want to ask Mr. Salo, you have mentioned
two principles that legislation that actually works should
have. You mentioned flexibility. Does ACE Kids have
flexibility?
Mr. Merrill. It absolutely does.
Mr. Barton. I am asking the Medicaid director.
Mr. Salo. I got this one. I want to be careful about not
spending too much time speaking to the actual structure of the
current version because, as we have said, this legislation has
evolved significantly over time. But our reading of the current
version does seem to allow for greater flexibility. I think
previous versions seem to say that States that were heavily
invested in managed care as a delivery mechanism would actually
get carved out, wouldn't be able to take advantage of this.
Mr. Barton. It is voluntary on a State basis----
Mr. Salo. If it is driven by the State, if it allows a
State either that is heavy managed care or managed fee-for-
service, like in a Connecticut, or something in the middle like
Massachusetts with ACOs, as long as it allows the State to be
able to design that in a way that meets not only the delivery
system in their State but also meets the needs of the patients
in that State.
And I think one of the other key issues is trying to get a
handle on exactly how you define the population that is
affected. As Mr. Merrill said, there is no Federal definition
of this, and so the question is, are you talking about 2
million kids? Are you talking about 50,000 kids? You had
research that talked about 8,000 kids and how that was
effective. It is going to be important to allow this to be
flexible enough for the State to figure out, how can we make
this work? Because if it creates silos within what a State is
trying to do, that is going to create conflict, and that is not
sustainable.
Mr. Barton. Mr. Chairman, my time has expired. Next time I
would ask unanimous consent if I could ask the question and
then answer it myself so that I could make sure I get the right
answer I want.
Mr. Burgess. You usually do.
Mr. Barton. With that, I yield back, Mr. Chairman.
Mr. Burgess. Thank you. Thanks to the vice chairman. The
chair now recognizes the ranking member of the subcommittee,
Mr. Green. I would ask just 5 minutes for your questions,
please
Mr. Green. Thank you, Mr. Chairman.
And I am following my friend Joe Barton that we would all
like to be able to answer our own questions.
So, thank you, thank the whole panel for being here today.
Mr. Chairman, I would like to ask unanimous consent request
on behalf of Ranking Member Pallone entered into the record
letters from the Medicare Payment Advisory Commission, MedPAC,
and Medicaid and CHIP Payment Access Commission, MACPAC,
concerning their request for legislation to ensure both
commissions can access drug rebate data for their respective
analysis. Ask unanimous consent.
Mr. Latta [presiding]. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Green. Thank you, Mr. Chairman.
Mr. Merrill, thank you for being here today and sharing
your expertise as a leading children's hospital, and, of
course, you know where I am from. I have been involved with
Texas Children's Hospital since I was a young State legislator
in the seventies, but Cook Children's Hospital, I am glad my
family hadn't had to take advantage of the Cook Hospital to
treat out-of-State patients. In fact, in your testimony, you
know that Cook Children's treated children from more than 35
States last year.
As you know the State-by-State nature of Medicaid program
has made it difficult to coordinate care across State lines.
The same State innovation and flexibility that makes Medicare/
Medicaid able to respond to unique needs of the State's
population can be the characteristics. I am hopeful that ACE
Kids Act will help provide Cook Children's overcome this issue
and ease some of the burden families are facing today when they
are trying to coordinate your child's care. Would you please
discuss difficulties that may arise when you are providing care
for a medically complex child from out of State?
Mr. Merrill. Yes, there are, as most of you know, some
States that do not have children's hospitals or some of the
high-level care that is offered in some of the other States.
And so, as a result, we do get referrals, as I mentioned, from
a number of States. That is true for Texas Children's. That is
true for a number of children's hospitals.
I would give you probably two examples. We had one
particular patient that was referred to us from a neighboring
State that did not have the high-level children services for
bone marrow transplant services, and it becomes a negotiation
and a long drawn-out discussion with the Medicaid program in
those States. Those discussions can last anywhere from 2 weeks
to 3 months. And in this particular case, it took well over 2
months for us to get this patient approved for the bone marrow
transplant that they needed.
There is another example of a patient from up in the
Midwest area who was referred to Cook Children's for some
services that we offer that only a couple of other children's
hospitals offer. It is a medically complex child, and it took
us 3 months to negotiate a single case agreement. And in the
end, we were never able to reach an agreement, and we do not
know what happened to that patient.
So it puts at risk the health of these patients. The
frustration, the anger from these parents, who really want to
care for their kid, and certainly us on the receiving end, who
want to deliver that care, all of us become very frustrated.
And it is very difficult; it is time-consuming. And I believe
that ACE Kids will allow us to streamline a lot of that effort
so that we can get these kids quicker, sooner, to the right
kind of care that they need.
Mr. Green. Thank you.
Mr. Salo, how can we disseminate, encourage more widespread
adoption of best practices and care for children with medical
complexity more effectively across State lines?
Mr. Salo. So I think that is a key function that our
organization can provide, working in close tandem with CMCS,
with Center for Medicaid and CHIP Services. I think we have
acknowledged that in the case of, when you are talking about
patients who are crossing State lines and dealing with
jurisdictional issues like that, there is clearly a need for
additional best practices, additional guidance, additional
tools to make that work well. And I think we have been open in
conversations with my colleagues here, as well as our friends
at HHS, about how can we do that, how can we figure out what
works, both in terms of--well, it is mostly, I think, finding
that balance between, how do you make the process as easy as
possible for the family while also making sure that the cross-
jurisdictional issues are respected and that we are not
obligating an individual State to another State's decision or
to individual providers who are setting up a silo that perhaps
is not in the best interest of the population as a whole?
I think we can get there. I think there is a lot of
potential for best practices in this, absolutely.
Mr. Green. Mr. Chairman, I know I am out of time, but I
want to thank our witnesses. And this is a piece of
legislation--I think it is important that we move on this.
Thank you.
Mr. Latta. Well, thank you very much. The gentleman's time
has expired and yields back.
And the chair now recognizes himself for 5 minutes.
Mr. Cunningham, if I could start with you. While preparing
for today's hearing, I heard from a local, independent-living
organization in northwest Ohio asking for my support of the
EMPOWER Care Act. The center connects people with disabilities
to programs and services that are necessary to achieve and
maintain independence in the community.
Without the Money Follows the Person, the MFP, Program,
this center would not be able to hire staff to serve as
transition coordinators and help individuals maintain
independence outside of nursing facilities. Since 2008, this
local program has achieved 524 total transitions, and 77
percent of those transitions have reached 365 days of
independence.
Furthermore, in the State of Ohio in 2017, the average
annual Medicaid savings for individuals utilizing MFP was over
$39,000 per person. How have the cost savings associated with
the program been utilized for the benefit of your State
Medicare population?
Mr. Cunningham. Sure. So, Wisconsin is fortunate to have a
very robust home and community-based services program, and the
way we have gotten there is through utilizing MFP and other
resources to create some innovative practices. And we look at
that and some of the practices, like housing counseling and
other things that we developed through MFP, we have now
included in our HCBS package of benefits because they have been
shown to be proven effective in making sure people relocate.
And we see a reduction in cost. The average nursing home
cost in fee-for-service is about $5,256 per month. Our family
care and HCBS programs have a PMPM of $3,200. So it is in our
interest.
MFP has also allowed us to, as we have expanded our HCBS
services, to move people off the waitlist, and we are on the
cusp of eliminating the waitlist for all of the people that
need HCBS services.
Mr. Latta. Let me follow up. Are there any challenges the
States face during the transitions that could be better
addressed in reauthorization?
Mr. Cunningham. I think the flexibility, again, is very
important. I think housing continues to be a challenge. The
housing counseling that is done, we developed a database of
available 811 housing vouchers through MFP. So I think just
continuing the funding, I think the certainty of having MFP is
also important because some of these programs that we have
going, take 2, 3 years to test out, to see if they are cost-
effective in moving forward. So I think that is what I would
ask for now is to make sure this there is certainty there so we
can keep some of these innovative practices going.
Mr. Latta. Well, thank you.
Mr. Salo--am I pronouncing that right, is it Salo?
Mr. Salo. Salo.
Mr. Latta. Salo?
Mr. Salo. Yes, rhymes with ``halo.''
Mr. Latta. Let me follow up, because in addition to the
letter of support I received for the MFP Program, I also heard
from an Ohio mother who has great concerns with the program.
She cited that MFP forces individuals with severe and profound
intellectual and developmental disabilities into a one-size-
fits-all care model rather than allowing the patients and
families to choose a care setting that best fits their own
medical needs.
Do you believe there are gaps in the program that should
better account for individuals with complex medical and
behavioral needs?
Mr. Salo. I know that there are differences in philosophy
about the nature of the spectrum of institutional versus non-
institutional care and some who come down along the lines of
the least restrictive, as Olmstead is always better, but I
think that, from the State perspective, it is really critical
to be mindful and respectful of the individual or the family
decision to figure out what is the setting that is best for
them.
In most cases, that will be in their home or in their
community. But we certainly know there have been lots of
conversations over the years with--so, for example, parents of
adult children with severe developmental or intellectual
disabilities, whose kids have been in settings for a long time
and are very fearful about having that changed. I think we need
to be very, very mindful about not abruptly changing settings
for people who are not ready for that.
But I think for most populations that we serve in the long-
term care arena, the clear and undeniable trend is to move away
from institutional and toward home and community-based
settings.
Mr. Latta. Thank you very much. My time is expired. And the
gentle lady from California is recognized for 5 minutes.
Ms. Matsui. Thank you very much, Mr. Chairman.
And I want to thank all the witnesses today for being here.
I am pleased that we are hosting this hearing to discuss
important opportunities in Medicaid and potential ways to
improve transparency in our healthcare system.
I want to follow up on the EMPOWER Act. It is really a
strong example of the importance of supporting Medicaid. The
Money Follows the Person, MFP, is particularly important to
seniors in institutional settings, such as nursing homes, who
may be seeking care or services while still being surrounded by
familiar faces and places.
And I think we all understand how important it is to look
at this somewhat individually too, that there is not a one size
fits all here as we move forward. And I really believe that
each of us understand the concept of how important it is. And I
also believe there are challenges here too.
I am interested also to hear more about the changes being
made to the institutional residency period requirement. I
understand that it will be decreased from 90 days to 60 days.
How do you think changing the requirement will impact
beneficiaries of the MFP? Mr. Cunningham?
Mr. Cunningham. Changing from 90 days to 30 days for the--
--
Ms. Matsui. Ninety days to 60 days. That period
requirement.
Mr. Cunningham. I am sorry. Could you repeat that?
Ms. Matsui. OK. There are changes being made to the
institutional residency period requirement. It will be
decreased from 90 days to 60 days. I understand that that will
give a lot more flexibility and allow other patients to be able
to be involved in this. Is that correct?
Mr. Cunningham. Yes. Yes, that is correct.
Ms. Matsui. OK. Now, there have been multiple studies
showing the MFP program can result in significant cost savings
to States. And I think it is really important that Mr. Salo
noted that the program expired in 2016, which forced States to
scale back the program. And I am really concerned that this may
have had unfortunate consequences for States and patients. Can
you give me some examples here, with the challenges that might
have occurred here?
Mr. Cunningham. Yes, so, as I mentioned, as many of the
programs that are ongoing, like our nursing home community
specialists, as many States are running out of grant funding,
they are having to wind down those programs. And that is
impacting their ability to have those innovative processes to
relocate people.
So I think a number of States have actually already
expended their full grant amount, and I think in 2020 is when
the full expenditures have to be completed. So, without an
extension, even at the State level, you start to look at these
programs and how do you maintain the staff to support these
programs in the future once your grant funding goes away?
Ms. Matsui. Certainly, thank you.
And I want to talk a little bit about gag clauses. It is
encouraging that this committee is taking steps to begin
tackling the issue of transparency in our healthcare system. My
understanding is that gag clauses impact the pharmacies, as
well as the patients.
Mr. Chancy, would you like to comment on the impact gag
clauses have on both patients and pharmacies, especially in
relation to pharmacy benefit managers?
Mr. Chancy. Yes, I would love to. The gag clauses,
actually, they do have an impact on both. The patient, our
relationship is based on trust, and they depend on us to bring
and help them maneuver through the intricacies of their
healthcare, specifically with their prescription benefits. When
we are not able to give them options, then it kind of puts us
in a situation where we aren't able to give them information
that we feel like they need.
If we do, then we are running the risk of being in
violation of contracts that sometimes we didn't even know that
we were in violation of.
Ms. Matsui. Right.
Well, Dr. Yoder and Mr. Chancy, how well informed do you
think the public is about gag clauses? Do you think the
patients know to ask about prices at the counter?
Mr. Chancy. They are not very informed, and I think that
because of the way the contracts have been written, not many
people have talked about them. I think they are seeing more in
the news now, and there is a little bit more interest, but it
is nowhere near where it needs to be.
Ms. Matsui. OK. If this legislation, Mr. Chancy, in front
of us is passed, will pharmacists start telling patients about
their alternatives? Or do you think there will be a need to
have some sort of awareness or education campaign?
Mr. Chancy. I think pharmacies will, and I think a lot of
pharmacists currently are doing that, but I think an awareness
campaign would be fantastic.
Ms. Matsui. OK. Thank you, and I yield back.
Mr. Burgess [presiding]. The chair thanks the gentlelady.
The gentlelady yields back.
The chair recognizes the gentleman from Kentucky, Mr.
Guthrie, the vice chairman of the Health Subcommittee, 5
minutes for questions.
Mr. Guthrie. Thank you, Mr. Chairman, and for the Ranking
Member, for holding a hearing on the EMPOWER Act, H.R. 5306,
which would reauthorize the Money Follows the Person Program. I
was very pleased to introduce this bill with my colleague as
bipartisan with Debbie Dingell.
First Mr. Salo and Mr. Cunningham, as you know, H.R. 5306,
as currently drafted, would extend the Money Follows the Person
for 5 years. While this is ideal, would a 1-year extension be
helpful?
Mr. Salo. A 1-year extension, I would argue, is better than
letting it die. If those are the options?
Mr. Guthrie. Those are the options. Well, I don't know if
those are the options, but if that is the option, then you
would rather have a 1-year----
Mr. Salo. A 1-year extension is better than letting it die.
A 1-year extension is not ideal. That is not enough time. If
you understand how State government works, you know that when
programs are dependent on Federal funding, or any source of
funding, if you don't have long-term certainty about where the
money is coming from, how much is coming, and the direction and
speed which it flows, you have uncertainty. When you have
uncertainty, you clamp down, you tighten up, and you stop
spending. You go really, really conservative.
And, if you get a year and you don't know what is going to
happen that following year, you are probably not going to spend
that money because you are going to be very, very cautious, and
that is extremely disruptive to the people who need this. So
the longer the extension, the better. I would argue making it
permanent if you can, but 5 years is better than 1. One year is
better than just letting it die.
Mr. Guthrie. Point well taken.
Mr. Cunningham?
Mr. Cunningham. Yes, I reiterate what he said. I think the
other thing to consider is that, when States see only a 1-year
extension, you start to look at one-time type of things that
are not as effective as really driving the long-term change
that we want to use this funding for, so, yes.
Mr. Guthrie. Thank you. I said for both. The point is well
taken.
Mr. Cunningham, through the Money Follows the Person
Program, over 88,000 individuals have transitioned from nursing
homes and other institutions back to their own homes? I know
there seems like a lot of support in the room for this, and I
am very supportive of that as well.
What have we learned through the MFP program and about how
the quality of life improves for individuals when they
transition back to their homes and communities?
Mr. Cunningham. Sure, the MFP program does require a
quality-of-life survey, and, at least in Wisconsin, when we ask
if they are satisfied where they live, that satisfaction went
from 68 percent to 72 percent. And then when we asked people
that have transitioned to MFP if they like where they currently
live, it went from 62 percent in the institution to 91 percent
in the community.
Mr. Guthrie. People like to be home. And it is even more
convenient and more helpful for the family members, too, to
spend time with them and see them, more than in an
institutional setting.
Mr. Cunningham. It allows them to become a participating
member of----
Mr. Guthrie. Well, there certainly is an appropriate role
for institutions, but that is absolutely right.
OK. Again, Mr. Cunningham, of the 44 States that have
recently participated in the Money Follows the Person, at least
10 States have exhausted their funds and stopped transitioning
new participants to the community. By the end of the year, all
remaining States will stop transitioning new participants
through the program. Without an extension of this program, will
we lose progress?
Mr. Cunningham. Yes.
Mr. Guthrie. It is a given, huh?
Will more seniors and people with disabilities be forced
into costly institutional placements?
Mr. Cunningham. Yes.
Mr. Guthrie. And then has the recent uncertainty hurt
transition efforts?
Mr. Cunningham. Yes.
Mr. Guthrie. You are going through that.
And then one extra one. You have spoken about the
importance of supporting people with disabilities to transition
from institutional settings to the community. What has
Wisconsin done to promote these transitions, both using MFP
dollars and making use of Medicaid as a whole, and how are
individuals counseled in the transition?
Mr. Cunningham. So one of the big things we do is a
community living specialist. And through the diagnostic service
information on--through the MDS at nursing homes, there is a
section Q that clearly asks the recipient, do you want to
relocate into the community? And so we review and have set up a
system where this information flows to our community living
specialists in the ADRCs. And then they reach out to these
people to discuss community options. So this is a cycling
process. And so people that want to move out in the community
are contacted and then worked to develop those community
resources to move them in the community.
Mr. Guthrie. OK. Thank you so much.
Thank you for your effort, Mr. Chairman. I really
appreciate your effort in bringing this today, and I will yield
back my time. Thank you.
Mr. Burgess. The chair thanks the gentleman. The chair
recognizes the gentlelady from Florida, Ms. Castor, 5 minutes
for questions, please.
Ms. Castor. Well, good morning, and thank you, Mr.
Chairman, for calling this hearing.
Today I am thinking a lot about the children with complex
medical conditions and their families. On behalf of the
families across America who are faced with a complex condition
that their child has, I want to thank everyone on this
committee for moving the ACE Kids Act forward. It hasn't been
easy. This has been a multiyear proposition. I have been
working on this bill since the 113th Congress with Congressman
Joe Barton, who has been the stalwart cosponsor and sponsor
here, along with our partners: Jamie Herrera Beutler, Gene
Green, Anna Eshoo, and Dave Reichert.
But the ACE Kids Act in this Congress has over 100
cosponsors, bipartisan, including a number of my Energy and
Commerce colleagues, and I want to thank them, specifically
Representatives Cardenas, Clarke, DeGette, Engel, Kennedy,
Peters, Rush, Bilirakis, Costello, Guthrie, Harper, Lance,
Long, and Olson. And I encourage our other colleagues to sign
on to the bill as well. And thank you for your steadfast
commitment to care for these children.
We also have a number of patient and stakeholder groups
supporting the ACE Kids Act that range from the Children's
Hospital Association to the March of Dimes to the American
Academy of Pediatrics, and many more. Thank you all for
consistently standing up for children with complex medical
conditions.
And I want to also take a moment to thank the committee
professional staff for their dedication to families and the
hours they have spent working on this bill in a bipartisan
fashion, especially Rachel Pryor and Samantha Satchell on the
Democratic side, and Josh Trent and Caleb Graff on the
Republican side.
Additionally, this bill would not be where it is today
without the stellar work of my legislative director, Elizabeth
Brown, and Representative Barton's staffers: Krista Rosenthall,
Gable Brady, and Jeannie Bender.
But it is really the families who are the heroes here. It
is the families of these kids that have explained to Members of
Congress on both sides of the aisle how important it is to have
coordinated care. I became an advocate for the children and
families that this bill will help after spending significant
time back home in Tampa at the St. Joseph's Children's Hospital
Chronic Complex Clinic that was started 16 years ago by a
wonderful pediatric critical care doctor named Dr. Daniel
Plasencia.
The ACE Kids Act is somewhat modeled after the St. Joseph's
Children's Hospital Chronic Complex Clinic and the 700 kids and
families that they serve. But, Mr. Merrill, you know this is
the idea of home health, a medical home for these kids, is not
unique. It is being done, and we need to take it to the
national level.
The families I met with over the years have shared with me
what they have gone through to get the proper care for their
kids. The care that they were receiving was often fragmented
and uncoordinated. But, most importantly, we have got to focus
on making sure the kids have a better quality of life. And we
think through this bill, we will be able to do that.
Mr. Merrill, you might remember Tish West testified a
couple of years ago, and she said--I met her daughter Caroline,
who has been treated at St. Joe's--she said: In the beginning
of Caroline's life, I used to carry around these gigantic
notebooks full of medical records and everything else so that
we went from doctor to doctor, she would have to explain what
was going on and what her illnesses were. But at this clinic,
at this medical home now, they have the medical records; they
are all electronic; everyone knows Caroline; they know what is
going on with her.
Tish said: It is just a real collaborative effort, and she
is much healthier as a result of that.
Do you think we are going to be able to make progress for
more families if we pass the ACE Kids Act?
Mr. Merrill. I absolutely do. And our own experience in
Texas with our STAR Program, which is somewhat equivalent of
ACE Kids, we actually have care coordination clinics and
medically complex clinics that would mimic a lot of structure
that we are contemplating in ACE Kids.
I would give you one example of, just recently--as we have
9,000 children that are signed up in our STAR kids; these are
medically complex kids--and the Cook Children's Health Plan.
And so we took the most complex children of those 9,000, and
our care coordinators, for the first 2 weeks, spent numerous
times on the phone with these families and made home visits to
these families to look at not only what their healthcare needs
were but their social needs.
There was one particular example where a child and family
had been for months and months carrying their child up the
steps because they had no wheelchair ramp for the child in the
wheelchair. We put a wheelchair ramp in for these families.
And so this care coordination and this care plan is, it is
tailored for these specific families. And when it is tailored,
we are able to anticipate needs, not just their medical needs
but other social needs, and make it so much more easier for
these families to navigate what can be a complicated system and
help these children remain healthy.
I will just give you one quick example. This was actually a
couple of weeks ago. We had a mother of one of these medically
complex children call her case manager--and by the way, these
case managers, as you well know, have these incredible close
relationships with these families. There is respect. There is
great communication going on.
And this parent was distraught that she was getting close
to the weekend and she wasn't able, through a series of events,
to get a prescription filled for her child that was much needed
for that weekend, called up our case manager. Our case manager
calmed the mom down, because of that relationship, took care of
the prescription order from the physician, went to the
pharmacy, picked up the drug, and delivered it to the home for
this family, avoiding, by the way, an ER visit, guaranteed, and
probably an in-patient admission. So that is the kind of
activity that we anticipate under ACE Kids, the kind of work
that will make life easier but keep these kids healthier, keep
them out of the hospital, keep them closer to home, and I think
that is a very positive thing for these families and their
children.
Ms. Castor. Thank you very much.
And, Mr. Chairman, I would like to ask unanimous consent to
submit for the record a letter from St. Joseph's Children's
Hospital's CEO in favor of the bill.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
The gentlelady's time has expired.
The chair now recognizes the gentleman from Virginia, Mr.
Griffith, 5 minutes for questions, please.
Mr. Griffith. Thank you very much, Mr. Chairman.
Mr. Chancy, I am going to ask you a couple questions. You
mentioned that community pharmacists have little negotiating
power when it comes to contract provisions set by the pharmacy
benefit manager, and we have seen that in PBMs; we have seen
that before.
Can you explain how smaller and rural community pharmacies
are disproportionately affected by this inability to
effectively negotiate and how that can, in turn, negatively
impact patients?
Mr. Chancy. Yes. And most of our pharmacies are in rural
Georgia, and like, for example, one of our pharmacies, 25
percent of our business is through one PBM. And if they change
their reimbursement model or whatever, it impacts us in a great
way.
And so the lack of getting on that contract or not getting
on that contract depends on whether we, as a business, survive.
One of the concerns in Georgia is we have four counties now
that have no community pharmacies because of some of this, that
they are dealing with.
Mr. Griffith. And not just that, but can't it affect the
patients as well? So I know the committee is tired of hearing
about Clintwood and Haysi, but if you look at them on a map,
they look like they are only about 5 or 10 miles, maybe 12
miles apart. But there is a big mountain in between them, and
the mayor of Haysi told me one time it takes him an hour; he
always plans on an hour to get to any of the meetings he has to
have in the county seat of Clintwood.
So, if you are the community pharmacy in Haysi and the PBM
takes you off, that patient is now going to have to drive to
Clintwood to get their drugs and rely on somebody that--because
most of us rely on our pharmacist, our community pharmacist. Is
that not also a problem?
Mr. Chancy. It is. And CVS Caremark, Caremark being the
PBM, many times they require their patients to go to one of
their pharmacies. And in rural Georgia, there is not a CVS in
every community or county, and so it compromises them with
access.
Mr. Griffith. Yes, sir, I understand that.
Beyond drug-pricing disclosures, what are some of the other
impacts that gag clauses have on the pharmacist-patient
relationship? Can you think of any? Because I can think of one.
A constituent came to me, and we were just talking about this
whole gag issue, and she had stumbled across, and at first, she
had questions about her pharmacist, because originally it
wasn't considered a part of the formulary. So she had to pay
cash for it. It cost her $17.
And as Chairman Walden said in his opening statement, then
they notified her it was in her formulary, and she called in
her prescription, and they told her she would have to pay the
copay of $50. So she called her pharmacist all upset, thinking
that he was doing something goofy. Doesn't that damage that
relationship? And he explained to her that he wasn't allowed to
tell her that, but since she had found out about it, she could
pay with cash if she wanted to.
Mr. Chancy. Oh, definitely. And there are some times where
the patient is required to get the brand instead of the
generic, which is a cheaper copay, and I think it is just the
rebates or some sort of agreements that they have worked out.
And so that impacts them as well.
Mr. Griffith. Attorney General Schmidt, I have some
theories. I like listening to the testimony and listening to
folks, and you did a great job, and you got some great people
signed on to these letters. But one of the concerns that I
might have if we have--and there is an answer to it, but it is
going to take money and effort.
If you have got somebody who is skilled at determining
financial fraud, they might go into the home--let's say the
fictional characters from ``Seinfeld,'' George Costanza's
parents, who were always fighting with one another--now, if one
of them was the patient, somebody who is a financial
investigator might automatically assume that there is some kind
of abuse going on there, and they have been having that
relationship that way, as the fictional characters, 50 years or
so.
And so aren't you going to have to train folks to be able
to distinguish between--financial fraud is different than
physical or mental abuse, and there is a concern, and it gets
complicated. Because I actually had a case one time where they
thought the parents were doing something to an infant. I know
this is a little bit different, but the infant was failing to
thrive whenever it was in the parents' home. We ultimately
discovered the infant was allergic to dogs, and they had a dog
in the house. So, every time they would put it in the aunt's
house, the child would do better. They put it back in the
parents' house, and the child would fail to thrive.
So there are a lot of complications with it, and I think
that your financial investigators are going to have to be
trained, if we give them this authority, and somebody is going
to have to pay for that training, or else we will have people
bringing cases that maybe they ought not.
And one of my concerns there is that when you bring a case,
particularly against a family member, you are yanking that
family apart, and you are pulling that person out, and you
really have to walk with care. What do you say about that?
Mr. Schmidt. Right. Representative, certainly speaking for
myself, I would be very sensitive to that concern. We see those
types of dynamics, not just in the context of our Medicaid
fraud work, but in the context of our broader criminal work for
the State.
So we are accustomed to dealing with those sorts of
distinctions. And we are human, and sometimes we get it right,
and sometimes we don't. But I believe we do in most cases.
I would say one thing: I can't speak for every State.
Perhaps the larger States with larger Medicaid Fraud Control
Units do have distinct, financial-crimes investigators versus
patient-abuse investigators. For Kansas and I think for most of
the small and midsize States, we do not. We do have dedicated
fiscal analysts who are the number crunchers that don't go on
and do field investigations. So they are purely financial.
But with respect to our investigators in our MFCU, we have
six sworn law enforcement officers. They are all cross-trained.
They handle physical abuse, sexual abuse, financial abuse, as
well as fraud. And the reason for that, under current law, is
that they are doing those abuse cases when they occur in a
healthcare facility. So they already have the skills; they just
can't apply them in the non-institutional setting.
Mr. Griffith. All right, I appreciate that, and I yield
back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentlelady from Colorado, Ms.
DeGette, 5 minutes for questions, please.
Ms. DeGette. Thank you so much, Mr. Chairman.
I note that we have a number of representatives of ADAPT
here in the hearing room listening to this, and I want to
welcome all of you. ADAPT was founded in Denver, my district,
and I have worked with them and also the Atlantis community for
many, many years. The Atlantis community is one of the oldest,
independent-living centers in the country for individuals with
disabilities, and they have really done courageous work over
the years in educating all of us about why it is so important
that we pass legislation that supports their independence and
their ability to live in their homes and their ability to
really lead the kind of productive American lives that
everybody in this country should be able to do. So thank you
all for coming out today.
There are a number of pieces of legislation that they
support, but one of them specifically is H.R. 5306, the
Ensuring Medicaid Provides Opportunities for Widespread Equity
Resources and CARE Act. And then I want to thank Congresswoman
Dingell and Congressman Guthrie for sponsoring that.
In Colorado, funding for the Money Follows the Person
Program is aimed at facilitating the transition of Medicaid
beneficiaries from nursing and other long-term care facilities
to community-based services. And since we implemented this in
Colorado in 2013, we have already transitioned 214 folks with
physical, intellectual, or developmental disabilities, mental
illnesses, and other impediments to really being able to live
in these community-based situations.
Mr. Cunningham, I wanted to ask you: Not only is this the
right thing to do, but what I have heard is this actually saves
money. Can you talk about the cost savings of programs like
this?
Mr. Cunningham. Sure. So, yes, it does. Community-based
care is cheaper than institutional care. We see, mentioned in
our nursing home fee-for-service, it is about $5,256 per
member, per month there. And in our home and community-based
services programs, or community-based programs, the PMPM on
average is about $3,233. So that is a savings of about $2,022
per member that you are moving out.
Given that they are numbers, there is always acuity and all
this other stuff, but that is just a broad stroke of the
estimate.
Ms. DeGette. And what are some of the other benefits to
moving folks out of nursing homes and into community-based?
Mr. Cunningham. Well, there is a lot. We operate from the
view of person-centered planning and informed choice. So, once
out in the community through person-centered planning, an
individual can really think about how they want to self-
actualize their own life and look at, employment, look at
engagement with loved ones, with family and community, and,
quite frankly, engage in a life and fulfill the hopes that we
all have in our individual lives.
Ms. DeGette. Thank you.
I want to talk briefly about this other bill--what is the
number--it is a draft, the PBM gag clause prohibition, what an
important bill that is. And I just want to talk for a minute to
you, Mr. Chancy, about this. I have been, for about the last
year, Congressman Tom Reed from New York and I have been--we
are the co-chairs of the diabetes caucus, and we have been
leading sort of an independent insulin inquiry.
And we sent letters of inquiry to the three brand name
insulin makers about patient assistance programs and drug
discount cards. And for a lot of these patients, these programs
are a lifeline. Now, in your testimony, you stated that
pharmacists can counsel patients about alternative purchasing
options in some cases, such as when patients don't present a
form of insurance.
If a patient asks about ways to lower their insulin cost at
your pharmacies, do you counsel them about patient-assistant
programs and drug discount cards?
Mr. Chancy. Yes, we do.
Ms. DeGette. OK. And as part of this consult, do you tell
the patients and clients that these financial assistance
programs may not count towards their out-of-pocket expenses
such as deductibles and copayments?
Mr. Chancy. Yes, we do.
Ms. DeGette. Good, that is great.
Mr. Chairman, I am hoping, not just the PBMs, but the
entire system of drug pricing is something we should be having
hearings on, and we should be doing it before the end of this
year. Because the PBMs, I mean, it is ridiculous that they tell
pharmacies that they have these nondisclosure agreements. But
really it is throughout the system. And I think we could still
do it. I don't know about all the rest of my colleagues here,
but I was home in Denver for most of the August recess; that is
all people wanted to talk to me about, was the cost of
healthcare and the ridiculous cost of prescription drugs.
Thanks and I yield back.
Mr. Burgess. Thank you. The chair thanks the gentlelady.
The chair would remind members, we do have another hearing
following this that is scheduled to begin at 1 p.m., and,
generally, I am fairly generous with the time, but I am going
to ask members to really confine themselves to the 5 minutes
for questions.
With that, Mr. Bilirakis, you are recognized 5 minutes for
questions.
Mr. Bilirakis. Thank you, Mr. Chairman, and I really----
Mr. Burgess. Oh, wait, would the gentleman suspend?
Mr. Bilirakis. Yes.
Mr. Burgess. I did not see Mr. Lance had ascended to the
dais.
Mr. Lance, you are recognized for 5 minutes.
Mr. Lance. Thank you, Mr. Chairman.
I am not sure I have ascended to the dais, but I am
certainly pleased to be here.
Mr. Merrill, in your testimony, you talk at length about
your involvement in the Center for Medicare and Medicaid's
innovations demonstration: Coordinating All Resources
Effectively Award Demo. You wrote, collectively, these programs
reduced emergency department visits by 26 percent and reduced
in-patient days by 32 percent.
The first full year of operations coordinating care for
these children, CARE ultimately reduced overall Medicaid costs
by 2.6 percent while improving patient experience for 8,000
children.
Mr. Merrill, can you walk us through how CARE coordination
works in practice? I certainly think it would be helpful for
the committee to hear how this process works on a day-to-day
basis in this demonstration and how the savings and patient
satisfaction are being achieved.
Mr. Merrill. Thank you for that question. I think CARE
Coordination and Health Homes, as I mentioned earlier, tailor
the care needs around that child, and by doing so, we are able
to create efficiencies, improve care, and alleviate the burden
that these families oftentimes experience in navigating what
can be a very complex healthcare environment. I think that is
where the patient experience improvement comes from.
If you look at the CARES grant, one of the things that we
did through this, with the 10 hospitals, Cook being one of
those that participated, is we did use a common definition. And
I believe, again, a common definition is really important if we
are going to make improvements in not just the care, but the
outcomes and the patient experience. Peter Drucker said: If you
can't measure it, you can't improve it.
And while we were able to take 10 hospitals across 8 States
and use a common definition, that was just really the first
year of savings. I think there is a whole lot more on the
table, but if we can scale that to more than just 8 States,
take it to 50 States, then I think we have a real opportunity
to drive best practices and ultimately improve the kind of care
we are looking for, for these children.
But the CARE coordination from the health home is really
where the rubber meets the road with these families, where you
are working to tailor that very specific care model for that
child.
Mr. Lance. Thank you very much.
Attorney General Schmidt, thank you for your work on the
important issue of expanding the authority of the Medicaid
Fraud Control Units, to detect, investigate, and prosecute
Medicaid patient abuse in noninstitutional settings. In your
testimony, you detail some certainly very unfortunate stories
that have been uncovered and stopped. I encourage all of my
colleagues to read the testimony carefully.
What has me all the more concerned is that, even as
noninstitutionalized care and Medicaid has expanded--and I
support the expansion of Medicaid, and New Jersey has expanded
it--the ability to protect these patients from the types of
abuse has not. My question to you, Attorney General, without
this important change to law, what tools do States have to
protect these patients?
Mr. Schmidt. Representative, the answer would vary State by
State, but as a general matter, and certainly in Kansas, it
would be the general tools we have for any criminal
investigation on any criminal subject. And the reason that
matters and is less optimal, in my view at least, than having
the specified authority under the Fraud Control Units, is that
these are specialized individuals in units focused on patient
abuse, as well as financial matters, within the confines of the
Medicaid program. They are focused.
We have 400-plus law enforcement agencies in Kansas. They
are terrific people. They do a great job, and they are
stretched far, far too thin and often are unable to be focused
in a way that a specialized entity can. So I think you just go
from the small pool to the big ocean if you don't have this
sort of specialized capacity to deal with abuse in the
noninstitutionalized setting.
Mr. Lance. Thank you very much, Attorney General, and my
thanks to the panel.
And I also want to thank those in the audience who are here
advocating on behalf of this wonderful cause. And I have been
honored to meet with some of those who are in the audience
today, and we certainly welcome them for their advocacy here in
Washington.
Mr. Chairman, I yield back 16 seconds.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentlelady from Illinois, Miss
Schakowsky, 5 minutes for questions, please.
Ms. Schakowsky. Thank you, Mr. Chairman.
Recently I met with a 9-year-old named Naomi Bytnar who has
a complex medical condition and is being treated at Advocacy
Children's Hospital in my district. And I am just so proud to
cosponsor H.R. 3325, the bipartisan ACE Kids Act, which will
help many children just like Naomi get the care they need. I
thank all of you who are supporting that.
I would also like to thank Representatives Dingell and
Guthrie for introducing the bipartisan H.R. 5306, the EMPOWER
Care Act, to reauthorize the Money Follows the Person, MFP,
Program, which I am proud to cosponsor. The MFP Program has
given over 88,000 individuals the opportunity to transition
from institutional care, something I have been working on for
decades now from my time in the legislature in Illinois.
Mr. Salo, without an extension of MFP, what will it mean
for seniors and people with disabilities?
Mr. Salo. Without extension of Money Follows the Person,
what you are going to have is a definite subset of people who
are in an institution, in a nursing home, who don't want to be
there, who don't need to be there, and are going to have
enormous difficulty making the transition out, so, yes.
Ms. Schakowsky. Mr. Cunningham, what challenges do States
face in supporting transition from institutions to the
community, and how does MFP address those challenges?
Mr. Cunningham. So I think obviously housing is a big issue
of finding a resident, especially if you no longer have the
housing since you have been in the institution. So, through
housing counseling funded through MFP, through projects like
developing databases of available section 811 housing vouchers,
that also provides assistance.
I also think another area that has been funded is the Aging
and Disability Resource Centers. And I would say that this
entity is critical in a comprehensive, long-term care system,
because they can not only advise about the resources that
Medicaid has but also about Medicare, about other resources
within the community, to create natural supports and lower the
cost of care and the Medicaid program bears but also other
systems bear. So we have used that MFP to fund those ADRCs
also.
Ms. Schakowsky. Thank you for that.
Turning to the gag clause, I want to emphasize that this
committee can be doing much more to lower prescription drug
prices, for example, basic transparency and price spikes
requiring that the price in direct-to-consumer prescription
drug ads and Medicare prescription drug negotiations. So there
are things that we could do, but we must get rid of gag clauses
because providing patients with information about pricing is
critical.
Dr. Yoder, though, I want to ask you--where are you? I am
sorry. There you are. OK. You raise a really interesting point
in your testimony that paying out of pocket impacts
deductibles, maximum out-of-pocket costs and for seniors, the
doughnut hole. Senior groups have told me that this information
would be useful at the pharmacy.
So what is the effect on the beneficiary's deductible,
maximum out-of-pocket limits when paying out of pocket? How
does this affect seniors in the doughnut hole?
Dr. Yoder. So, generally, when the medication is paid for
out of pocket, those prescriptions don't get adjudicated to the
PBM system. So there is no way for those accumulators to be
added to that would reflect what the member's out-of-pocket is.
So essentially that prescription is opaque to the health plan
as well as the PBM. No one knows it was actually dispensed,
other than the pharmacist who dispensed that. So it doesn't go
toward any of those accumulators at all.
Ms. Schakowsky. So, when we talk about eliminating the gag
rule, would it be useful, do you think, to share that
information as well, so people really understand the
consequences of paying out of pocket? In other words, someone
might be told that if you pay the $50, you now will climb out
of the doughnut hole, rather than the $10 if you pay out of
pocket?
Dr. Yoder. Absolutely. We support making sure that the
members and the enrollees do know what the consequences would
be for doing that. In addition to not just the accumulators, in
most cases those prescriptions don't go against any of the
checks for medication duplication, drug interactions, things
like that, because they are not going into the PBM system to
see what all the other medications that member may be taking.
So we absolutely do support that transparency so members do
understand what the consequences would be for paying out of
pocket versus using their copay cards.
Ms. Schakowsky. What you just said is a safety issue that
it seems to me, why couldn't this be recorded?
Dr. Yoder. Because the way the prescription adjudication
system works, the PBMs don't see those prescriptions. They
never go into the systems at all because they are just at the
local pharmacy. The local pharmacy can do checking on the
prescriptions they have for that member, but if the member goes
to different pharmacies, if the member uses mail order, things
like that, those prescriptions never even enter into the
system.
Ms. Schakowsky. That is a concern we ought to deal with.
Let me just say, as somebody who has--I am over time. I am
going to respect what you said, Mr. Chairman, and yield back.
Mr. Burgess. Thank you. The chair recognizes Chairman
Walden, 5 minutes for questions, please.
Mr. Walden. Thank you very much, Mr. Chairman.
Really good hearing, appreciate all your testimony.
Mr. Yoder, your testimony contemplates the possible
downsides of cash purchases for medications which you were just
talking about, such as mechanisms to catch potentially harmful
drug interactions or medication nonadherence.
So I am kind of interested to hear how Mr. Chancy would
respond to those concerns.
Mr. Chancy, in your experience, when discussing cash
prices, do pharmacists have the necessary information before
them to identify harmful drug interactions?
Mr. Chancy. Yes. Whether it is cash or whether it is
insurance, our computer system will run the analysis on any
drug interactions.
Mr. Walden. All right. And are there ways that we can
improve this legislation to avoid any unintended consequences
concerning potentially harmful drug interactions or medication
nonadherence, things we could do to improve this legislation to
prevent the kind of problems that are being discussed right
now?
Mr. Chancy. Yes.
Mr. Walden. What would those look like?
Mr. Chancy. Pertaining to adherence?
Mr. Walden. Yes, to medication nonadherence and to harmful
drug interactions.
Mr. Chancy. Well, I think if we are actually running it
through the insurance, and I was not familiar with the
insurance doing the drug-drug interactions on the back side,
but I think if we were to know about those interactions, that
would be helpful for us to help with the patients upfront, to
make sure if there are any issues they are having, we can
actually work with their physician to change medications or
change drug regimens.
Mr. Walden. All right. Thank you.
Dr. Yoder, I am going to change gears here to the other
bill. So I appreciate your providing ways we can improve the
Healthcare Fraud and Prevention Partnership, and so I would
like to focus on two of those. First, you mentioned that Blue
Cross Blue Shield recommends creating improved mechanisms for
the exchange of findings so that all participants are best
informed of lessons gained from the experience.
What are some of the existing limitations on information
sharing that we should be aware of?
Dr. Yoder. A couple things come to mind. So one would be
some of the HIPAA requirements that are out there. So right now
the way the data sharing goes through a third party which
deidentifies the data, which is great for analysis. But if
there are actual particular instances of fraud, that
information doesn't necessarily flow through because of HIPAA
and because people are not real comfortable about having those
conversations.
Mr. Walden. All right. Are there things Congress could do
to improve that information sharing?
Dr. Yoder. I think we would support any way that we could
strengthen the committee charter or the charter for the
organization to make it clear that you can share information
within the confines that would not be HIPAA violations.
Mr. Walden. A violation of HIPAA, OK.
And, second, you note the partnership appears to be
prohibited in its charter from advising Medicare and Medicaid
of the schemes it identifies. I know that our staffs have asked
HHS for a better explanation of why the charter is not allowed
to provide advice to the Federal Government, a Federal
official, or a Federal agency.
Are you familiar with the background of why the charter
includes this firewall?
Dr. Yoder. No, unfortunately, we are not familiar with why
that would be in there.
Mr. Walden. OK. And the draft bill includes report language
that Congress recommended by Ranking Member Pallone. Do you
believe that having the partnership report to Congress would
amplify opportunities to prevent fraud and abuse across all
payers?
Dr. Yoder. We actually don't have a position on that. It is
hard to tell whether that would be impactful or not.
Mr. Walden. All right. Frank and I think it probably would
be, so you might want to have an opinion on that later that is
good, positive. Just kidding.
I think that is all I have for now. I appreciate your
testimony on all these bills. We have got a lot of work to do,
and we do it well on this subcommittee, and I appreciate the
leadership of Dr. Burgess and yield back.
Mr. Burgess. The chair thanks the gentleman.
The chair recognizes the gentleman from Maryland, Mr.
Sarbanes, 5 minutes for questions.
Mr. Sarbanes. Thank you, Mr. Chairman.
I want to thank the panel for your testimony. Very
important pieces of legislation that we are discussing today.
All have earned bipartisan support for obvious reasons, given
what you have been telling us and, I think, given the
statements of our colleagues here on both sides of the aisle.
I wanted to focus on the EMPOWER Care Act again because a
lot of people have spoken to it, but I think it is really
critical. Obviously, we are at this stage where the
authorization has expired. States have been sort of living on
the reserves associated with it for some time, but that is
going to be running out quickly. And the State of Maryland
faces that challenge as well. So it is important for us to get
this done, and that is what the purpose of the legislation is.
The reason this is called the EMPOWER Act is because it is
about empowerment. It is about giving the opportunity for
independence, to make sure that seniors, people with
disabilities, others have the opportunity to live and thrive in
a more independent setting and redesigning the Medicaid program
so it can help to support that.
So, Mr. Salo, I am going to direct this to you. And you
have addressed it to some degree already. But I am interested
again in just the perspective on what this does to promote
independence and the benefits of it. I was thinking earlier
that we often or increasingly we have been talking about how
social determinants are having an impact on the way we deliver
healthcare. But in a sense, what is offered by the EMPOWER Act
and the Money Follows the Person approach is kind of a reverse
of that.
If you think of it, it is using our healthcare system and
the way we reimburse and organize the delivery of care to, in a
sense, create social dividends. And so maybe you could speak
again to that idea of how this program is creating social
dividends, independence, employment opportunities that might
not have been possible under the old construct, empowering
individuals to be contributing members of their own community
in ways that previously they might not have been able to be
and, therefore, strengthening the broader community that
benefits our country.
So talk about the social dividends. I have sort of just
grabbed that phrasing for the purposes of this question, but I
would be interested in, again, your perspective on what that
independence opportunity offers to people.
Mr. Salo. Sure. I think I would be somewhat remiss--and
acknowledging it is outside of the purview of this conversation
today, but I would be somewhat remiss in not reminding everyone
that this country doesn't have a long-term care system. We have
Medicaid. Medicaid is it. Medicaid is by far the dominant
player in long-term care, whether it is institutional or
noninstitutional, for everyone in this country.
And because Medicaid is a means-tested program, that means
that when Americans need long-term care services and supports,
they have to go on Medicaid, and they have to impoverish
themselves. Those are the rules. We didn't design it that way,
but that is how we have fallen into it. That is how the system
works. And I would argue, as a macro construct, that is not
terribly empowering to begin with.
So I would just encourage as we look to the future to say,
are there other ways we can think about providing the necessary
long-term services and supports to Americans through other
means? But having said that, within the construct of Medicaid,
clearly what we are seeing is if we can embrace--and we have,
but as we embrace the trend for self-determination--whether
that is where do I want to live, do I want to work, how can I
work, who do I want to associate with--MFP and many other
efforts that have been underway in Medicaid for the past three
decades have all been about empowering people and about
providing freedom.
That I think is an incredibly important dividend. And I
think what you see as a result of MFP, specifically getting
people out of an institution who don't want to be there or who
shouldn't be there, or whether it is any of the other efforts
to try to provide upfront alternatives to prevent people from
going into that institution in the first place, it is all
about, how can we empower the individual and give them the
self-determination that they need to make those meaningful
choices for themselves? And I would argue that that makes their
lives better, their family lives better, and their community
lives better.
Mr. Sarbanes. I appreciate that. Just to close, I would say
that, within that larger construct, it can be frustrating
sometimes. I think what you are saying is the MFP approach is
an innovation, and we should pursue more innovations like that
that can be empowering to people because it is better for our
entire community when we do that.
Thank you, and I yield back.
Mr. Burgess. The chair thanks the gentleman.
The gentleman from Florida is recognized for 5 minutes for
questions, please.
Mr. Bilirakis. Thank, Mr. Chairman.
I appreciate it. And I appreciate you agenda-ing the ACE
Kids Act today. It is great legislation. I have been a strong
supporter, a longtime supporter of that legislation. Bipartisan
bill.
In the Tampa area, St. Joseph Children's Hospital has been
running a Chronic-Complex Clinic for children, and I have
toured that particular hospital and that clinic, and I tell you
it is a wonderful thing. It is a great concept.
I have had the opportunity again to tour it over the past
few years and see how integrated care model can benefit the
children with complex medical issues. Again, the children, we
have seen examples time and time again where the children come
up here and show us how well they are doing and how it benefits
them and their families.
Mr. Merrill, you mentioned that children with medically
complex conditions account for a large share of the Medicaid
costs for children. Can you talk about how a medical home, such
as the one at St. Joseph's, can bring savings to Medicaid? Do
you have research showing these savings?
Mr. Merrill. Yes, thank you. Great question. There have
been some studies, independent studies, done that have shown
that the potential savings for ACE Kids for the Medicaid
children could be anywhere from up to $5 billion to $13 billion
over a 10-year period. And, as I said, under the CAREs grant,
even though 2.6 percent sounds fairly small, I think that is
just the beginning of some opportunity for us to really, if we
can scale this across all 50 States instead of just one-offs at
different organizations--and I know the hospital you mentioned,
they do incredible work there, but they are by themselves. They
are siloed. And if we can create a national database in which
we are sharing data, working together, driving best practices,
then, in the end, I think we truly can create the savings that
everyone is looking for but also improve the patient experience
through these coordinated care health homes.
Mr. Bilirakis. And that is the priority, to improve the
patient's experience and the quality of care for the child.
And, again, it is convenient for the parents. So I would like
to see a hospital in every region of the country that has the
ACE Kids model.
Again, is quality measure data currently collected in
Medicaid or Medicare?
Mr. Merrill. Yes, I think it is by State, and you will see
different States starting to implement quality measures with a
pay-for-play component to it. We are unaware of any quality
measures that are specific to this medically complex
population. I think that this bill contemplates that, as it
should.
One of the very most important first things that I believe
we should look at as a quality indicator is patient and family
satisfaction. That is really what this bill is all about,
making life much more convenient for these families, allowing
them to navigate the healthcare system easier and have the
better outcomes.
We could implement outcome measures, reduced readmissions,
for example, for this population, because this population tends
to bounce back into the hospital. But if we are successful at
creating the medical home, then we believe that we can keep
these children out of the hospital more often, closer to home,
and deliver better care and better outcomes as a result of
that.
Mr. Bilirakis. It is so very efficient too, because the
doctors, they have multiple appointments during the day, they
can see----
Mr. Merrill. That is correct.
Mr. Bilirakis [continuing]. The doctors. And, again, it is
great for the child and the family. So I appreciate it. It is a
no-brainer, as far as I am concerned, but sometimes no-brainers
don't get passed up here. And I really appreciate the chairman
agenda-ing this bill. It has got to get done.
Mr. Salo, you mentioned that it is important to avoid one
size fits all and to allow for a flexible benefit design. And I
agree. We have one Medicare program, but we have 50 Medicaid
programs, each designed to serve the unique needs of their
States.
Mr. Salo and Mr. Merrill, do you think that the latest
discussion draft for ACE Kids promotes a flexible benefit
design for States? Maybe, Mr. Salo, you want to go first. I
know we don't have a lot of time.
Mr. Salo. Sure. I think we made a lot of progress, and I
think as long as it continues to allow Florida to acknowledge
its current delivery system, Florida has a separate managed
care organization completely focused on kids in the foster care
system.
New York has a system in place that holds pediatricians
accountable for making sure that kids arrive at school at
kindergarten ready to learn. There are efforts like this
underway in lots of places. We want to make sure that this is a
complement and improvement to those efforts as opposed to just
running into them in a conflicting way.
Mr. Bilirakis. Mr. Merrill.
Mr. Merrill. This bill actually allows each State to
implement the program that works for them. In Texas, with our
STAR Kids, we have Medicaid managed care, and it works pretty
well. I think it can work equally well in a fee-for-service
environment. And so I think that is the flexibility that is
built into this, so that the States can, number one, opt in or
out; and if they opt in, they can use their delivery system
that they have in place today.
Mr. Bilirakis. It makes sense to me. And I want to thank
the lead sponsors of this bill, of course, former Chairman
Barton and also Representative Castor, and all the cosponsors.
I am one of them as well.
Thank you very much. And I yield back, Mr. Chairman.
Mr. Burgess. The gentleman yields back. The chair thanks
the gentleman. The chair recognizes the gentleman from
Oklahoma, Mr. Mullin, 5 minutes for questions.
Mr. Mullin. Thank you, Mr. Chairman. And thank you to our
witnesses for being here. I am going to jump right into it.
Mr. Salo, first of all, can you talk about how, in addition
to the obvious benefit to States of enhanced funding, the
ability to incorporate medically complex children into a health
home is a critical improvement compared to the current law?
Mr. Salo. Sure. I think if you look at any State in the
country, what Medicaid directors are trying to accomplish is a
move away from a historical healthcare system in this country,
not just Medicaid but Medicare and commercial, that has been
fee-for-service. And we are moving toward a world where care is
coordinated. It is managed. It is holistic, and it is patient-
centered.
That will look different in different States. It might be
managed care. It might be ACOs. It might be patient-centered
medical homes. It might be health homes. Each of those is going
to work in the political and geographic and cultural realms in
which those States reside.
If we acknowledge those, then I will channel my good friend
Dennis Smith, who once talked about the historical healthcare
system for people with disabilities, for kids with medically
complex needs, for frail seniors. The fee-for-service system,
FFS, he said, it should stand for fend for self because that is
what we require; that is what we are requiring of them.
And what Medicaid is trying to do is to create a system
that is going to make it so that people don't have to spend
their lives navigating multiple different silos and that the
care itself is coordinated and managed in a better way. That is
what Medicaid is trying to do.
Mr. Mullin. Thank you.
Mr. Schmidt, what protections do patients currently have
when Medicaid Fraud Control Units detect abuse in a
noninstitutional setting?
Mr. Schmidt. With respect to protections from the Medicaid
Fraud Control Unit, I think the historic answer is none, or
realistically, if we detect it, we are going to call some other
law enforcement agency and say: Please take a look, we can't.
Mr. Mullin. How often do they actually pick it up?
Mr. Schmidt. It depends on the jurisdiction. We have had
cases in Kansas that, for example, in some of our more robustly
staffed jurisdictions, that they will take it. We have had
others where we haven't felt good about having to hand the case
off.
Mr. Mullin. They simply don't have the manpower or the
knowledge to do it?
Mr. Schmidt. That is correct.
Mr. Mullin. Are there any other settings that Medicaid
Fraud Control Units are prohibited from addressing patient
abuse?
Mr. Schmidt. I believe the answer to that is no, but I
would sure want to double-check that with the folks that--there
is nothing else on my radar screen. Nothing else on my radar
screen.
Mr. Mullin. Can Medicaid Fraud Control Units detect,
investigate, and prosecute fraud inside the Indian Health
Service facilities?
Mr. Schmidt. I don't know the answer to that. Sir, we don't
have that issue having arisen in Kansas and I just don't know.
I can certainly check with folks that would, if that would be
helpful, and have them follow up.
Mr. Mullin. Can Medicaid Fraud Control Units pursue cases
of patient abuse in his facilities?
Mr. Schmidt. I would have to do the same.
Mr. Mullin. Do the same?
Mr. Schmidt. Do the same.
Mr. Mullin. My point that I am trying to get at, obviously,
Medicaid is a tool which can be utilized for the benefit of
those in need and those in most critical need. It can also be
utilized to help strengthen systems like his. But if we are
going to be in the business of trying to investigate fraud,
then we also need to have the ability to go into where it is
being used, not limited access.
And I am sure you can appreciate that. We want to make sure
that, one, the dollars that was invested in Medicaid is being
used properly by those that are receiving the funds.
And what I am trying to get at is, if there is a way for us
to be able to help, we do want to help because, as you
mentioned, our attorney general, Mike Hunter, is associated in
helping on an important bill. We are also in desperate need of
wanting to find out how we can help strengthen our his system.
We don't know if there is abuse going on, because it hasn't
been investigated. We don't believe there is, because we
believe our Tribes are extremely good stewards of what they are
using their assets for. You can go and you can look at the his
facilities and the health clinics and the Indian hospitals
throughout my district, and it is amazing what is happening,
but can it be utilized further?
So my whole point on asking those questions--and I didn't
expect you to know, because currently I don't think there is--I
am here wanting to say I want to help. If we believe there is a
reason for us to do it, I want to help. I want to make sure
that those dollars are being used properly so we are not going
after everybody, but we are only going to focus on the bad
actors.
With that, Mr. Chairman, I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
I think all members of the Health Subcommittee have been
recognized, and we will now turn to members off the
subcommittee.
And, Mr. Welch, you are recognized for 5 minutes for
questions, please.
Well, let me clarify that statement. All members of the
subcommittee with the exception of your subcommittee chairman,
who deferred his questions. So you may go ahead of me. Mr.
Welch, you are recognized for 5 minutes.
Mr. Welch. Mr. Burgess, you are always doing a generous
thing. Thank you very much.
I want to speak to Mr. Chancy about the gag rule. That is
astonishing. Mr. Carter and I have a bill in to get rid of it.
But can you just give some description of what it feels like to
be a pharmacist. And in my experience, the pharmacists have
very close customer-pharmacist connections, and they are
guiding their customer in the use of that medication, and it is
a place the customer can go to because they trust the
pharmacist.
So what is it like for a pharmacist to have this gag order
when if he or she didn't have it and was free to speak, they
could save that customer, who they value, an awful lot of
money?
Mr. Chancy. It puts us in a very compromising situation
because, like we had mentioned earlier, our relationship with
our patients are based on trust. And they depend on us to
maneuver--this stuff is complicated. We have to stay on our
toes to keep up with it, and our patients really depend on us.
And when we can't be fully forthright with them, then that just
puts us in a compromising situation.
Mr. Welch. It kind of makes you feel dirty, right? It is
awful, because they trust you. They are putting their medical
situation in your hands. They are asking you intimate questions
about, you know, this was my reaction, what do you think I
should do? And they are assuming, since they trust you, that
among other things, if you could save them a hundred bucks, you
would, because it is not money going in your pocket.
Mr. Chancy. Oh, no, definitely not.
Mr. Welch. Do you have any idea why it is legal to put
handcuffs on your ability to act?
Mr. Chancy. It has always been a bad rope for us.
Mr. Welch. Mr. Chairman, just bipartisan, I hope we can get
rid of this. The idea that a pharmacist can't give relevant
information on how to save money for their customer really is
inexcusable. So I appreciate the hearing that you are having.
Thank you. And I want to talk to the attorney general a bit
about your work. Our Medicaid Fraud Unit in Vermont does a
tremendous job, and it is both recovering money and, I think,
also a deterrent against would-be malefactors. And, of course,
when this legislation was initially passed, most of the
Medicaid services were provided. They were provided in
institutional settings.
So I would just ask you to elaborate about your reasons for
supporting this legislation, and I have a bill in in order to
accomplish your goals. But thank you.
Mr. Schmidt. Thank you, Representative. And, again, thanks
to you and Representative Walden for your leadership in making
this real. And as I mentioned earlier, I worked very close with
my friend, your attorney general, General Donovan, on this. And
he and I have talked many times--I certainly don't purport to
speak for him--but both coming from lightly populated States
with substantial rural areas, how important this expansion is
to allow us to have the capacity of skilled investigators and
prosecutors who are expert in patient abuse matters to be
available and deployable in areas that simply don't have them
with respect to local resources.
So I think it is vitally important, and it doesn't make any
sense to have this arbitrary restriction that I can see.
Mr. Welch. Right. And my understanding, in the Vermont
Medicaid Fraud Unit, we return a lot more money than it costs
to run it. I think it is like six to one. I don't know what it
is in your State.
But is there any reason to be apprehensive that if we
expanded your authority to recover and deter bad conduct
outside of the current law, that it would be a financial drain?
Mr. Schmidt. No, I don't think so. And I guess I would
offer just a couple of thoughts on that point. Number one,
obviously, the financial recoveries of a MFCU come principally
from the fraud side, not the abuse side. And so I do understand
at least those who articulate, well, it is different. But,
having said that, most of the Medicaid Fraud Control Units,
including ours in Kansas, are self-funding, and they are
returning money to the taxpayers. And so I have no concern
along those lines.
Mr. Welch. In Kansas, sort of like Vermont, you are kind of
tight with a dollar, right?
Mr. Schmidt. I think that is true, and we wear that as a
badge of honor.
Mr. Welch. Well, I think Mr. Walberg is too, so it has been
great working with him. And I thank you for your work and your
testimony on that.
Mr. Schmidt. Thank you, Representative.
Mr. Welch. Thank you. And I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentleman from Michigan, Mr.
Walberg, 5 minutes for your questions, please.
Mr. Walberg. Well, my good friend and colleague from
Vermont, I am not tight; I am efficient.
Mr. Chairman, thank you for holding this hearing, and thank
you for including our legislation as part of the bill packages
here. I would like to ask, Mr. Chairman, unanimous consent to
submit for the record letters from the National Association of
Attorneys Generals, Families USA, and Partnership for Medicaid
Home Based Care, and express support for H.R. 3891.
Mr. Burgess. The ranking member is concerned about the
letter from Families USA, but I think I will go ahead and
accept them. We will.
[The information appears at the conclusion of the hearing.]
Mr. Walberg. Thank you.
Attorney General Schmidt, thank you for being here today
and for your efforts in highlighting the need for legislative
reforms offered by myself and my colleague, Representative
Welch.
Medicaid Fraud Control Units play a vital role in bringing
those who commit Medicaid provider fraud, patient abuse and
neglect to justice. In my home State of Michigan, Medicaid
Fraud Control Units, or MFCUs, recovered over $7 million in
taxpayer dollars in 2017 and contributed to 24 convictions.
Nationally, MFCUs are responsible for about $1.8 billion in
recovered funds and 2,500 convictions.
I commend the work of these State Fraud Control Units and
the attorneys general for protecting the most vulnerable of our
population from harm as well as ensuring taxpayer resources are
being used appropriately. So thank you.
Attorney General Schmidt, as you know, currently MFCUs may
only investigate cases of patient abuse that occur in
institutional facilities, et cetera. Let me move to what this
bill could possibly do. If our legislation were to become law
and MFCUs were permitted to widen the scope of their
investigations, do you have any sense of how many Medicaid
beneficiaries could be protected from abuse or the amount of
taxpayer funds that could be recovered?
Mr. Schmidt. Representative, I don't have hard data, and I
am not aware that it exists. If it does, I don't have it. I can
give you anecdotal information from Kansas with numbers.
Mr. Walden. That would be helpful.
Mr. Schmidt. And you can draw from that what you will. In
State fiscal year 2018--we are on a July through June fiscal
year in Kansas. In State fiscal year 2018, our MFCU received 16
referrals of suspected patient abuse. Of that number, we found
a way to investigate or cause to be investigated 11. That
leaves a difference of five. Out of those five, I didn't go
back and personally review the files before this hearing, but
if normal patterns hold, I suspect probably half of those there
simply wasn't evidence of a crime, and so there was no further
action to be taken, which leaves one or two that, had we had
the ability to proceed in the noninstitutional setting, we
could have investigated and, assuming there was evidence,
prosecuted.
To put that in context for Kansas, we also prosecuted to
conviction 16 criminal cases last year in our MFCU. It is
coincidental that is the same number as the referrals. They
aren't connected. So had we added one from a noninstitutional
setting because of your bill, that would be a 6-percent
increase in the number of convictions. If it were both, it
would be a 12-percent increase.
Mr. Walberg. Could you give us an example of one of those
where you had to turn a blind eye because of the inability?
Mr. Schmidt. Absolutely. The one that comes to mind that
troubles me the most, it was a case in a very small county,
very rural county, lightly resourced, both on the police law
enforcement side and on the prosecutor side.
The matter came to our attention technically on a fraud
claim, but it was obviously more than that. It was a case where
an individual was being paid by the Medicaid program to provide
personal care services in home for a beneficiary. The
beneficiary was either nonambulatory or had substantial
mobility restrictions, and so the PCA was supposed to be there
all night long sitting with this person, providing the
appropriate care. They didn't, and they billed for it, which is
how it came to our attention as a fraud matter.
The reason it was particularly distressing is that, on one
of those evenings before this was all uncovered, the
beneficiary, who was a smoker, was home alone when the PCA was
supposed to have been there. The person was smoking, it
appears, in bed. The cigarette dropped. It caught the house on
fire, and the individual died. Now, there was Medicaid fraud in
a small amount of dollars, but obviously the much greater harm
there was the question of whether there was a criminal
homicide, whether there was a negligent manslaughter or
reckless manslaughter or some other form of prosecutable
homicide, and we did not have the ability to use our MFCU
assets to investigate that.
So we had to go back to the local police and the county
attorney who called us in the first place and say: We are sure
glad to help out of other assets, but we can't take this. We
can prosecute him for two or three thousand bucks' worth of
fraud, but that is not what this is really about.
Mr. Walberg. Thank you. Thank you, and I yield back.
Mr. Burgess. The chair thanks the gentleman. The gentleman
yields back.
The chair recognizes the gentlelady from Michigan, 5
minutes for questions, please.
Mrs. Dingell. Thank you, Mr. Chairman and Ranking Member
Green, for allowing me to participate today in holding this
hearing.
There are several bills being considered today. I am going
to mostly confine myself to the EMPOWER Care Act before my
colleague Mr. Carter speaks. And when his bill gets introduced,
I am going to tell you of a story last week of picking up a
prescription that was $1,300, and after you peeled me off the
ceiling and I called the doctor and screamed and talked to the
pharmacist, got an equivalent for $40. I am much more
aggressive than many in asking questions, but, Mr. Carter, I am
on your bill when you get it in.
But now I will confine my remarks to--and that is a very
true story--H.R. 5306, the EMPOWER Care Act, which I am proud
to author with my friend and colleague, Congressman Brett
Guthrie.
Improving long-term care has been one of my top priorities
since coming to Congress. And as I have listened to all of you
talk today, our long-term care system is broken. It doesn't
work. Most people think Medicare covers it, as Mr. Salo
previously noted, and are shocked to learn that if you are
going to get sick, better do it only 90 days, 90 first, you are
out, and that Medicaid is actually the single largest payer of
long-term care in this country. And the private market is
totally broken as well.
As we have heard in the testimony this morning, one program
that is working well in terms of enhancing opportunities for
independent living and supporting aging with dignity and has
bipartisan support is the Money Follows the Person Program. We
have discussed what it is this morning. It provides grants to
States to cover transitional services for individuals who want
to leave a nursing home or another institution and transition
to the community care setting.
I have been working with my colleague Brett Guthrie from
Kentucky to reauthorize this successful program that is proven
to save taxpayers money and has successfully transitioned
thousands of people from institutions to a community setting
where they can be with their loved ones. We need to expand the
program before it expires. I agree with you that 1 year isn't
enough, but I will take 1 year if that is all we can get,
because time is running short.
So I am going to ask Mr. Cunningham these questions. Mr.
Salo, if you want to chime in.
Money Follows the Person was created through bipartisan
efforts. The program has been operating for more than a decade,
and the legislation we are considering would have reauthorized
the program for another 5 years. We will take the 1. Why is
this such a priority? How does this kind of long-term
reauthorization support institutional transition efforts?
Mr. Cunningham. So I think one of the big things for MFP is
that every State kind of has their own home and community-based
waiver programs. And so depending on each State, MFP can be
that flexible tool that can be used to move people out of
institutions into the community. And so that flexibility is
critical.
Mrs. Dingell. What challenges do States face in supporting
transition from institutions to the community? How does MFP
help address these challenges?
Mr. Cunningham. So, for many States, a lot of the services,
such as housing counseling and other referrals, counseling,
detection of people that want to relocate, these may or may not
be covered as part of the Medicaid program.
So MFP can step in to provide those services. And then they
can relocate into the community where some States may have
available personal care assistants and other home and
community-based services that can support them. So it bridges
that gap.
Mrs. Dingell. Thank you. We know that hundreds of thousands
of people with disabilities continue to wait on waiting lists
for home and community-based services. How does MFP help
address the problem for the population of people in
institutional settings, and what would happen if we don't renew
this?
Mr. Cunningham. So, in Wisconsin, what we have done with
the enhanced Federal match is that we have reinvested that into
our long-term care program to reduce and eliminate waiting
lists. And within 36 months, we are going to be an entitlement
for all individuals that need Medicaid home and community-based
services.
And so MFP has been a vital part, and that reinvestment of
those dollars into the long-term care system continue to
support providing community-based services.
Mrs. Dingell. I want to thank all of you for everything
that you are doing. Five minutes isn't enough time. But before
I yield back, I would ask the chairman for unanimous consent to
include for the record letters of support for H.R. 5306 from
the Area Agencies of Aging Association of Michigan, the
National Association of State Directors of Developmental
Disability Services, the National Association of States United
for Aging and Disabilities, and a group letter signed by dozens
of health and aging organizations.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mrs. Dingell. Thank you. And I am over my time.
Mr. Burgess. The chair thanks the gentlelady.
The chair now recognizes the gentleman from Georgia, 5
minutes for your questions, please.
Mr. Carter. Thank you, Mr. Chairman. And thank all of you
for being here.
Mr. Chairman, I want to thank you for holding this hearing
today and for including the discussion on the gag clause
legislation. It is something that is very important and
something that I have stressed since I have been in Congress
and something that is important to patients. I think that is
the point that I would like to get across most is that this is
something that is really hurting patients more than it is
hurting anyone.
Mr. Chancy, I want to thank you for being here. I
appreciate it very much. I know you have traveled a long way,
as a lot of you have, but I wanted to ask you, Mr. Chancy,
examples of gag clauses. Now, I think everybody by this point
understands what we are talking about when we are talking about
gag clauses, but have you actually seen a contract that had the
language in there that--and perhaps it wasn't written the way
that you would understand it, but have you ever seen a contract
like that?
Mr. Chancy. First of all, it is very difficult for us to
even get our hands on these contracts, and they change
frequently. So I have not seen anything that even stated that
it was a gag clause.
Mr. Carter. Right. But just because it is not stated, there
are other ways that the pharmacy benefit managers can get at
this. You mentioned earlier about CVS/Caremark. CVS, of course,
is a competitor, a national chain, I believe the largest drug
chain in America. And yet Caremark, one of the top three PBMs
in America, is the same company. You can make the argument that
the Caremark owns CVS or CVS owns Caremark. It doesn't matter;
they are the same thing. But there are other ways. Do you ever
get audited by any of these groups?
Mr. Chancy. Yes, we do. Actually, one of our stores is next
door to a CVS, and they do audit us.
Mr. Carter. So, actually, you have got a contract with a
PBM that has a drugstore right next to you, and you are getting
audited by that PBM that owns that drugstore right next to you.
Do you find that somewhat intimidating, if you will?
Mr. Chancy. Yes, and it is challenging at times.
Mr. Carter. I can imagine. I wanted to ask you, in your
written testimony, you gave some examples of where you had
actually told some patients about this. And I believe there was
one example with a mayor of one of the municipalities around.
Can you share that very quickly?
Mr. Chancy. Yes, that is correct. He came in, and his
prescription came to be $26. And they had just changed
insurance plans. And we told him that if you paid cash for
this, it would be cheaper. And he said: I don't understand; I
want to use my insurance.
And I said: Well, our cash price is $8, but if we use your
insurance we have to charge you $26--because the PBM was
actually taking $24 back from us.
Anyway, the point was out of pocket was $8 for him. Using
his insurance, he had to pay $26.
Mr. Carter. So this point was brought up. I believe, Dr.
Yoder, you may have brought it up. And it is a valid point,
that, if you don't use your insurance, it is not going to go
toward your deductible.
Mr. Chancy, do you have an opportunity to know how close a
patient is to their deductible? Is that any kind of information
that you are privy to as a pharmacist?
Mr. Chancy. No, we don't. The only way we find that out is
if we bill it through their insurance and we find out that they
have met their deductible or they haven't. So we fill
prescriptions or process prescriptions until we get to that
point.
Mr. Carter. But if we were realistic about this, the
example that Representative Dingell just gave, now, that would
have been $1,300 going toward a deductible. She made the choice
to pay the $40, which obviously I think most of us would have.
But the other example that you gave where it was $7 as compared
to $26, that is not really going to impact the deductible that
much, is it?
Mr. Chancy. Oh, no, not at all.
Mr. Carter. I don't think it is going to help them get
there. So, with all due respect, Dr. Yoder, that is the point
we are trying to make here. Generally, that is an extreme case.
And that is exactly what we are talking about. That is nothing
short of ridiculous, and we all understand that.
One other point that was made by Dr. Yoder was the fact
that if you don't get it filled through the insurance company,
that you may not see a drug interaction. But is it true, Mr.
Chancy, that most pharmacies now have programs where--drug
interactions are--before you fill a prescription, you are going
through the patient's profile and looking at all the drugs that
are on there anyway?
Mr. Chancy. That is correct.
Mr. Carter. OK. So it really should not be that much of a
problem, unless they are getting it somewhere else, which could
happen. But, for the most part, you find your patients to be
getting their medications at one drugstore.
Mr. Chancy. That is correct.
Mr. Carter. OK. Boy, 5 minutes flies when you have been
waiting around all day to ask questions. I do want to thank all
of you for being here, and this is something that is very
important. Again, Mr. Chairman, I want to thank you for this
discussion and this hearing today. Very important. I could not
agree with you more that this is the most important
subcommittee in Congress. So thank you, and I yield back.
Mr. Burgess. And the most productive.
I recognize myself for 5 minutes.
Mr. Chancy, I just have to ask you, when you sign a
contract, it is voluntary, so no one is forcing you to sign the
contract. Do you have the option of not signing the contract
and saying, ``Hey, come back to me with a contract that doesn't
have these nondisparagement riders in it''?
Mr. Chancy. We do have the option of opting out, but we
don't always know what is in the contract.
Mr. Burgess. I guess that bothers me a little bit. But I
can remember early in the days of managed care, as a physician,
I had complained about a contract, and the lawyer advising the
practice said, ``Well, you signed a stupid contract.''
I said, ``Well, how do you tell it is a stupid contract?''
He said, ``That is the first one they give you, and you
signed it.''
The only reason I am bringing this up is because, as a
profession, it may be incumbent on us as part of our profession
to be ever-vigilant on behalf of our patients, especially as we
get into more and more situations where ownership is not in the
hands of the community pharmacist, not in the hands of the
practicing physician, but in the hands of an insurance company,
the government, or someone else. And, again, that is the only
reason I bring that up is the charge for all of us has got to
be not--transparency will only go so far. You have got to be
vigilant on top of that.
Mr. Cunningham, let me just ask you, because you mentioned
some of the supplemental services that are covered, and you
mentioned housing specifically. Is transportation ever covered?
Mr. Cunningham. I know the ability to develop plans to
assist with transportation, in Wisconsin that is a covered
benefit in our community. So what the ADRC would do is assist
in developing a plan to ensure the individual has proper
transportation in the community to both medical and also for
social events.
Mr. Burgess. Because Wisconsin is one thing, but Texas, the
distances are large. But it seems with ride-sharing abilities
now, that actually could be quite cost-effective. You are not
sending a taxicab company out to pick someone up, but with the
ride-sharing apps that people are so accustomed to using now,
again, it seems like that could be an option for increasing
participation or increasing compliance on the part of the
patient. That is why I was wondering if that had been one of
the things that you had studied in your efforts.
Mr. Cunningham. Yes, it is a covered benefit in our waiver
program. But to the extent they don't have transportation, I
think that would be either MFP would be able to--used to
identify an affordable transportation. I am not totally sure of
the exact reimbursement to the transportation provider.
Mr. Burgess. I may follow up. I will do some followup on
that myself. But you intrigued me with your comments, General
Schmidt. We have spent a lot of time in this subcommittee and
the full committee dealing with the problems from opiate abuse
and the recovery therefrom. And so some of your comments about
the prosecutorial side, it is one thing to find that there has
been diversion, but if a patient is actually harmed in the
process.
We study sober homes to some extent here, and we had a
panel of family members that came and talked to us. And three
of those five panel members, family members, all talked about
the danger and the damages from sober homes in not providing
the type of care that they were supposed to provide, and people
actually suffered as a consequence. Has that been any part of
your experience as well?
Mr. Schmidt. I don't know about the sober homes in
particular, Mr. Chairman. But yes, I think I mentioned in my
written testimony, we have criminal charges currently pending
against an individual, of course, not yet adjudicated, so she
is innocent unless and until proven guilty, but who was
delivering--she was a nurse in a variety of facilities, sort of
rode a circuit and was supposed to be delivering medications to
beneficiaries and instead was diverting those medications to
illicit uses and obviously causing some fairly substantial harm
to the beneficiaries, either in terms of pain management didn't
happen or some of the medications' other purposes. So, yes, we
have seen that.
And then the flip side of that, with respect to perhaps the
intersection between H.R. 3891 and opioid enforcement, we are
looking at cases currently. We haven't filed any of these yet,
so they may or may not pan out, either under current law or
under expanded authority. But potential diversion cases, I will
call them pill mill-type cases in a colloquial, where the
diversion occurs outside of a healthcare facility or outside of
a board and care facility. So they are outside the scope of the
MFCU now.
And one of the things that we just sit around and sort of
scratch our heads on is, well, what is our legal theory if we
were able to prove this? And right now our legal theory if I
want to use the MFCU assets is the fraud to the program for
diverting those pills. I can prosecute for a few bucks a pill
the financial loss.
But if that diversion results in serious bodily injury or
death to somebody who is misusing those pills, which would be a
separate crime under Kansas and Federal law, I can't use the
MFCU assets to prosecute that much greater ill, and that just
doesn't make sense to me.
Mr. Burgess. You are right. And this subcommittee, we are
all about making sense.
Mr. Merrill and Mr. Salo, I apologize.
Mr. Merrill, I just have to ask you, because we talked
about this a little bit offline when we visited about this. You
mentioned the STAR programs in Texas, and, of course, some of
the headlines recently from one of the big managed care
companies was not providing quite the services or their ability
to reduce cost was essentially reducing benefits. And you had
some thoughts about it is important to pay attention to the
payer in some of these instances.
So could you kind of reprise those comments for this
subcommittee?
Mr. Merrill. Well, I guess in its basic level, care is
really never and should never be coordinated at the payer side
of the equation. It should be coordinated at the provider side
of the equation.
All of these caregivers play a role in this, but I can
speak specifically about our own experience at Cook Children's.
Since we are a provider-based HMO, we don't have premium
expense or dollars or profits that have to go to Wall Street.
It is a model that has been out there for quite some time. But
the dollars that would normally go to Wall Street we actually
reinvest in our community, and that allows us to do more care
for these kids.
So I think you have a difference in philosophy on these two
different approaches. I do believe personally that provider-
based health plans do better work, because their premium
expense is all focused on taking better care of these kids. And
I know there has been some controversy over that in the STAR
Kids program. If you read those articles, you will see that the
complaints or concerns that were expressed were on that side of
the equation and not on the provider side of the equation. I am
telling you as straightforward as I know how, but that is I
think the reality of the situation.
Mr. Burgess. I thank you for sharing that, because when you
told me that the other day, I thought that was an important
concept that needs to be out there.
Mr. Green, do you have any concluding thoughts?
Mr. Green. Nothing further, Mr. Chairman. Can I ask for 3
minutes at some future hearing?
Mr. Burgess. I was just aggregating all of the extra time I
gave members on your side and capitalizing upon it. It is like
access to capital, right?
So seeing that there are no further members wishing to ask
questions, I once again want to thank our witnesses for being
here today.
Additionally, in addition to all the other documents that
we have accepted for the record, I want to submit documents
from PillPack, Incorporated; LeadingAge; Medicaid Health Plans
of America; and the American Association of Medical Colleges.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. 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 responses
to those questions within 10 business days upon receipt of the
questions.
Without objection, the panel is again thanked and the
subcommittee is adjourned.
[Whereupon, at 12:54 p.m., the subcommittee was adjourned.]
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