[Senate Hearing 115-687]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-687

    PATIENT-FOCUSED CARE: A PRESCRIPTION TO REDUCE HEALTH CARE COSTS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             SECOND SESSION
                               __________

                             WASHINGTON, DC
                               __________

                            OCTOBER 3, 2018
                               __________

                           Serial No. 115-21

         Printed for the use of the Special Committee on Aging
         
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         

        Available via the World Wide Web: http://www.govinfo.gov
        
                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
35-285 PDF                 WASHINGTON : 2019


                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            KIRSTEN E. GILLIBRAND, New York
THOM TILLIS, North Carolina          RICHARD BLUMENTHAL, Connecticut
BOB CORKER, Tennessee                JOE DONNELLY, Indiana
RICHARD BURR, North Carolina         ELIZABETH WARREN, Massachusetts
MARCO RUBIO, Florida                 CATHERINE CORTEZ MASTO, Nevada
DEB FISCHER, Nebraska                DOUG JONES, Alabama


                                CONTENTS

                              ----------                              

                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Statement of Senator Robert P. Casey, Jr., Ranking Member........     3

                           PANEL OF WITNESSES

David Howes, M.D., President and Chief Executive Officer, 
  Martin's Point Health Care, Portland, Maine....................     5
Jeff Micklos, Executive Director, Health Care Transformation Task 
  Force, Washington, DC..........................................     7
Sean Cavanaugh, Chief Administrative and Performance Officer, 
  Aledade, Bethesda, Maryland....................................     9
Reverend Sally Jo Snyder, Director of Advocacy and Consumer 
  Engagement, Consumer Health Coalition, Pittsburgh, Pennsylvania    11

                                APPENDIX
                      Prepared Witness Statements

David Howes, M.D., President and Chief Executive Officer, 
  Martin's Point Health Care, Portland, Maine....................    34
Jeff Micklos, Executive Director, Health Care Transformation Task 
  Force, Washington, DC..........................................    64
Sean Cavanaugh, Chief Administrative and Performance Officer, 
  Aledade, Bethesda, Maryland....................................    68
Reverend Sally Jo Snyder, Director of Advocacy and Consumer 
  Engagement, Consumer Health Coalition, Pittsburgh, Pennsylvania    78

                  Additional Statements for the Record

Justice in Aging (formerly the National Senior Citizens Law 
  Center)........................................................    92
LeadingAge, an association of nonprofit aging services providers.    93

 
    PATIENT-FOCUSED CARE: A PRESCRIPTION TO REDUCE HEALTH CARE COSTS

                              ----------                              


                       WEDNESDAY, OCTOBER 3, 2018

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:30 a.m., in 
room SD-562, Dirksen Senate Office Building, Hon. Susan M. 
Collins (Chairman of the Committee) presiding.
    Present: Senators Collins, Fischer, Casey, Nelson, 
Gillibrand, Donnelly, Cortez Masto, and Jones.

    OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The Committee will come to order. Good 
morning.
    First, let me apologize to our witnesses that we have a bit 
of a media ``circus,'' I guess is the right word for it, 
outside of the hearing room today. But that does not detract 
from the important work that we are doing inside this hearing 
room today. And I very much appreciate your patience with 
getting through the hoards of reporters and protesters and 
others because the issue that we are focusing on today, like so 
many issues that are confronting the Senate right now, are 
extremely important.
    According to a recent poll, for more than a year now, 
Americans have listed health care as the most important issue 
facing our country. This should come as no surprise. Health 
care is deeply personal. It is a complex issue that affects 
each and every one of us. It comprises one-sixth of the 
American economy. In 2016, we spent $3.3 trillion on health 
care. If we want to improve the affordability and accessibility 
of health care, we simply must get a handle on the cost while 
also focusing on improving the quality and patient outcomes.
    This Committee has already addressed health care costs from 
several different angles. We have focused on how market 
failures and a lack of transparency affect the pricing of 
prescription drugs. For example, we have examined the rising 
cost of insulin and rheumatoid arthritis drugs, as well as the 
tangled nature of the relationships among pharmaceutical 
companies, pharmacy benefit managers, and various other 
components of the supply chain.
    We have also highlighted the need for more investment in 
medical research in the areas of diabetes, Alzheimer's disease, 
and other devastating illnesses, which have significant 
financial costs for our country.
    Today we examine a different aspect of health care costs: 
How can we better leverage spending on innovations and quality 
initiatives that help keep patients well? And, critically, what 
specific actions would help us to succeed in that mission and 
to help moderate the rising cost of health care?
    Health care providers often refer to the ``Triple Aim'': 
improving the patient experience of care, including quality and 
satisfaction; improving the health of populations; and reducing 
the per capita cost of health care.
    Without a doubt, tremendous opportunities exist for 
improvement. As Dr. Atul Gawande correctly observes, ``The one 
thing the medical profession is not rewarded for is providing 
better, higher-value care. . . . In a fee-for-service payment 
system--a system of paying doctors and hospitals by pill and 
procedure--we are actually penalized for making the effort to 
organize and deliver care with the best service, quality, and 
efficiency we can.''
    Part of the solution to bringing down health costs is to 
emphasize prevention as well as other cost-effective health 
interventions. According to the Centers for Disease Control, 
chronic diseases that are avoidable through preventive care 
services account for 75 percent of the Nation's health care 
spending, yet all too often, the incentives are wrong.
    For example, colorectal cancer is one of the leading causes 
of cancer deaths, yet it is also one of the few cancers that 
can be prevented with proper screening. A recent study finds 
more than 14,000 colon cancer deaths could be prevented every 
year if health care providers matched the screening and 
mortality rates of America's highest-performing health systems.
    We need to learn more from these providers and remove 
barriers that prevent better performance, but we also need to 
examine Medicare reimbursement policies. Seniors covered by 
Medicare are eligible for colorectal cancer screenings without 
out-of-pocket costs; however, if a physician takes a further 
preventive action--such as removing a polyp--during the 
screening while the patient is under anesthesia, the patient is 
billed as if the procedure were a treatment rather than 
prevention. This makes no sense to me at all, and I have talked 
to physicians in Bangor, Maine, where I live, who tell me that 
when their patients learn this, they will actually cancel the 
colonoscopy because they are so afraid of being saddled with 
considerable costs. And that is why I have cosponsored the 
Removing Barriers to Colorectal Cancer Screenings Act, and I am 
joining several of my colleagues in sending a letter to CMS 
encouraging the agency to change its reimbursement and solve 
this problem. That is just one example.
    The care of individuals with diabetes--I know it is an 
issue of special interest to Dr. Howes--offers another lesson. 
Medicare will pay for all the serious complications of 
uncontrolled diabetes--amputations, blindness, heart disease; 
it affects every system in the body--but the program often 
reimburses poorly for innovative programs that can help avoid 
these devastating consequences. Again, that just makes no sense 
to me. Recently I joined with my Senate Diabetes Caucus Co-
Chairman Jeanne Shaheen to expand Medicare coverage for 
diabetes self-management training sessions, where diabetes 
educators help train patients on how to manage their glucose, 
maintain a healthy weight, eat healthy foods, manage their 
insulin levels, and improve general care for their diabetes.
    On the other end of the spectrum from prevention is the 
problem of inefficient and wasteful health care spending. 
According to the Institute of Medicine, spending in the United 
States on health care waste totaled approximately $750 billion, 
or as much as 30 percent of our Nation's health care spending.
    Today we will hear from witnesses who bring a variety of 
very valuable perspectives on how we can successfully achieve 
better value, lower costs, and higher quality in health care 
spending. Participating in innovative care models that align 
payment with quality and value, improving patient engagement 
and communication efforts, and deploying data to help both 
clinicians and patients manage chronic conditions are all 
critical components to improving our health care system and 
reducing costs.
    I want to thank our witnesses for joining us today. I know 
you have a lot of valuable information to share with the 
Committee, and I look forward to your statements.
    I now would turn to our Ranking Member, Senator Casey, for 
his opening statement.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING 
                             MEMBER

    Senator Casey. Thank you, Chairman Collins, for holding 
this hearing today.
    Every American will interact with our health care system, 
and we owe every citizen a system that ensures that they can 
afford the care that they need, no matter what illness or 
accident that they will endure. We owe taxpayers a system that 
guarantees federal dollars are spent wisely and efficiently. We 
owe health care providers a payment system that allows them to 
focus on what matters most: patient care.
    The Affordable Care Act provides individuals, families, 
taxpayers, and providers all of these benefits. The Affordable 
Care Act expanded coverage to 20 million Americans. It provides 
key consumer protections, like protections against being denied 
coverage or being charged more for coverage due to a pre-
existing condition. It invests in proven reforms to our health 
care delivery system and updated payment models so that 
providers and patients can work together as partners in shaping 
their care. These are key improvements to health care in 
America, enhancing care and reducing costs for patients, 
providers, and health care systems alike.
    The Affordable Care Act is not perfect, and we have more 
work to do to lower costs--just by way of one example.
    Recently, the administration refused to defend the 
Affordable Care Act's protections for people with pre-existing 
conditions in a lawsuit led by 20 Republican-led states.
    Each of us is one accident or one illness away from joining 
the millions of Americans with a pre-existing condition. In 
Pennsylvania, that number is 5.3 million people with a pre-
existing condition. Chairman Collins and I agree that we must 
keep our promise to Americans with pre-existing conditions 
while working to improve care quality and lower costs.
    Congress made a commitment to payment innovation in the 
Affordable Care Act as well. The law expanded an important 
program called ``Money Follows the Person.'' It makes it 
possible for seniors and people with disabilities to receive 
the care they need in the very place they most want to be--at 
home and among those in their community. Alongside Chairman 
Collins, I am a proud cosponsor of this legislation to extend 
this essential program. Congress should act to continue Money 
Follows the Person before the year's end.
    Today the Committee will discuss ways to build upon 
improvements like Money Follows the Person and other programs 
made possible by the Affordable Care Act. This is an important 
conversation.
    I look forward to hearing from our witnesses about how we 
can preserve everything from coverage protections to the 
innovative programs included in the ACA, but also what more we 
can do to make our health care system even stronger.
    Thank you, and I look forward to today's discussion.
    The Chairman. Thank you very much, Senator Casey.
    I also want to acknowledge two of our colleagues who have 
joined us. Senator Donnelly and Senator Jones, thank you for 
being here this morning.
    Dr. Howes, we are going to start with you, but I want to 
give you a proper introduction first.
    Our first witness today is Dr. David Howes, the president 
and CEO of Martin's Point Health Care, a not-for-profit health 
care organization headquartered in Portland, Maine. I have 
known Dr. Howes for many years and have always been so 
impressed with the innovative approach that he brings. He began 
his career as a family physician in rural Maine. In fact, he 
actually served on some of Maine's islands for a while. That 
truly is providing health care to a population that otherwise 
would have great difficulty in accessing it. He brought this 
background to Martin's Point, first as a primary care physician 
and now as the president and CEO.
    Martin's Point is unique in that it provides direct patient 
care at seven health centers in Maine and New Hampshire, and 
also offers highly rated Generations Advantage plans to 
Medicare beneficiaries in Maine and New Hampshire, as well as 
the U.S. Family Health Plan's TRICARE Prime to military 
families in northern New England, New York, and Pennsylvania.
    We will then hear from Jeff Micklos, the executive director 
of the Health Care Transformation Task Force. The Health Care 
Transformation Task Force is an industry consortium of payers, 
providers, purchasers, and patients who are committed to 
accelerating the pace of transforming the health care delivery 
system. They share a common commitment to transforming their 
respective businesses and clinical models to deliver person-
centered, high-quality care at lower cost through innovation.
    Next we will hear from Sean Cavanaugh, a famous name around 
here these days.
    [Laughter.]
    The Chairman. But it is spelled differently, I would note. 
He is--and this is sheer coincidence--the chief administrative 
and performance officer at Aledade. Aledade provides value-
based care through physician-led accountable care 
organizations, ACOs, across the country. Mr. Cavanaugh will 
discuss his company's successes thus far in reducing spending 
and improving health care outcomes as well as how accountable 
care organizations fit into the health innovation landscape. 
Mr. Cavanaugh previously served as Deputy Director and 
Administrator of the Centers for Medicare at CMS.
    I now will turn to our Ranking Member to introduce our 
witness from the Commonwealth of Pennsylvania.
    Senator Casey. Thank you, Chairman Collins. I am pleased to 
introduce Reverend Sally Jo Snyder, a Pittsburgh resident and 
long-time consumer and patient advocate. Reverend Snyder and I 
met I guess last year in McKeesport. I did not have a chance to 
say hello to her personally today. I will do that after the 
hearing. But thank you for being here.
    Reverend Snyder's organization, the Consumer Health 
Coalition, provides consumer education and health insurance 
counseling to Pennsylvanians across the state. Among many 
programs, Reverend Snyder provides trainings to help empower 
patients to be active participants in their care. These issues 
are not only at the heart of Reverend Snyder's profession, they 
are deeply personal. She lost her Mom to what should have been 
an avoidable hospital-acquired infection. To borrow a phrase 
from Reverend Snyder, I am confident her testimony will inspire 
us to ``make good ripples'' as we work together to transform 
our Nation's health care system.
    Reverend Snyder, thank you for being here, and we look 
forward to your testimony.
    The Chairman. Thank you very much.
    Dr. Howes.

 STATEMENT OF DAVID HOWES, M.D., PRESIDENT AND CHIEF EXECUTIVE 
      OFFICER, MARTIN'S POINT HEALTH CARE, PORTLAND, MAINE

    Dr. Howes. Thank you, Senator Collins, Ranking Member 
Casey, and members of the Committee on Aging for this 
opportunity to provide testimony regarding the health care 
landscape for seniors in Maine.
    My name is David Howes, and I am the president and CEO of 
Martin's Point Health Care. We are a not-for-profit integrated 
health care organization based in Portland, Maine, and we 
provide care and coverage to about 155,000 people.
    In my testimony today, I want to share with you a picture 
of the health care landscape for seniors in our home state--a 
landscape shared, I am sure, by many states with significant 
aging populations in rural areas. I will also tell you what 
relatively small, but we like to think mighty, health care 
organization is doing to address the significant needs of this 
population and how our nonprofit status allows us to go the 
extra mile in serving both patients and members and improving 
the health of our communities.
    If you would like to learn more, please refer to my 
testimony for full details on my credentials and background, as 
well as a number of innovative outcomes that define the high-
quality care we provide at Martin's Point.
    I would like to start, though, by sharing a personal story 
from my home State of Maine. This summer my son, Owen, began 
work in one of the most physically demanding careers in Maine. 
He is serving as a sternman on a lobster boat under the 
tutelage of his boss, ``Captain Mike.'' I mention this because, 
to my delight, after he took the job, I discovered that Captain 
Mike is a Martin's Point health plan member and a Martin's 
Point patient. He comes to one of our health care centers 
before each lobster season, making the journey from his island 
home in Vinalhaven to our health care center in Brunswick, some 
70 miles south. He comes to have his knees treated for his 
increasing arthritis--he calls it ``getting a grease job''--the 
result of many years hauling lobster pots. Now at an age when a 
lot of people are planning retirement, Captain Mike is teaching 
my son, a member of the new generation, the intricacies of 
catching lobsters. In the off-season, he returns to the 
mainland as an art teacher. I think Senator Collins would agree 
that his career reflects the way many Mainers make a living--
doing what they do best, often combining a variety of 
occupations to add up to a satisfying and sustaining whole. 
Mike could choose to have his knees worked on closer to home, 
but he chooses to travel to Martin's Point because we have 
earned his trust. By providing both his primary care and his 
insurance coverage, we are uniquely positioned to consider the 
full spectrum of his health and support him on land and sea, 
reliably and affordably.
    At Martin's Point we believe we have much to offer members 
like Mike and thousands of other rural seniors in Maine, who 
seek a trusted health care partner who shares their local 
roots. It is important to remember, though, that for every 
energetic lobsterman in Maine, there are many more of our 
members who are confronting the converging effects of chronic 
illness, forgetfulness, and limited mobility.
    Some of the most poignant examples of our provider-patient 
connections come to me from the nurses who administer our home-
based care management programs. They tell me about the little 
things that they note in their assessments during a home visit, 
such as the condition of the house, the person's appearance, 
and the visible signs of declining self-care.
    During a recent visit to conduct medication reconciliation, 
our nurse arrived at an older man's home to find that he was 
storing his medication in various receptacles throughout his 
home, including spice jars in his kitchen. He had lost track of 
the number and schedule of his medications. She worked to place 
all of his pills in one of our organized containers and then 
reviewed the dosage and frequency with him. The pill box 
probably cost us less than a dime, but the time spent in 
conversation and companionship and instruction allowed us to 
make a full assessment of his circumstances and offer him 
additional support and monitoring.
    As we do this with more and more seniors in Maine, the dime 
containers represent thousands of dollars per patient in 
avoided incidents, hospitalizations, and readmissions. I regard 
our care management programs as some of the best innovation 
work we are doing at Martin's Point, and they continue to 
illustrate to me that the little things, not always medical, 
make a huge difference.
    All in all, we care for a lot of people in Maine, but at 
the heart of what we do is our ``true north'': We are people 
caring for people--our patients, our members, each other, and 
our community. We are very committed to the Triple Aim and 
score ourselves on the Triple Aim quarterly to see that we are 
actually making a difference against each of those objectives.
    Our care extends to our annual quality metrics that we 
believe are essential to better health outcomes and form a 
central part of our organization-wide employee incentive plan. 
A quarter of our employees' annual incentive is based on a set 
of quality metrics that are uniform for all 800 employees.
    We have dedicated particular attention to the care of 
chronic conditions such as diabetes and congestive heart 
failure. We seek great promise in comprehensive home-based care 
and are seeing promising early returns on our investment in 
this care model. We have been recognized for our recent work in 
opioid mitigation, particularly for elders, and we accomplish 
all that we do through our lean health care management system.
    I am pleased to be with you here this morning and would be 
glad to take your questions on any of the work that we are 
doing to support our patients and members. Thank you.
    The Chairman. Thank you very much, Dr. Howes.
    Mr. Micklos.

  STATEMENT OF JEFF MICKLOS, EXECUTIVE DIRECTOR, HEALTH CARE 
           TRANSFORMATION TASK FORCE, WASHINGTON, DC

    Mr. Micklos. Good morning, Chairman Collins, Ranking Member 
Casey, and members of the Senate Special Committee on Aging. 
Thank you for the opportunity to appear before you today to 
discuss innovative approaches to improving value in the health 
care system for older Americans. My name is Jeff Micklos, and I 
am the executive director of the Health Care Transformation 
Task Force. As Chairman Collins said, we are a diverse group of 
industry stakeholders across providers, health plans, 
employers, and consumers. We are looking to accelerate the pace 
of delivery system transformation. Our payer and provider 
members aspire to have 75 percent of their business in value-
based payment arrangements by 2020.
    While the task force supports many types of value-based 
payment and care delivery models, my testimony this morning 
will focus on accountable care organizations. ACOs refer to 
health care organizations that manage the health of their 
population by tying payment incentives to quality metrics and 
the cost of care. Last year the task force conducted a study of 
the 21 highest-performing Medicare ACOs based on 2015 
performance data. The most successful ACOs focused on three key 
elements: one, achieving a high-value culture; two, developing 
strong population health management programs; and, three, 
creating structures that can ensure continuous improvement in 
performance over time.
    The highest-performing ACOs first and foremost have a 
strong commitment to developing a culture that supports 
innovation and is committed to the mission of improving care 
delivery. That commitment must be unwavering in the face of 
multiple obstacles. Changing culture takes time and requires 
effective leadership at many levels. Most of the successful 
organizations we profiled had previous experience managing 
financial risk before implementing an ACO model, including 
through commercial payment arrangements with payers. They also 
had the support and commitment of executive leaders who saw the 
importance of investing in new models, as well as governance 
structures that are conducive to fostering a high-value 
culture.
    Organizations with high-value cultures understood the 
importance of engaging clinicians and care teams to accomplish 
shared goals and demonstrated a commitment to practice 
education, support services, and compensation structures that 
reward continuous improvement. ACOs succeed with truly engaged 
multidisciplinary care teams committed to understanding how 
their practice patterns influence the goals of the ACO and 
serving as champions to help guide their peers.
    The crux of any successful payment program is top-notch 
care delivery. For ACOs, having very strong population health 
management programs is critical. These programs serve the 
essential function of identifying at-risk patients with 
multiple medical conditions and acting swiftly to ensure that 
these patients receive the best, most personalized care 
possible to avoid unnecessary hospitalizations.
    Effective population health management programs truly put 
the patient first by using tools and resources that facilitate 
personalized, proactive care. Vanguard health care providers 
risk-stratify patients using homegrown analytics models, 
electronic health record modules, and population health 
software. These high-tech processes are combined with expert 
recommendations from physicians on how best to provide 
treatment that is individualized to patient needs.
    Risk stratification practices are key. For example, Atrius 
Health, a physician-led ACO based in Boston, has taken on risk 
for its Medicare fee-for-service members for several years, 
most recently in the Next Gen ACO program. The organization 
determined that the second-largest opportunity for savings 
after post-acute care was hospitalization prevention. Atrius 
built an analytical model that would allow it to proactively 
identify patients with high clinical risk and assign a score to 
those individuals based on their likeliness of hospitalization 
in the next six months. The score is reviewed by a care team to 
ensure a comprehensive care plan is in place for each patient. 
A case management team conducts outreach, and high-risk 
patients are provided with access to additional services such 
as same-day appointments.
    Atrius' approach has resulted in the organization saving 
Medicare an impressive $10.4 million in 2016 and $6.8 million 
in 2015, while maintaining a quality score of over 95 percent.
    The best population health management programs employ 
interdisciplinary care teams that typically consist of 
physicians, nurse care managers, pharmacists, social workers, 
and care guides or navigators. Patient needs inform who from 
the care team should focus on the patient. For example, a 
social worker may be best equipped to interact most often with 
the patients struggling with social factors such as housing or 
food instability or access to transportation that directly 
contribute to his or her health status. Strong population 
health programs also partner with existing community resources 
and local public health departments to ensure that all facets 
of a patient's health challenges are addressed. Today 
addressing social determinants of health is a concept that gets 
a lot of attention, and rightfully so, and maturing ACOs are 
increasingly focused on those factors as a way of caring 
completely for patients. Partnering with community 
organizations is important to a comprehensive care regimen for 
individuals.
    Finally, we have found that successful ACOs must have 
continuous improvement structures in place to drive value once 
the low-hanging fruit has been plucked. It is simply not enough 
for health care providers to change their business model in one 
go and coast. They must constantly reevaluate their performance 
and business structures. The most sophisticated organizations 
have dedicated data, actuarial, and performance improvement 
resources that are constantly looking for new opportunities to 
increase value.
    All organizations should expect to run into challenges on 
their journeys. That is why participation in shared learning 
opportunities is critical. The ability to share experiences, 
compare data with peers, and access to organizations that are 
more advanced in their value models can be tremendously helpful 
for budding ACOs. Regional health improvement collaboratives, 
such as those found in Maine and Pennsylvania, and national 
consortiums offer outlets for organizations that are interested 
in learning from peers and cross-industry partners. The task 
force serves this function for national collaborators.
    In closing, changing our health care system is not 
something that can be accomplished in one fell swoop. Rather, 
we are rebuilding brick by brick the foundation upon which our 
care is paid for and delivered. Not all innovation will be an 
immediate success, and it is incumbent upon all to identify 
what holds promise and stay the course until sustainable change 
is achieved. Patience and diligence are absolutely essential.
    Chairman Collins, Ranking Member Casey, and members of this 
Committee, thank you again for the opportunity to testify, and 
I look forward to your questions.
    The Chairman. Thank you very much for your testimony.
    I also want to welcome Senator Cortez Masto and Senator 
Fischer, who have joined us this morning.
    Mr. Cavanaugh.

     STATEMENT OF SEAN CAVANAUGH, CHIEF ADMINISTRATIVE AND 
        PERFORMANCE OFFICER, ALEDADE, BETHESDA, MARYLAND

    Mr. Cavanaugh. Chairman Collins, Ranking Member Casey, and 
members of the Committee, thank you for inviting me today to 
discuss how Aledade is partnering with independent physicians 
to provide patient-focused care that reduces costs and improves 
outcomes.
    My name is Sean Cavanaugh. I am the chief administrative 
officer at Aledade. Prior to joining Aledade, I served at CMS 
for six years, including a period as Deputy Director of the 
Innovation Center and three years as the Deputy Administrator 
and Director of the Center for Medicare, where I supported the 
movement toward value-based models. I am proud to continue that 
work at Aledade.
    At Aledade, we bring together independent primary care 
practices who are committed to value-based care. We form them 
into an ACO and join the Medicare Shared Savings Program. 
Aledade ensures the success of the ACO by providing data-
informed population health tools and transforming how the 
practices deliver care. We also negotiate value-based contracts 
with commercial payers, too, so our physicians can transform 
care for their entire panel of patients.
    I am pleased to report to the Committee that value-based 
payment is working in the Medicare Shared Savings Program. 
Beneficiaries are getting better care, and Medicare is saving 
money. In 2017, 10.5 million Medicare beneficiaries were 
aligned with ACOs in the Shared Savings Program. We now have 
evidence from the CMS Actuary, from MedPAC, and from Harvard 
researchers, and the findings among all three are consistent: 
one, ACOs are saving money for Medicare; two, the savings grow 
over time, the longer an ACO is in the program; and, three, 
physician-based ACOs are generating the strongest results.
    So, if you think of the three major ways that a beneficiary 
can receive care in Medicare--traditional fee-for-service, 
Medicare Advantage, or ACOs--ACOs are the lowest-cost provider 
of care in Medicare. And, perhaps most important, these savings 
are the result of Medicare beneficiaries actually receiving 
better care.
    Aledade is proud to be part of the success of the Shared 
Savings Program. Last year our ACOs saved Medicare over $40 
million. Some of that success was from one of our ACOs in 
Pennsylvania outside of Philadelphia. We did this by helping 
independent physicians deliver more primary care, which reduced 
unnecessary hospitalizations, typically by 10 percent on 
average, and shortened post-acute-care stays by 22 percent on 
average. And like the rest of the program, our results improve 
the longer our practices work with us.
    I will give you a very simple example of one of our 
strategies. We provide our practices with real-time 
notifications when their patients are discharged from the 
hospital. This is information that the typical small 
independent primary care physician would not receive if they 
were not participating in an ACO and receiving the help of an 
organization like ours. These practices proactively reach out 
to the discharged patient and manage that transition to the 
home. Our physicians ensure that patients comply with follow-up 
care protocols and, importantly, make sure they understand 
their medications, why they are taking them, which ones they 
should be taking. These are simple strategies, but when applied 
consistently and reliably, they reduce unnecessary 
readmissions.
    Because of our success, Aledade is growing. Next year we 
will partner with over 2,000 doctors in 350 practices, FQHCs, 
and rural health centers, organized in 32 ACOs across 24 
states. These physicians will be accountable for around 330,000 
Medicare beneficiaries and an additional 120,000 commercially 
insured patients. More than half of our primary care providers 
are in small practices with fewer than ten clinicians.
    Congress has done much to support value-based care, but 
there is always more you can do. One, we need to reduce the 
complexity and uncertainty in the Shared Savings Program. It is 
hard for physicians to succeed in a complex environment, and 
some ACOs have been reluctant to move to two-sided risk in the 
ACO program because of the complicated benchmarking 
methodology. A simple solution would be for CMS to move all ACO 
benchmarking methodology toward the methodology used in 
Medicare Advantage. Those benchmarks are well understood and 
more predictable.
    Two, we can make risk taking less risky, especially for 
physician-based ACOs. ACOs that do not have access to capital, 
especially rural ACOs and physician-based ACOs, should not be 
required to take on potentially crippling levels of risk. The 
Medicare ACO Track 1+ model took a big step toward creating a 
two-sided model that is feasible for rural and physician-based 
ACOs. CMS has proposed to make this a permanent part of the 
program, and we support that.
    Finally, the benchmarking methodology has to be fairer for 
rural ACOs. Currently an ACO's own performance is included in 
its regional comparison group, so when that ACO drives down 
costs, it is making its regional target that much tougher. For 
most ACOs, it is not a big deal because they have a small 
percentage of beneficiaries in their region. But a rural ACO 
could have a majority of the beneficiaries in their county, and 
this is punishing them for their success.
    Thank you for the opportunity to share Aledade's 
experiences with you, and I look forward to the rest of the 
hearing.
    The Chairman. Thank you very much for your testimony.
    Reverend Snyder.

STATEMENT OF REVEREND SALLY JO SNYDER, DIRECTOR OF ADVOCACY AND 
  CONSUMER ENGAGEMENT, CONSUMER HEALTH COALITION, PITTSBURGH, 
                          PENNSYLVANIA

    Reverend Snyder. To Chairman Collins, Ranking Member Casey, 
members of the Committee, fellow panelists and persons in 
attendance, thank you for the opportunity to provide testimony. 
Furthermore, I want to commend you for realizing the importance 
of including the perspective of the consumer voice in health 
care. It has been my experience that the most successful and 
the most effective policies and programs are initiated with 
having sought, heard from, listened, and responded to the voice 
of the consumer.
    My name is Reverend Sally Jo Snyder, and I am the director 
of Advocacy and Consumer Engagement at the Consumer Health 
Coalition. Our organization educates and activates consumers to 
be engaged and to take charge of their own health care. We 
educate our shared community about pertinent health policy 
issues, and we also enroll eligible Pennsylvanians in public 
health insurance programs.
    I travel across western Pennsylvania performing patient 
activation trainings. Recently, I conducted a focus group of 
125 seniors in southwestern Pennsylvania. The questions asked 
were: ``Who helps you live well?'' and, ``Who is on your health 
care team?'' With intention, I met with both persons living in 
high economic areas and with individuals living in poverty and 
asked the same questions to both groups. Those with resources 
and financial health answered the questions very succinctly by 
responding, ``My doctor, my specialist, my therapist.'' When 
pressed, the answer remained the same.
    When persons living below or near the poverty line answered 
the questions, they talked to me for 25 minutes, and they 
mentioned the bus driver, members of their congregation, their 
pastor, the social worker, the clerk at the local 7/11, the 
pharmacist at the CVS, their friends and their family. There is 
a quote, ``We do not heal in isolation, we heal in community.'' 
The more we can broaden a person's base of connections and 
increase one's trust points, we can create better outcomes in 
physical health, mental health, and overall wellness.
    As clergy and advocacy director, I have earned my status as 
a trust point for the persons our agency serves and journeys. I 
am trusted because I know their names, I listen, I remember, I 
pay attention, I am present, and I follow through on what is 
shared. Providers and care staff must do those same things and 
become trust points as well.
    Being a trust point in the community, I know firsthand how 
important it is that people of Pennsylvania retain access to 
affordable health care coverage. The passage of the Affordable 
Care Act was a watershed moment in our communities, expanding 
the availability of private insurance coverage as well as 
Medicaid. Continued threats to these programs undermine 
community trust and risk the basic health and well-being of 
Pennsylvanians. This is particularly acute for people with pre-
existing conditions, who now worry that the courts will take 
away the guarantee of health care coverage provided to them by 
consumer protections in the Affordable Care Act. In fact, it is 
the threat of persons with pre-existing conditions losing 
health care coverage that is the most pressing issue of those 
with whom I educate and advocate.
    We provide ``Activated Patient Trainings'' for seniors. 
These sessions walk persons through every step of the health 
care encounter from: finding a provider; communicating with a 
provider; what to bring to every appointment; questions to ask 
to understand your diagnosis, including my all-time favorite 
question in the guide, ``Can you explain this to me in a way 
that I can explain it to the members of my health care team?''; 
medications; one's care plan; and that most important question 
of why. Because these trainings are done in a group setting, 
persons from these learning communities offer their insights 
and provide support for their fellow students. In these 
sessions, additional trust points are formed.
    As health care advances, the experience and insight of the 
patient must be intentional, heard, listened to, and 
implemented. To fail to involve this perspective from the 
foundation to the completion is to have a health care system 
that functions only at half capacity.
    A person who fears being able to afford any health care 
because they lack insurance is not someone who can meaningfully 
participate in their care and focus on being the most valuable 
player of their health care team. Patients, providers, and 
payers are the central players in an effective health care 
system. All have roles to play, all have responsibilities to 
fulfill, and all have reasons to work together as a team to 
build and to bear a health care system that works for all of 
us.
    Thank you, and I welcome your questions.
    The Chairman. Thank you very much. As I was listening to 
you on the importance of those connections, I was reminded of a 
previous hearing we held on the impact of prolonged isolation 
and loneliness on health, and I was astonished to learn that--
among seniors, and I was astonished to learn that prolonged 
isolation and loneliness has the same kind of detrimental 
impact on health as smoking 15 cigarettes a day. I mean, that 
is just astonishing. So those connections you talked about are 
really important, and I think Dr. Howes, in talking about the 
success of his home health visits, is helping to make those 
connections as well.
    Dr. Howes, I want to turn to another area that you did not 
have time to get into in your oral statement, and that is the 
very impressive work that Martin's Point has done in the area 
of diabetes. Could you tell us what the results have been in 
terms of reducing emergency department visits, inpatient 
admissions, and cost reductions, and what you did to achieve 
those results?
    Dr. Howes. Thank you, Senator Collins. Let me start by just 
saying that we have had dramatic reductions in both admissions 
and in total cost of care. As you know, diabetic patients in 
our system on an annual basis cost about 75 percent more than 
the general population. And most of them, in fact, two-thirds 
of them have a second chronic illness. Very seldom does 
diabetes travel alone as an illness. So you have a second 
chronic illness, which is very important, and we have very 
significantly reduced admissions and emergency room visits for 
this population.
    The tool set that we have used is, first of all, to learn 
about this best, we decided to initiate a special needs plan, a 
Medicare special needs plan. So we have a diabetes special 
needs plan. It starts with an analytic infrastructure so that 
we are able to identify who has diabetes and how do we reach 
out to them. And we reach out to them initially with relatively 
simple means, such as mailings and the like, but then call them 
and urge them to come in. Sometimes we will do that using our 
own staff. This summer and last summer, we had the pleasure of 
having interns from local colleges do that, which was really a 
thrill for them. They were making a real difference for these 
people and really a positive for the member that was called.
    We really focus on meeting these people where they are 
because not everyone is ready to deal with their diabetes, and 
we start with a social work conversation or a nurse 
conversation, which is a motivational interview. What makes it 
worth you changing the way you are living and improving your 
diabetes, that when we give you medicine, you will take it; 
when we ask you to change your diet, you will do it?
    We have a multidisciplinary team that lives under that, 
that works with them and manages medications, diet, and 
activities. That consists of a physician, a nurse, pharmacist, 
social worker, dietician. So all of that stuff comes together.
    We do meticulous tracking and followup of these people, and 
where they drop out, we get them back in so that we see them 
multiple times in the course of a year. And we measure our 
performance quite carefully and actually feed that performance 
back to the team.
    We reward the team, and the team is rewarded financially, 
but what I am really struck by is that is much less important 
to the team that is caring for them than the pride they get in 
seeing real improvement in these patients. And in the medical 
field, to an amazing degree, what motivates people is the sense 
they have done a good job and made a difference in someone's 
life. And so as this data comes back and they see improvement, 
it is very self-reinforcing.
    So that is really the model that we use for the care of 
these people. We have many people who are not in our diabetic 
special needs program, but we extend as much of the same 
techniques to the community members and non-special needs plan 
members as we can.
    The Chairman. When you consider that the care of people 
with diabetes consumes one out of three Medicare dollars, what 
you are doing is really important in terms of helping to 
sustain the Medicare program as well as obviously making such 
an improvement in the lives of these individuals.
    Dr. Howes. The great pleasure for our people, I will tell 
you, is improving the lives of the people they serve.
    The Chairman. Exactly.
    Mr. Cavanaugh, I referred earlier to an Institute of 
Medicine report that said that the spending in our country on 
health care, the large percentage, as much as 30 percent, is 
not useful. And this report found that $55 billion of the total 
resulted from missed prevention opportunities or opportunities 
for preventive care that could have avoided more expensive 
services in the future.
    In your testimony, your written testimony, you specifically 
mentioned that ACOs are unable to waive co-pays for high-value 
primary care services and that ACOs are unable to include 
Medicare beneficiaries in any financial benefit from the cost 
savings.
    Could you elaborate on that and give us some 
recommendations in that area?
    Mr. Cavanaugh. Sure. A couple things.
    One, you are absolutely right and the IOM, of course, is 
right about prevention, and the core of the Aledade model 
starts with the annual wellness visit. Our primary care 
physicians reach out to high-risk patients and get them into 
the office so they can identify those preventive services that 
they have not received and do that consistently.
    Two, you specifically asked what more could we do to 
motivate patients on the benefit side. There are some proposals 
and possibilities to help waive co-payments or encourage 
certain services. There is much more that could be done. For 
example, one of the big strategies all of us use is chronic 
care management, which I think has benefited our patients 
tremendously. But this is not a service that the beneficiaries 
see their physician providing, and then they are surprised when 
they get billed for the co-payment. Transitional care 
management is the same thing. It is an essential form of care 
that our physicians provide, and then oftentimes the 
beneficiary is surprised with a co-payment. You mentioned the 
problem around colonoscopies.
    These are services that are of high value in which the 
notion of creating a disincentive through co-payment or 
deductible does not make any sense.
    I would suggest one way to get out of this bind--all these 
co-payments and payment rules were created in a fee-for-service 
environment where we were worried more about overutilization 
than underutilization. As ACOs move to two-sided risk where 
they are truly accountable for the total budget, you do not 
need to worry about those things as much. If we can encourage 
policies that move the ACO program to two-sided risk, both CMS 
and Congress can start looking at these issues and relaxing 
some of these rules and giving us more flexibility.
    The Chairman. Thank you.
    Senator Casey?
    Senator Casey. Thanks very much, Madam Chair, and I was 
thinking earlier, my staff knows that I have become a little 
obsessive about these numbers of people that got health care by 
county in my state. But Senator Nelson was here earlier, and I 
think when people think of states like Florida and Pennsylvania 
and Maine, too, people focus on the high percentage of seniors. 
In our state, depending on the number you look at or the year, 
the number of people over age 65 approaches 2 million people. 
And those numbers are big, and the number of people that got 
health care in our state through the ACA was about 1.1 million 
people. Just imagine that. More than 60 percent got their 
health care only because we had Medicaid expansion. But the 
number that I think a lot of Americans have not thought about 
until recently is the number of people with pre-existing 
conditions. Nationally, it is about 130 million. In 
Pennsylvania, the latest estimate is 5.3 million people. In a 
state that has a little less than 13 million people, 5.3 
million. So I will start with that number.
    Reverend Snyder, you have seen not just a big number; you 
have seen individuals, human beings that have health care and 
have those protections now and will not have it if the 
administration's point of view prevails in this litigation. And 
all the administration has to do is withdraw the argument, just 
say we are going to make every effort, no matter what, to give 
people those protections.
    So it is pretty clear that we have to make a choice as to 
whether or not we are going to protect--or I should say 
maintain the protections for pre-existing conditions.
    So I ask you about that in the context of, from your 
experience dealing with real people, not dealing with numbers 
in Washington debates, but with those real people, what was 
their life like before, meaning those with pre-existing 
conditions, and what is their life like now after having the 
protections?
    Reverend Snyder. Thank you. I think the deal was in our 
experience with them, it was kind of a course, and before 
getting health care coverage, they were afraid. But prior to 
getting the Affordable Care Act coverage, they would not go to 
the health care provider because they were afraid. They were 
afraid to go. They were not feeling well. They were afraid, and 
I think kind of having a sense of what they had and knowing I 
am going to go, they are going to diagnose me, this is going to 
be a label that is going to be attached with me, and then am I 
going to be able to get health care coverage, and the health 
care coverage I currently have, if I have it, am I even going 
to be able to afford it. So there was a lot of fear.
    Then the Affordable Care Act comes, and they can get 
coverage, and it was a big exhale. It was literally like a 
weight off their shoulders. They definitely exhaled. It was a 
relief, and they were then going to get care, going to the 
physician, getting the care they needed, getting on a course of 
treatment plan, and all going along quite well. And now here 
they are and there is once again fear. If this is taken away, 
now what? And that fear is mixed very understandably with 
anger, and I get that. It is kind of the double ouch: ``I did 
not have it. Now I got it. I was on a course of treatment plan, 
and now you are going to take that away from me? Seriously.'' 
And there is understandable anger and fear, and that is kind of 
a nasty combination, but it is a very real combination. It is 
something that the folks now that we are talking with and 
meeting with, this is issue No. 1, that this needs to be 
continued and needs to be maintained.
    Senator Casey. As you were talking about that, referencing 
that weight lifted off the shoulder, at the other end of the 
state, in southeastern Pennsylvania, we had a meeting a couple 
weeks ago now where a young woman was speaking about her pre-
existing conditions. That is exactly what she said, the 
language that you just used. She said, after she had all kinds 
of bouts with cancer at a very young age and all kinds of 
surgery and ups and down, she literally said exactly what you 
just said: ``A weight lifted off my shoulder.'' That is what 
this means.
    I know we are running low on time. I will just try to get 
one more question in. The Money Follows the Person program 
helps folks who might be a senior or have a disability stay in 
their community. As of 2016, the program has transitioned over 
75,000 people with disabilities and chronic conditions out of 
institutions. By the end of 2018, this will include 3,500 
Pennsylvanians. Can you share why Money Follows the Person is 
important to older adults and people with disabilities in your 
experience?
    Reverend Snyder. Sure, absolutely, and starting--you had 
referenced in your introduction my Mom, and talking from that 
perspective, my mother was one--and it is kind of the norm in 
southwestern Pennsylvania. She literally was born in the house 
where she lived all of her 84 years, literally born, married my 
Dad, raised her five kids in that house, and rocked numerous 
grandchildren and neighbors' kids and cousins in her mother's 
rocking chair. And I share that very personal point of this 
because home matters. People want to stay in their homes. I 
could walk down 2nd Street or Avenue or whatever it is in 
Washington, DC, and ask the first ten people I pass, ``Do you 
want to live in your home or an institution?'' And we know what 
the answer is. ``I want to live in my home.'' Why? It is 
familiar. It is where they are comfortable. I firmly believe 
and have evidence that people live longer and recover stronger 
when they are at their homes. This is absolutely critical for 
folks to be able to remain in their homes surrounded by family, 
what they know, what is familiar, surrounded by their own trust 
points that are very intimate. People know where they live. 
Meals on Wheels knows this is who I deliver the food to, right? 
Congregations and support networks know this is where I find 
this person is absolutely critical for seniors as well as for 
persons with disabilities.
    Senator Casey. Thank you, Reverend.
    The Chairman. Thank you, Senator.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you. Thank you all for being 
here today.
    You know, I am from Nevada. In Reno, Nevada, we have Renown 
Health ACO, and it has been in existence since 2014, serving 
over 18,000 beneficiaries, and there is no doubt it has 
progressively improved the quality scores and work flows by 
integrating care that we have all talked about, that you have 
talked about today. And, in fact, in 2017, Renown also 
generated $2.6 million in savings.
    However, talking with them--and I do on a regular basis--
one of the things that they share with me--and I am curious. I 
am going to open it up to the panel for what you think. What 
they said to me is some of the difficulties they have are data 
sharing at the point of care, and it has been a challenge for 
them. In Renown, the network includes both rural and urban 
facilities as well as providers that practice across state 
lines. And I understand that standardizing the electronic 
health records within the ACO can be challenging. But I hear 
from Renown that the full data integration would allow accurate 
and timely data at the point of care and empower the physicians 
to make the most informed decisions and eliminate duplicate or 
unnecessary orders.
    So I guess my question for you is: What can the Federal 
Government do to help data integration or interoperability for 
ACOs? Is that something that you see as well or an issue or 
difficulty or challenge that you are dealing with as well? And 
maybe, Dr. Howes, I can start with you.
    Dr. Howes. Yes, first of all, the lack of data 
interoperability and data flow between care entities is a real 
issue, and we are blessed in Maine that we have a health 
information exchange, which I am not sure is the optimal 
solution, but it does allow us to get good data on all patient 
encounters over a period of time. But the need to get data 
interoperability--and I think this is an opportunity for 
Congress to push data interoperability between electronic 
health records and to build really good data warehouses, so 
that we can understand all of the care that is being delivered 
in all the locations in which it is being delivered, and 
intervene in an intelligent way in order to improve the health 
and avert costs for our patients and members. Very important 
issue as the health care system evolves forward from really 
what was an analog system to a digital system and something 
that has not been sorted out well.
    Senator Cortez Masto. Thank you.
    Mr. Cavanaugh, do you have something to add?
    Mr. Cavanaugh. First of all, you have identified a really 
complex but important issue, and we fully agree. The better 
interchange of clinical data would be critical. We spend a lot 
of money--because all of our physicians have very different 
EHRs, we spend a lot of Aledade's money just integrating with 
very different EHRs.
    But I will tell you one simple issue that Congress could 
help with. As I mentioned in my testimony, one of our basic 
interventions is to tell our physicians when their patient has 
been discharged from the hospital. The way we do that is we tap 
into the health information exchange that Dr. Howes referred 
to. Some states do not have those exchanges. When that happens, 
we go around to the local hospitals, and we say--you know, at 
our expense we tap into their systems and just say, ``We just 
want to know when our doctors' patients are discharged.'' And 
most hospitals are fine with that. They realize it is good for 
the patient.
    We do run into instances where the hospital says, ``No, we 
will not share that data for competitive reasons.'' Either we 
are starting our own ACO and we want your doctor to come to our 
ACO, or whatever reason. And they are very up front that it is 
for competitive reasons.
    But, you know, if you think of it from the beneficiary 
perspective, they do not care what corporate entity is 
benefiting from their data. They want their primary care doctor 
to know that they have been discharged. And often when our 
doctor calls the patient, they are startled: ``How did you 
know?'' But pleasantly startled. They are glad to hear from 
their primary care.
    So I think Congress and CMS should not allow hospitals to 
block this. You know, at our expense we are willing to go tap 
in and just ask, ``Tell us when the patient is discharged.'' 
And some hospitals are resistant to that. Not all. Some are 
more than happy to share the data. But that is something 
policymakers could help us with.
    Senator Cortez Masto. Thank you.
    Mr. Micklos?
    Mr. Micklos. Yes, thank you, Senator, and I would echo what 
both panelists have already responded. I will add, too, that 
there continues to just be positive movement in the ability for 
patients to be able to kind of capture their own information 
and share it directly, too. And there is a lot of work in the 
technology arena there that supports that activity. And so that 
is not going to be a foolproof solution, but to the extent 
there have been barriers between proprietary medical--EHR 
products, the ability to have the beneficiary be the 
quarterback, as it were, of their information, being able to 
share that is one solution.
    In addition to the clinical data sharing, I think, though, 
that the opportunities that are out there for ACOs both in the 
public sphere but also in the commercial sphere is the 
ability--the greater sharing of claims data and better 
understanding from an actuarial standpoint where you can manage 
it. So a provider-led ACO, you see quite a lot of investment 
now in new experience and expertise with regard to actuarial 
analysis, and sometimes the data that comes from Medicare is 
not as complete or as timely as you would like to see. And to 
Mr. Cavanaugh's point, you know, you often see in commercial 
arrangements where there are competitive reasons, and I think 
we are seeing increasing--and the task force is actually 
involved in activities where we are trying to further the 
dialog so that parties who sit across the table from each other 
can understand better about how they want to use each other's 
information to move it forward. So the data sharing is both 
clinical and also claims data.
    Senator Cortez Masto. Thank you. And I know my time is 
running out. I do not know, Reverend, if you had anything to 
add.
    Reverend Snyder. Sure, I did. And I appreciate that. I 
think letting the primary care physician know when someone is 
being discharged from the hospital is absolutely from the 
consumer perspective coin of the realm movement, right. It 
really is, because as you have been in this strange land and 
you have discharged, now it is trying to get everything in 
order, and, again, what a moment to have the primary care know 
and contact you. It is incredible that they know, and then you 
can help them to get on to this next course of treatment, 
right?
    And with the digital records, with our folks, again and 
with all of this I would be remiss, representing a consumer 
voice here, if I did not say from the very get-go involve the 
voice of the consumer. Tell us what it is. Explain it. Listen 
to their feedback. Implement that feedback to build this much 
better system.
    Senator Cortez Masto. Thank you.
    The Chairman. Senator Gillibrand.
    Senator Gillibrand. Thank you, Madam Chairwoman. Thank you, 
Mr. Ranking Member.
    A common theme that we have heard today from your testimony 
is the importance of preventive care. Studies have repeatedly 
shown that people who are uninsured are less likely than those 
with insurance to receive preventive care for major health 
conditions and chronic disease.
    Given that on average an American with multiple chronic 
conditions will end up spending up to 14 times more on health 
care services than someone without chronic conditions, it is 
imperative that these Americans continue to have access to 
quality, affordable care.
    In New York, I am particularly concerned about the more 
than 1.9 million older adults between the ages of 55 and 64 who 
have a chronic or pre-existing condition and rely on existing 
protections in order to access basic health care.
    Reverend Snyder, in your testimony you mentioned the 
uncertainty and worry around the corner of the Texas v. United 
States case that could potentially overturn protections for 
people with pre-existing conditions and how many of the 
individuals you work with will have one of these health 
concerns and fear that they will be unable to access basic 
quality care.
    Can you speak to some of the health and financial 
challenges that these individuals could face if protections for 
pre-existing conditions or chronic conditions are lost?
    Reverend Snyder. Sure. Thank you, Senator. First of all, if 
this is taken away and all the buzz around it, they are 
automatically going to stop, and they are not going to go. They 
are not going to get treatment for diabetes. They are not going 
to get treatment for a chronic health condition. Even worse 
than that, if it is a cancer diagnosis or they are a cancer 
survivor, they are not going back because they are scared. And 
that is problematic, and it impacts not only them but their 
base and their family on that whole line.
    Some of them definitely--and I do not think--well, I will 
probably say in Pittsburgh, blue-collar Pittsburgh, right? And 
these are very proud folks, right? And they are not going to be 
ones who are going to go to a hospital, even knowing they do 
not have insurance, and, quote-unquote, put that burden on a 
hospital system. They are not going to do that. They are simply 
not going to go. And it is horrific. It really is. And, again, 
I have to emphasize the fact that they had it and were on the--
it was an exhale. Kind of they literally got that burden off 
their shoulders. They kind of stood a little taller and lived a 
little fuller, which we all should be expected to, and they are 
simply now dealing with, ``I had it and now you are taking it 
away,'' and there is anger and shock with that, and it is the 
emotional toll of that as well as the physical toll of that. 
Yes, it is a significant burden that could happen.
    Senator Gillibrand. Dr. Howes, in your testimony you 
mentioned that Martin's Point Health Care's quality care 
practices include improving health outcomes through managing 
chronic conditions, preventive care, and early detection of 
common cancers. How has access to quality and affordable health 
care for these patients helped control health care costs?
    Dr. Howes. Both on the acute side and on the chronic side, 
having good access to primary care is absolutely critical. 
Small conditions which can become severe quickly are dealt with 
early, and on the chronic disease side, there are the 
opportunities to carefully manage people's medications and all 
of the other services that they need in order to do what we 
call advance preventive care, that is, when people have chronic 
illness, they are at risk, getting in to see the clinician, 
getting in to see the nurse practitioner who is managing their 
chronic illness makes an enormous difference in the total cost 
of care and, consequently, in their access.
    Senator Gillibrand. Right.
    Dr. Howes. And so I would tell you, that had I written the 
high-deductible health plan law, I would have made primary care 
something that could be purchased out of the health savings 
account because I think we need to lower those barriers. I 
think it has long-term benefits. I think the same should 
probably be true in the ACA exchange plans. And I know that we 
have a couple of plans in your state--Independent Health, led 
by Dr. Mike Cropp and CDPHP led by Dr. John Bennett--have 
really worked to reduce barriers to primary care and improve 
chronic disease care in that way. And it is a win for 
everybody.
    Senator Gillibrand. We talked a lot about innovation, and 
so for Mr. Cavanaugh and Mr. Micklos, given your work with 
providers and experiences at HHS, could you share with us the 
importance of patient involvement and consumer education to the 
success of innovative health care models?
    Mr. Cavanaugh. Certainly. When I was at CMS and we were 
initially kicking off the whole ACO program, there was a lot of 
speculation: Well, would ACOs want sick patients or would they 
want well patients? You know, which way would they select? Now 
that I am in the ACO business, what I learned is what ACOs want 
are engaged patients. They do not care if you are sick--the 
doctor does not care if you are sick or healthy, but if you are 
engaged, it makes the physician's job so much easier. So we are 
constantly looking for ways to engage the patient, working with 
community organizations, religious organizations, anything that 
motivates the patient, trying to address issues beyond the 
medical issues that are really important to the patient, 
because if they see that their physician practice cares about 
their life more broadly, they are more likely to be engaged.
    Mr. Micklos. I agree with that. I would just add to that 
that as you build a value-based care model, if you cannot 
engage the patient, it is not worth the investment, right? So 
in our organization, we do talk about patient activation and 
how best to reach patients. I think Dr. Howes said earlier in 
his testimony it is critical that you meet patients where they 
are and then you engage with them appropriately and move them 
forward.
    I think some of the earlier conversations also talked about 
in the Medicare population, in particular some of the barriers 
that still continue to exist from a fee-for-service 
architecture, where maybe there are not certain services that 
can be provided in the home, but that patient really needs to 
be in their home, would benefit from being in their home. So 
looking at breaking down some of those barriers I think still 
remains to be an option.
    And then to the extent that we can continue to incentivize 
proper support of preventive medicine, it is very important. 
And there is increasing flexibility, so we are encouraged 
there. But more is necessary. We have had members who have 
contracted with ride-sharing services now that have been able 
to get people to their appointments, and there is a lot of 
investment now in public housing and in addressing food 
deserts.
    There have been fraud and abuse laws that have stood in the 
way of that in the past, and there are still some concerns 
there, but at least it is going in the right direction. We 
should encourage this care to be kind of coordinated and 
integrated across systems and not have some of those last 
boundaries still stand in the way.
    Senator Gillibrand. Thank you, Madam Chairwoman.
    The Chairman. Thank you.
    Senator Jones?
    Senator Jones. Thank you, Chairman Collins, and thank you 
all for being here on this really interesting and important 
topic, especially for states like Alabama that are poor and 
rural and unhealthy, to be honest with you.
    I want to focus on a couple of things. One, we have talked 
about technology, and I think from my perspective telehealth is 
going to be--we are going to have an increasing role in the 
coming years. The State of Alabama is trying to put a 
telehealth clinic in every county health department. The 
University of Alabama in Birmingham, one of the really world-
class medical facilities, has got a program that they are 
working on.
    I would like to just hear from maybe each of you what 
experience you have had with that, and are there specific 
models that our states and our communities need to be looking 
at for telehealth? We will just start down the row, I guess, if 
anybody wants to chime in on that. I think it is important.
    Dr. Howes. Martin's Point does not have any telehealth 
capabilities now, but has been looking at it carefully. And 
there is an enormous benefit in a rural state like Maine where 
over 50 percent of our population is rural in telehealth. 
Actually, in parentheses, I started practicing on the island of 
Deer Isle in 1979, and there had been a telehealth capability 
out there at that point, which was shut down when we opened our 
practice. But it really is incredibly valuable for a lot of 
different populations. On the mental health side, it can be 
accomplished relatively easy and at low cost. Other specialties 
like dermatology, et cetera, are very easy to build telehealth 
capabilities, and it increases access, it can reduce cost, and 
it can really benefit the population that we serve.
    Our larger issues with putting it in place have been how do 
we fit it into the larger spectrum of other services that are 
offered both locally and regionally in a way that optimally 
benefits the patient and does it at high quality.
    Senator Jones. All right. Thank you.
    Yes, sir?
    Mr. Micklos. It is a great question, Senator. I think that 
there are so many opportunities in this space. I think we have 
historically thought about it as telehealth. I think there is 
really just now this broader umbrella of virtual care, and 
whether it is--it helps with access, that is obviously a 
critical point, but also for reaching patients where they are. 
We are talking about from the elderly all the way down to, you 
know, millennials who want to kind of engage in a different 
way.
    I think there is some really interesting work that the 
military has done. I heard a presentation just last week about, 
you know, what the military has done in light of the fact that 
they have been in theater for 17 years, and there are 
advancements in how they use it.
    It also is a significant way to address the physician 
shortages, especially in neurology and other areas where there 
really are some great opportunities to make sure that the 
consults are ready. And it is a timeliness issue as well. If 
someone needs that consultation immediately, that is really the 
way many patients will be able to obtain it.
    Senator Jones. Thank you.
    Mr. Cavanaugh?
    Mr. Cavanaugh. A lot of our ACOs serve rural areas and are 
located in rural areas. We are starting an ACO in your state 
next year, interestingly.
    Senator Jones. Good.
    Mr. Cavanaugh. Not many of them participate actively in 
telehealth, and when you talk to them to find out why, it is 
because of all the restrictions around the current way it is 
structured in the Medicare benefit, that it just does not fit 
the way they practice and it does not fit the way their 
beneficiaries live. But as Mr. Micklos said, the technology is 
evolving and our physicians are very excited about it.
    Going back to my answer to an earlier question, I think as 
we move ACOs to being more and more accountable for the total 
cost of care, all these Medicare regulations that were built 
around preventing overutilization of services hopefully will 
fall by the wayside, and we can get more--I think it would work 
well for many of the beneficiaries that our ACOs treat. I think 
our doctors would love it. It is just that the way it is 
currently constructed, it is problematic.
    Senator Jones. Yes, sir. Thank you.
    Reverend Snyder?
    Reverend Snyder. Thank you for the question, Senator, and I 
think with this as well is from the get-go, right out of the 
gate, involve the consumer, the patient, seek their 
perspective, how it works, because I think the piece of this is 
going to be that they understand it, No. 1, how it works, and 
are going to be concerned about the personal aspect of this. Is 
that going to be part of it? All the more reason when that 
occurs to make sure the trust point, the person, you know, with 
them when they are having that interaction with their provider 
and setting that up is someone that they absolutely trust. And, 
again, involve them from the beginning. Share with them, get 
their feedback in this.
    Senator Jones. My time is just about up, but could you, 
Reverend Snyder--following up on Senator Gillibrand's question, 
what can we do as Members of Congress to try to help with what 
I call ``health literacy,'' getting patients to be engaged as 
you all talked about and understanding? What is it that we 
might do from the Congress that might help with that program?
    Reverend Snyder. I think the point of that is realizing 
that we are all involved in this. You can look at it from the 
economics, and I get that perspective, but as well, I mean, we 
are all going to be health care consumers and interact with 
that. And I think becoming available and really listening to 
these stories of these folks, involving them in this, yes, it 
is economic, but ultimately it is a person, and it is who they 
are, and to provide--to gather those stories and listen to them 
around that piece and be very accessible to hearing those 
stories and involving them in this piece.
    As far as health literacy, again, it really is that, and 
programs to provide even in your offices, right? And interact 
with your local community organizations that do that. Honestly, 
to get people into programs in health literacy as respected 
trust points and the connection people have with the offices, 
more than maybe going to get a fishing license or a hunting 
license, which that is important, too, but as well to have that 
being a connect point with that office into the broader 
community I think would be a really good piece as well.
    Senator Jones. Great. Well, thank you. Thank you all very 
much.
    The Chairman. Thank you, Senator.
    We are going to do a very brief second round of questions. 
There are so many issues that have been raised that deserve a 
little more attention.
    Mr. Cavanaugh, I noticed in your testimony that you said 
you had been able to achieve a 22 percent average decrease in 
skilled nursing facility stays. That is astonishing for two 
reasons: one, the difference in cost between home health care 
and a skilled nursing facility; but, second, as Reverend Snyder 
said, all of us or virtually all of us would so much rather be 
able to stay in our own homes. So how did you do it?
    Mr. Cavanaugh. Thank you for the question. I should preface 
my answer by saying we think we can do a lot more. What we have 
done so far has been fairly basic. One is having our physicians 
in our ACOs go out and talk to the local skilled nursing 
facilities and explain we are now in an ACO, we are now 
watching, we now care that the right patients come to you, that 
they stay for the right duration, that they get the right 
therapies while they are there. There is value in just having 
that conversation and letting the skilled nursing facility know 
that someone now is watching and cares, which has not been true 
in the past.
    In some of our markets, we have created post-acute 
liaisons, so there is someone in the ACO designated to check in 
and say, ``I see Ms. Smith is still there. What is the plan? 
When is she getting home? Can we help you plan the discharge so 
that when she goes home, the services she needs to go home are 
ready?'' So it is almost like augmenting the discharge process 
for the skilled nursing facility.
    There are a series of these things that are really--they 
are sort of resource-intensive, and that is why--but I think we 
have just scratched the surface of this.
    When I was at CMS and we looked at the variation in 
spending in Medicare across the country, almost all of it is 
explained by post-acute-care utilization, how expensive the 
site of care is. There are just different cultures in different 
regions, so trying to break out of that and stay focused on the 
actual needs of the beneficiary.
    We have done some basic things and had really remarkable 
results, but we think there is a lot more potential there.
    The Chairman. That is very encouraging.
    Dr. Howes?
    Dr. Howes. We have made some really substantial reductions 
as well, and one of the very interesting facts that we have 
learned is that, for example, post-joint replacement, our 
orthopedists in Maine feel that people do better when they go 
home than when they go to a skilled nursing facility if they 
have an adequate rehabilitation plan and they follow it. Their 
perspective is that their recovery is quicker and more 
complete. And so that has served as a nice motivator for our 
teams to get people home as quickly as possible, as much of the 
time as possible.
    The Chairman. That is absolutely fascinating. I just think 
this is very exciting.
    The final question I want to ask involves the treatment of 
and the identification of depression and other mental 
illnesses. And, Dr. Howes, you and I started to have a brief 
conversation about that. I bring it up because this is the 10-
year anniversary of the passage of the Paul Wellstone and Pete 
Domenici Mental Health Parity Act that was intended to make 
sure that insurance treated the limits on mental illnesses the 
same as physical illnesses. And there is a 2016 study that 
found that a depressed mood, which included symptoms such as 
anxiety and fatigue, was as strong a predictor of heart disease 
as well-known risk factors like high cholesterol and obesity.
    So, Dr. Howes, what are you doing at Martin's Point to 
better integrate screening for mental health and substance 
abuse disorders?
    Dr. Howes. Well, in our population we do the same thing 
that Mr. Cavanaugh's people do, which is an annual wellness 
visit, which includes a mental health screen.
    The other piece of work that we are doing, which is our 
home care program adapted from Health Quality Partners in 
Doylestown, Pennsylvania, is that when our nurses take on a 
sick, chronically ill patient, they screen very thoroughly for 
depressive illness and substance abuse, which is both 
associated with and exacerbates mental illness. And we are 
finding a fair amount of treatment need there.
    I would also tell you that we find opioid addiction in the 
elder community is higher than we would like it to be. We are 
dealing with that, and we actually have now got a zero co-pay 
for people in our health plans to access opioid treatment for 
the very reason that it all ties together. Mental illness, 
substance abuse, and depressive illness are really connected.
    The Chairman. Thank you. That is very helpful.
    Senator Casey?
    Senator Casey. Madam Chair, thank you for the second round. 
I will get to two questions.
    Mr. Cavanaugh, I will start with you. You get extra credit 
because you went to Penn, but that is not why I am asking you 
the question.
    [Laughter.]
    Senator Casey. I want to take you far away from a big city 
like Philadelphia into rural communities. As you know from your 
work, you have got a proven track record working in those parts 
of states like mine. I represent a state that has 48 out of 67 
counties are considered rural. That means we have a larger 
rural population than any other state except maybe three or 
four, over 3 million people living there. So access to health 
care in rural areas is a big issue in our state.
    People who worry about getting food on the table or 
figuring out a way to get to their doctors' appointments is a 
bigger deal when you have great distances to travel, as you 
know. We know that in our state and in a lot of states the Area 
Agencies on Aging are critically important.
    So I guess in light of your experience with these rural 
communities and access to care, can you explain the importance 
of community partners in addressing the social needs of a rural 
patient?
    Mr. Cavanaugh. Those community partners are absolutely 
essential, and even more so for a model like ours. Our model is 
based on the physician practice, and in a rural area, the 
physician practice is bare bones. It is maybe one or two 
physicians, maybe one or two staff. So the notion that they are 
going to personally address the non-medical needs of their 
patients is just not viable. They need to tap into community 
resources in a big way. And they do not have the resources of a 
health plan. So a lot of what we do is try to help them with 
backup resources, but also help them map out what are the 
community resources in your community. And the AAA agencies are 
often the starting point.
    I would say one of the hard lessons we have learned both in 
rural and non-rural communities is a Meals on Wheels program in 
one community might be the best provider of food services, and 
then you go one community over, and it is a weaker agency.
    So part of it is learning not just what the resources are, 
but which ones are really worth working with that are really 
going to deliver, are going to be customer friendly. And, 
unfortunately, you have to relearn that in every community you 
work in. We try to stay close with our doctors. They often know 
this. But often if it is their first time in an ACO, they are 
doing these sort of functions for the first time, so they are 
learning.
    So I could not agree with you more that tapping into 
community resources is essential. The aging agencies often are 
one of the best--not always but often one of the best. So it is 
a big part of our model.
    Senator Casey. Thank you.
    Reverend Snyder, I will go back to you as well for another 
kind of real-life issue, which is the work that navigators do. 
It seems like if you had a Ph.D. in health care, you would 
still need a navigator on some days. But we are grateful for 
the work that gets done. The navigator grants are critically 
important. But, unfortunately, the administration has chosen to 
reduce funding for navigators from $62.9 million in 2016 to 
only $10 million in 2018. So over the course of two years, 
cutting it by roughly $53 million. I do not know who the hell 
thought of that idea. I do not know how the United States of 
America is better off by taking $53 million from navigators. 
But some bright star, I guess, in the administration thought 
that was a good idea. It is a dumb idea, a really stupid idea.
    But I wanted to ask you, what is the value of those 
navigators and the in-person assistance that they bring?
    Reverend Snyder. Thank you, and I would resonate with not 
the greatest idea, what they are planning to do. When open 
enrollment started back in 2013, on October 1, we literally had 
folks show up at our office asking this question: ``OK. I am 
here for my free health care.'' And you are, like, ``Well, time 
out.'' And part of that is on us about educating what the 
Affordable Care Act was. And as that caught its stride, I mean, 
we have folks coming here and we are a trust point, right? It 
is confusing. They are intimidated. They are not sure, and to 
have someone that is with them person to person helping them to 
navigate it, answering their questions, giving them that 
comfort, and then the all important followup is absolutely 
golden. That has been one of the pieces of the Affordable Care 
Act along with, as we have discussed already, you know, the 
covering of pre-existing conditions, having the navigators has 
been absolutely beneficial because folks come in, they are 
confused, they are intimidated. And we had folks walking in 
having no idea what a deductible was. So it is meeting them, 
that person-to-person, that trust point, and helping them to 
navigate through the system, it was valuable and I think made 
the Affordable Care Act be the success it has been in a lot of 
ways.
    Senator Casey. Thank you.
    Thank you, Madam Chair.
    The Chairman. Thank you.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you. And I want to follow up on 
the Chair's latest conversation with all of you on mental 
illness, but let us turn it to Alzheimer's and dementia. We 
have spent a number of hearings, thank you very much, trying to 
address and understand how those patients and their families 
dealing with Alzheimer's and dementia navigate the health care 
system. Could you talk to us about how you address and work 
with patients and their families who are navigating your health 
care system through an ACO that are dealing with either 
Alzheimer's or dementia? Maybe, I do not know, Dr. Cavanaugh, 
do you mind starting--or, excuse me, Mr. Cavanaugh, do you mind 
starting?
    Mr. Cavanaugh. You just made my Mom very happy.
    [Laughter.]
    Mr. Cavanaugh. Sure, it is one of the great challenges. I 
hate to keep harping on it, but it starts with the annual 
wellness visit and making sure you know that the patient has 
dementia and, you know, screening and just the awareness of the 
primary care practice and wrapping their arms around the 
patient. But typically then the practice needs to know who the 
caregiver is, so it is not just working with the patient, but 
understanding the patient's support system. And this is, 
frankly, where traditional American practices have not been 
well oriented to. But now that you have an ACO model where they 
see that, it is the type of medicine they want to practice, 
like this is something physicians want to get involved in, they 
just have never felt they had the time or that the business 
case warranted it. You see physicians recognizing the challenge 
and stepping up to it and saying, ``This is how I want to 
practice. I want to know what this patient is going home to.'' 
So a big part of this also is the care manager. Most of our 
practices, we have embedded care managers if the practice is 
big enough. It would be not just the physician dealing with the 
medical side but the care manager dealing with the family side 
and, again, linking into community resources.
    But we do not have any magical clinical programs that solve 
this problem, but getting the basics right at the outset like 
that is the important first step.
    Senator Cortez Masto. Thank you.
    Reverend?
    Reverend Snyder. And I really want to play off of the whole 
idea of the caregiver in this piece, right? And a lot of times, 
I mean, the person living with Alzheimer's and dementia, they 
are scared. They are scared about what they have already lost 
and what they are going to lose. And the most important thing I 
think they are scared of is the loss of independence, right?
    So one of the things we encourage with the caregiver is a 
lot of times they will walk in, and a good provider is going to 
talk directly to the patient, as they should. It is always 
defend the person's dignity. And they might ask, ``How is it 
going?'' And the person might say, ``Oh, I am fine. It is well. 
Everything is good,'' when the caregiver knows that there have 
been instances and issues, and maybe there has been falls and 
what have you. And one of the neat things we recommend is for 
the caregiver then, before the visit, to either email or call 
and talk to the provider and share with them, ``Hey, look, this 
has been happening. You might want to address this in the 
visit,'' so you are not embarrassing the person who has 
dementia or Alzheimer's in the visit, saying, ``No, that is not 
true. Things have not been well.'' It is just another way of 
defending dignity and involving, again, the caregiver and that 
whole team--I cannot stress that enough as well--in this whole 
journey through Alzheimer's and dementia.
    Senator Cortez Masto. Thank you.
    Yes, Mr. Micklos?
    Mr. Micklos. I will just add to that that I think the 
increasing focus on the ability to provide home care services 
is also very important in that realm. It is really important to 
be able to meet that patient where they are, and as we talked 
about, even in a demented state, it is still a better outcome 
for them to be at home and receiving home care. And so I think 
we need a greater opportunity to really kind of focus on that.
    I think in the Medicare Advantage space and watching the 
policies around supplemental benefits will also be interesting 
to watch. There will be opportunities beyond the caregivers, 
but also potentially for companionship and other opportunities 
that I know at least from a social work perspective are really 
important for that patient population.
    Senator Cortez Masto. Thank you.
    Dr. Howes?
    Dr. Howes. We really are beginning now to scan our claims 
data base to us who is showing various signs of dementia to try 
to begin to provide for them services like referrals to 
dementia daycare, to provide respite for families. In our area 
we have a wonderful organization called the Southern Maine Area 
Agency on Aging which has put together a great daycare 
facility.
    But, in addition, we are beginning to figure out what are 
the social supports that these individuals and their families 
need. The clinical interventions, while they are making some 
difference, are not really very effective at this point, and 
this is really about supporting the patient and supporting the 
family through this terrible illness and loss.
    Senator Cortez Masto. Thank you. Thank you so much. I 
appreciate the hearing today. Thank you all for being here. 
Thank you.
    The Chairman. Thank you.
    I want to thank all of our witnesses for your compelling 
testimony today. It is extremely helpful to our Committee as we 
contribute ideas for moderating health care costs while 
actually improving the quality of patient satisfaction and 
outcomes, and the two are not incompatible goals at all, as 
your experiences clearly demonstrate. In fact, oftentimes the 
lower-cost interventions, the emphasis on prevention, can 
prevent more serious illnesses from developing or worsening and 
increase patient satisfaction and outcomes. I appreciate your 
sharing your very specific ideas with us. That is very helpful 
as well.
    I also want to thank our staff on both sides of the aisle 
for working hard on this hearing, which, as I said, I think 
contributes to the general debate. We have had a lot of focus 
on the cost of health insurance, which clearly is vital, but we 
need to focus more on health care costs, which obviously has a 
direct impact on the cost of health insurance. And I am also 
concerned about the sustainability of our entitlement programs, 
and this debate is very important for that as well.
    Senator Casey, do you have any closing comment?
    Senator Casey. Just briefly, Madam Chair. Thank you for 
having this hearing on such an important set of issues.
    I also want to thank our witnesses for their testimony, 
particularly Reverend Snyder, not only because she is from 
Pennsylvania but that helped, and I am grateful. And I am 
really grateful for all of our witnesses who are here today.
    Congress, when we passed the Affordable Care Act, took 
strides to expand coverage and to help make coverage more 
affordable and transform the health care delivery system. I and 
I know others will continue to work to keep the promise that 
our Government made to 130 million Americans and 5.3 million 
Pennsylvanians with pre-existing conditions. I will also 
continue to work with Democrats and Republicans to improve the 
patient and provider experience. We have got a lot of work to 
do, but I look forward to working with my colleagues in both 
parties to improve our health care system.
    Chairman Collins, thank you very much.
    The Chairman. Thank you.
    Committee members will have until Friday, October 12th, to 
submit questions for the record. If we do receive some, we will 
be passing them along to you.
    Again, my thanks to our outstanding witnesses today, to 
Ranking Member Casey, and to all the Committee members who 
participated in today's hearing. Given all else that is going 
on, I was really delighted that so many members were able to 
come by for parts of the hearing, and I think that shows their 
interest in this topic.
    This concludes the hearing. My thanks.
    [Whereupon, at 11:02 a.m., the Committee was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
      
      
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