[Senate Hearing 118-166]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-166

               IMPROVING CARE, LOWERING COSTS: ACHIEVING 
                           HEALTH CARE EFFICIENCY

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

                                HEARING

                               BEFORE THE

                        COMMITTEE ON THE BUDGET
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            October 18, 2023

                               __________

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


                              __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-120 PDF                  WASHINGTON : 2024                    
          
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                        COMMITTEE ON THE BUDGET

               SHELDON WHITEHOUSE, Rhode Island, Chairman
PATTY MURRAY, Washington             CHARLES E. GRASSLEY, Iowa
RON WYDEN, Oregon                    MIKE CRAPO, Idaho
DEBBIE STABENOW, Michigan            LINDSEY O. GRAHAM, South Carolina
BERNARD SANDERS, Vermont             RON JOHNSON, Wisconsin
MARK R. WARNER, Virginia             MITT ROMNEY, Utah
JEFF MERKLEY, Oregon                 ROGER MARSHALL, Kansas
TIM KAINE, Virginia                  MIKE BRAUN, Indiana
CHRIS VAN HOLLEN, Maryland           JOHN KENNEDY, Louisiana
BEN RAY LUJAN, New Mexico            RICK SCOTT, Florida
ALEX PADILLA, California             MIKE LEE, Utah

                   Dan Dudis, Majority Staff Director
        Kolan Davis, Republican Staff Director and Chief Counsel
                   Mallory B. Nersesian, Chief Clerk
                  Alexander C. Scioscia, Hearing Clerk
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                      WEDNESDAY, OCTOBER 18, 2023
                OPENING STATEMENTS BY COMMITTEE MEMBERS

                                                                   Page
Senator Sheldon Whitehouse, Chairman.............................     1
    Prepared Statement...........................................    34
Senator Charles E. Grassley, Ranking Member......................     3
    Prepared Statement...........................................    36

                    STATEMENTS BY COMMITTEE MEMBERS

Senator Chris Van Hollen.........................................    18
Senator Mike Braun...............................................    20
Senator Roger Marshall...........................................    22
Senator Ron Wyden................................................    25
Senator Tim Kaine................................................    29

                               WITNESSES

Dr. Matthew Fiedler, Senior Fellow, The Brookings Institution....     6
    Prepared Statement...........................................    39
Dr. Leemore Dafny, Professor, Harvard Business School and Harvard 
  Kennedy School.................................................     8
    Prepared Statement...........................................    53
Dr. G. Alan Kurose, Chair, Rhode Island Foundation, and Former 
  President, Coastal Medical.....................................    10
    Prepared Statement...........................................    70
Mr. Theo Merkel, Director of Private Health Reform Initiative, 
  Senior Research Fellow at the Paragon Institute, and Senior 
  Fellow at the Manhattan Institute..............................    11
    Prepared Statement...........................................    79
Dr. Chapin White, Director of Health Analysis, Congressional 
  Budget Office..................................................    13
    Prepared Statement...........................................    91

                                APPENDIX

Responses to post-hearing questions for the Record
    Dr. Fiedler..................................................    94
    Dr. Dafny....................................................    96
    Mr. Merkel...................................................    97
    Dr. White....................................................   104
Charts submitted by Chairman Sheldon Whitehouse..................   107
Documents submitted for the Record by Chairman Sheldon Whitehouse   109
Statement submitted for the Record by The OrthoForum.............   186
Statement submitted for the Record by Patient Rights Advocate....   190

 
    IMPROVING CARE, LOWERING COSTS: ACHIEVING HEALTH CARE EFFICIENCY

                              ----------                              


                      WEDNESDAY, OCTOBER 18, 2023

                                           Committee on the Budget,
                                                       U.S. Senate,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:01 
a.m., in the Dirksen Senate Office Building, Hon. Sheldon 
Whitehouse, Chairman of the Committee, presiding.
    Present: Senators Whitehouse, Wyden, Kaine, Van Hollen, 
Grassley, Johnson, Marshall, Braun and R. Scott.
    Also present: Democratic staff: Joshua P. Smith, Budget 
Policy Director; Melissa Kaplan-Pistiner, General Counsel; 
Anirudh Srirangam, Healthcare Policy Advisor; Dan RuBoss, 
Senior Tax and Economic Advisor and Member Outreach Director.
    Republican staff: Krisann Pearce, General Counsel; Nic 
Pottebaum, Professional Staff Member; Ryan Flynn, Staff 
Assistant.
    Witnesses:
    Dr. Matthew Fiedler, Senior Fellow, The Brookings 
Institution
    Dr. Leemore Dafny, Professor, Harvard Business School and 
Harvard Kennedy School
    Dr. G. Alan Kurose, Chair, Rhode Island Foundation, and 
Former President, Coastal Medical
    Mr. Theo Merkel, Director of Private Health Reform 
Initiative, Senior Research Fellow at the Paragon Health 
Institute, and Senior Fellow at the Manhattan Institute
    Dr. Chapin White, Director of Health Analysis, 
Congressional Budget Office

          OPENING STATEMENT OF CHAIRMAN WHITEHOUSE \1\
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    \1\ Prepared statement of Chairman Whitehouse appears in the 
appendix on page 34.
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    Chairman Whitehouse. I have the permission of the Ranking 
Member to proceed while he comes here from the Finance 
Committee. We will be having members in and out throughout the 
morning because this is a very busy day for hearings in 
Congress. In fact, I have three this morning. So, you'll see 
people come and go.
    I do want to use this hearing to build a record for ways 
that we can save in the budget on health care costs. And so, 
today's hearing is about excess costs in health care, and ways 
we can reduce the budget by spending health care dollars more 
efficiently.
    As I point out often, and as this graph shows (insert 
footnote in editing), the United States (U.S.) continues to 
spend more on health care as a percentage of gross domestic 
product (GDP) than any other peer Organisation for Economic 
Cooperation and Development (OECD) country.
    And at the same time, the vertical graph is life 
expectancy. And our national, the average life expectancy in 
this country is lower than that of most of our peer countries, 
parallel to Estonia.
    We also spend more on health care per person, not just per 
GDP, over one and a half times more than the next closest 
country, Switzerland. We're spending $4 trillion a year. And 
the Centers for Medicare and Medicaid (CMS) actuary estimate 
that health spending will grow to 20 percent of GDP by 2031.
    Not only is our life expectancy in America lower than you 
would expect compared to other OECD countries, for all the 
money we spend, but has actually declined over the last two 
years. An American's life expectancy is now the lowest it has 
been in two decades. We can do better than to be on par with 
Estonia, particularly when we're spending nearly double on 
health care as a percentage of GDP.
    Put very simply, we get very little bang for 4 trillion 
bucks.
    It is grim, but there are some signs of progress. And we'll 
hear today from experts about how we can do better. The 
Congressional Budget Office (CBO) has found that federal health 
care spending between 2010 and 2020 was more than a trillion 
dollars lower than CBO had projected prior to implementation of 
the Affordable Care Act (ACA).
    And as this chart shows, CBO now projects the U.S. will 
spend $4.6 trillion less on the major federal health programs, 
mainly Medicare and Medicaid, over the next decade than was 
projected pre-ACA.
    CBO also found growth slowed in spending per beneficiary. 
While there are many contributing factors, the deceleration 
shows that smart policymaking and reforms can help bend the 
cost curve. The Affordable Care Act fundamentally changed 
health care. And thanks to the payment modernization and care 
transformation it initiated, we're seeing reduced health 
spending. But our work isn't done.
    Notwithstanding Medicare's new power to negotiate the price 
of some drugs, thanks to the Inflation Reduction Act, Medicare 
spending continues to grow faster than the rest of the federal 
budget. And our national health expenditures are rising rapidly 
still.
    That's because our fragmented and endlessly complex health 
care system creates the perfect environment for inefficiencies 
to fester. It is where excess costs live and grow.
    Today we will hear from experts about three areas of 
inefficiency that have increased health care costs for 
patients, families, and the Federal Government. And I would 
add, also, increased frustration.
    First, we will hear about the dizzying web of 
administrative tasks, the billing, the reporting, and all the 
non-clinical work incidental to the actual delivery of care 
that providers face. We will hear how these burdens are 
responsible for over half a trillion dollars in health care 
spending every year, and annoyances like prior approvals that I 
think for Accountable Care Organizations (ACOs) are not even 
necessary.
    Our discussion on this is especially timely. Research 
released last week revealed possible savings between $40 and 
$60 billion a year just from fixing the mess of health care 
billing and claims.
    Next, we'll hear about how consolidation in health care can 
raise prices for patients, leading to higher federal health 
spending. We'll also learn about potential solutions, like 
health cost databases that don't just bring much needed 
transparency into the opaque world of health prices, but also 
enable stakeholders to take actionable steps to control 
spending based on that data.
    18 states, including Rhode Island, are already making use 
of tools like these known as All-Payer Claims Databases, to 
reduce patients' costs and improve care.
    Then we'll hear from one of Rhode Island's leading health 
care experts, Dr. Al Kurose, about how our fragmented health 
system, with patients often navigating multiple providers at 
different sites instead of obtaining care from a primary care 
provider, results in worse care at higher cost.
    We'll hear how delivery system reforms like Accountable 
Care Organizations can promote higher quality care with less 
money spent. Patients seeking care are often lost in the maze 
of our current fee-for-service system. Transitioning to value-
based care, predicated on strong primary care, can help achieve 
the long-sought triple aim of better care, better health, and 
lower costs.
    Within our current health care system there is no doubt 
that value-based care is the best solution. Value-based care 
rewards providers not based on how much care they deliver for 
patients but on how well they deliver it.
    A decade on from the implementation of the ACA we have 
learned a great deal. We have learned that simplifying non-
clinical work in health care, changing how we pay for health 
care, and transforming how we deliver health care can both 
lower costs and improve outcomes. If we do all of this more 
often and at scale, we can deliver the best and most accessible 
health care for America's patients.
    With that, I will turn to my distinguished Ranking Member 
Chuck Grassley.

           OPENING STATEMENT OF SENATOR GRASSLEY \2\
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    \2\ Prepared statement of Senator Grassley appears in the appendix 
on page 36.
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    Senator Grassley. Thank you for this very important 
hearing, Mr. Chairman, a very important subject of improving 
health care and lowering costs. And thanks to all of our 
witnesses for the time that you've put in, the extra time you 
put into educating Congress and preparing for this.
    Health care might be one of the few markets in our economy 
where the consumer doesn't know the price before they buy it. 
And they rarely pay for it directly. Yet, Americans spend more 
than $4.3 trillion annually on health care. Our spending has 
more than tripled as a percentage of gross domestic product 
since 1960.
    Growing health care costs don't just strain Americans' 
pocketbooks, they also are key drivers of widening budget 
deficits and the Federal Government's unsustainable fiscal 
outlook. And it's not clear that we're getting our money's 
worth for all that spending.
    Major health care programs' spending eats up 32 percent of 
federal revenue today, and it will be 45 percent of revenue 
by--mid-century. Our health care system has plenty of waste and 
inefficiencies that need fixing. Increasing transparency and 
competition, fighting fraud, and getting rid of red tape are 
some key areas to start with.
    You should know what something costs before you buy it. 
That's common sense for any consumer. That transparency is what 
we need.
    Until recently, we didn't apply sunshine to health care 
prices. I'm glad hospitals and health plans are now required to 
report their pricing data, but I'm not sure that it's in 
consumer-friendly ways in which it's put out, and may not be as 
effective as it was intended to be.
    More transparency should also be applied to Pharmacy 
Benefit Managers, a very opaque middle people between 
pharmaceutical companies and the consumer. And I think this 
would lower patient and taxpayer prescription drug costs.
    Another way to lower health care costs is to ensure 
taxpayer dollars are being used wisely. Last year alone our 
federal major health care programs lost over $130 billion to 
what we refer to around here as fraud, waste, and abuse.
    I'm the author of a major and more recent update to the 
Federal Government's most powerful tool in fighting fraud, the 
False Claims Act. And since I got that adopted in 1986, we have 
seen the Federal Government recover more than $72 billion lost 
to fraud, and saved billions more by deterring would be 
fraudsters.
    We should also be reducing unnecessary red tape and 
administrative burdens. Between 1975 and 2010, the number of 
physicians grew 150 percent while the number of health care 
administrators increased by 3,200 percent. This administrative 
growth is driven by regulations which take more compliance time 
and financial resources away from patient care.
    We need policies, that promote the discovery of new cures 
and better treatments, not overly-administrative price controls 
that stifle innovation.
    I worked for five years to allow the sale of over-the-
counter hearing aids with Senator Warren of Massachusetts. 
Today, consumers can buy a pair of high quality and safe 
hearing aids at $3,000 less compared to a year ago.
    I also support improving value in our health care system. 
But we need to accurately account for what's working and what's 
not working.
    Recently, the Congressional Budget Office found that the 
Center for Medicare and Medicaid Innovation, a program created 
with a goal of lowering costs, did not lower Medicare costs. 
Let me emphasize, that's not Chuck Grassley saying that, the 
Congressional Budget Office has said that.
    CBO says the program increased federal spending. I invited 
CBO to this hearing, and look forward to learning about their 
analysis today.
    We should look to the market-based solutions similar to 
Medicare Part D, which I also led the team on Finance Committee 
to get adopted in 2003, because it lowers costs and improved 
care. In the first decade of Part D, the Congressional Budget 
Office found that this Part D program ended up costing 
taxpayers 36 percent less than projected.
    Finally, we can't talk about waste and inefficiency in the 
health care system without discussing the country's fiscal 
situation. According to CBO, the federal budget deficit in the 
fiscal year that just ended clocked in at about $2 trillion. 
And future deficits are projected to be even higher, partly 
because of growing health care spending.
    Health care spending can be made more efficient without 
compromising quality of care and reducing access, especially in 
rural America. I hope that we can build upon the ideas that we 
hear here today from this outstanding panel to address our 
country's fiscal challenges, while also improving health care 
for Americans.
    Thank you.
    Chairman Whitehouse. Thank you very much, Senator Grassley.
    Our witnesses today are, first, Dr. Matthew Fiedler, who is 
the Joseph A. Pechman Senior Fellow in Economics Studies at The 
Brookings Institution, where his research examines a range of 
topics in health care, economics, and policy.
    Prior to joining Brookings, Dr. Fiedler served as Chief 
Economist on the staff of the Council of Economic Advisors, 
where he oversaw the council's work on health care, including 
implementation of the Affordable Care Act.
    We'll then hear from Dr. Leemore Dafny. Dr. Dafny is the 
Bruce V. Rauner Professor of Business Administration at the 
Harvard Business School, and Professor of Public Policy at 
Harvard Kennedy School.
    Professor Dafny's research focuses on competition and 
consolidation in health care markets. She previously served on 
the Panel of Health Advisors for the Congressional Budget 
Office, and was Deputy Director for Health Care and Antitrust 
in the Bureau of Economics at the Federal Trade Commission.
    Then we'll hear from Dr. Al Kurose. Dr. Kurose worked as a 
practicing primary care physician in a community-based office 
for 20 years. In his second career as a health care executive 
and community leader he has continued his focus on innovative 
approaches to how care is delivered and paid for.
    For 14 years, Dr. Kurose led Coastal Medical through its 
transition into an ACO and, indeed, a star performer in the 
Medicare Shared Savings Program. He'll be speaking to us today 
about lessons from that experience and the movement to 
accountable care that he and Coastal have been a part of.
    Next will be Mr. Theo Merkel. He is the Director of the 
Private Health Reform Initiative and a Senior Research Fellow 
at the Paragon Institute, and Senior Fellow at the Manhattan 
Institute.
    Previously, he served as Special Assistant to the President 
for Economic Policy at the National Economic Council in the 
White House, and served as legislative director here in the 
Senate for Senator Pat Toomey.
    Our final witness today is CBO's own Dr. Chapin White, the 
Director of Health Analysis at the Congressional Budget Office. 
Dr. White first joined CBO in 2005 as a health economist, and 
went on to serve as a Senior Health Researcher at the Center 
for Studying Health System Change, as well as a Senior Policy 
Researcher at the RAND Corporation, before rejoining CBO in 
2020.
    My hope is that this hearing sets a foothold or a 
foundation for bipartisan discussions on ways that we can move 
legislation to reduce the costs of care and improve the quality 
of care in the health care system. And I hope we can focus on 
that, not only today, but in the months ahead as the Committee 
continues to rely on all of you for your expert advice.
    Let me start with Dr. Fiedler. You all will have five 
minutes each. Your full statements will be made a matter of 
record.

STATEMENT OF DR. MATTHEW FIEDLER, SENIOR FELLOW, THE BROOKINGS 
                        INSTITUTION \3\
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    \3\ Prepared statement of Dr. Fiedler appears in the appendix on 
page 39.
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    Dr. Fiedler. Chairman Whitehouse, Ranking Member Grassley, 
and members of the Committee, thank you for having me here 
today. My name is Matthew Fiedler, and I am a health economist 
and a Senior Fellow at The Brookings Institution.
    My testimony today examines ways that policy makers can 
reduce the administrative costs generated by interactions 
between health care providers and payers. These interactions, 
which include contract negotiations, claims transactions, prior 
authorization activities, and quality reporting, are costly. A 
reasonable estimate is that they generate administrative costs 
totaling around $0.5 trillion per year, equivalent to about 11 
percent of annual health care spending.
    Most of these costs are ultimately borne by consumers and 
taxpayers.
    Importantly, administrative activities can be valuable. 
Billing processes compensate providers for delivering care. 
Prior authorization processes can help prevent delivery of 
inappropriate services. And audit processes can help uncover 
and deter fraud.
    So, efforts to reduce administrative costs have to proceed 
thoughtfully.
    In exploring reforms, it's worth considering both targeted 
policy changes and policy changes that would affect a broader 
swath of provider-payer interactions.
    A good example of a targeted policy change is eliminating 
Medicare's Merit-Based Incentive Payment System, or MIPS. Under 
MIPS, Medicare scores clinicians in several domains, including 
the quality and efficiency of their care. Clinicians' payments 
rates are then adjusted up or down based on their scores, with 
the goal of encouraging high performance. Much of the 
information used to score clinicians, particularly on quality, 
is reported by clinicians themselves. And practices are 
expected--practices are estimated to spend thousands of dollars 
per physician, per year reporting the MIPS.
    Yet, despite these large administrative costs, MIPS is 
likely not improving patient care. One problem is that 
clinicians can choose the measures they are evaluated on, which 
makes it hard to meaningfully compare across clinicians. Plus, 
past studies of programs like MIPS have found little evidence 
that they improve performance. Since MIPS appears to be 
generating large administrative costs with few benefits, there 
is a strong case for eliminating MIPS and, ideally, replacing 
it with something more effective and less burdensome.
    There are other targeted changes that could also reduce 
administrative costs with few tradeoffs, such as performing the 
processes to determine prices for out-of-network services under 
the No Surprises Act, and reforming the risk adjustment methods 
used in Medicare Advantage.
    But my larger point here is that many seemingly narrow 
health care policy decisions affect administrative costs. And 
it is worth being attentive to those effects.
    Turning to broader reforms, one salient feature of our 
health care system is that providers must deal with a menagerie 
of public and private payers, all of which set different rules. 
This may be a key reason that administrative costs are higher 
in the United States than in many other countries. And it 
suggests that standardizing billing, coverage, or quality 
reporting processes across payers could help reduce 
administrative costs.
    Relative to the targeted reforms I just discussed, these 
approaches may offer greater savings potential, but may also 
present more significant risks and tradeoffs.
    One target for standardization is the method that providers 
and payers use to exchange claims information. Some have 
proposed creating a central clearinghouse that would accept 
claims from providers in a standardized format and route them 
to payers, similar to approaches used in some other industries 
and some other countries' health care systems.
    This approach would likely more fully standardize claims 
transactions than past federal efforts which have focused on 
establishing standards to govern bilateral provider-payer 
interactions. The key challenge would be ensuring that the 
clearinghouse was well run, as a poorly run clearinghouse could 
have few benefits or even do harm.
    Policymakers could also consider trying to standardize the 
substance of some payer rules around billing, coverage, or 
quality reporting. This approach may have particularly great 
potential to reduce administrative costs. But, at least in some 
cases standardized processes might be less effective, whether 
because they lack tailored specific payer circumstances or are 
just poorly crafted.
    For example, a standardized prior authorization process 
might be less effective in deterring inappropriate utilization, 
which could partially or even fully offset any administrative 
savings. Thus, the attractiveness of this type of 
standardization is likely to be highly case-specific.
    Quality reporting may be one domain where the balance of 
costs and benefits favors aggressive standardization, such as 
by requiring all payers to rely on a standard set of quality 
measures reported through a central clearinghouse. This 
approach might not only reduce administrative costs, but also 
make the resulting data more useful by increasing sample sizes, 
and facilitating comparisons across payers.
    It is also questionable whether payers currently produce 
substantial value by tailoring quality measures to their 
specific circumstances, which may reduce the potential 
downsides of standardization.
    Thank you again for the opportunity to testify. And I look 
forward to your questions.
    Chairman Whitehouse. Dr. Dafny.

  STATEMENT OF DR. LEEMORE DAFNY, PROFESSOR, HARVARD BUSINESS 
             SCHOOL AND HARVARD KENNEDY SCHOOL \4\
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    \4\ Prepared statement of Dr. Dafny appears in the appendix on page 
53.
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    Dr. Dafny. Chairman Whitehouse, Ranking Member Grassley, 
and distinguished members of the Committee, thank you for the 
opportunity to testify to you today.
    My name is Leemore Dafny. I'm an academic health economist 
with longstanding research interests in competition and 
consolidation in the health care sector. Currently, I am a 
professor at the Harvard Business School and at the Harvard 
Kennedy School. Previously, I was a Deputy Director for Health 
Care and Antitrust in the Bureau of Economics at the Federal 
Trade Commission and a member of the Panel Health Advisors to 
the Congressional Budget Office.
    The U.S. spends a larger share of its GDP, over 18 percent, 
on health care than any other country. Studies show that high 
prices, not the type or quantity of services consumed, nor the 
health of our population, are the primary driver of higher U.S. 
spending. International comparisons also show the U.S. lags 
other leading developed countries on most dimensions of health 
care quality.
    My focus today is on health care providers, such as 
hospitals and physicians, who jointly account for half of our 
health care spending.
    As you are aware, government programs like Medicare set 
prices for provider services, like hospital admissions. But the 
private sector relies on market-based prices, and those prices 
are high and growing. In the 90s, private prices were about 10 
percent higher than Medicare prices. By 2012, they were 75 
percent higher. And today, private insurers pay more than twice 
what Medicare pays on average for hospital care.
    While public insurance programs don't pay these commercial 
prices, there are significant federal budgetary implications of 
high commercial prices. High commercial prices mean high 
employer-sponsored premiums, raising the cost of the tax 
exclusion for employer-sponsored coverage.
    High commercial prices also impact the premiums and, 
therefore, the federal subsidies for enrollees purchasing 
subsidized plans through the health insurance marketplaces.
    Consolidation is a key driver of rising prices in the 
health care industry. Scores of studies find that mergers and 
acquisitions result in higher commercial prices, with little, 
if any, evidence of improvement in quality. In addition, 
Medicare's payment policy has driven some of that 
consolidation, in particular, acquisition of physician 
practices by hospitals.
    Providers assert that high commercial rates are needed to 
cover the costs of Government-insured patients for whom care is 
reimbursed at lower rates, below their actual cost. This 
dynamic ignores the fact that costs are themselves affected by 
reimbursement. Economic research finds that hospital expenses 
fall when prices fall. And health care at the current pace of 
cost and price growth is untenable.
    I have three recommendations to offer today:
    First, establish a national All-Payer Claims Database, or 
APCD, which contains insurance claims from public and private 
insurers. Currently, researchers and regulators can't track 
what's happening in order to understand where and why we are 
paying more. The industry is running circles around us, mining 
the data to their benefit and exploiting loopholes. And it's 
too important and expensive for us to be this far behind.
    The APCD could also be used by states, if they wish, to 
regulate commercial health care prices. Setting price ceilings 
or restrictions on price growth would not only address a 
symptom of consolidation, it would also prevent additional 
consolidation aimed at amassing market power to raise prices.
    Second, invest in vigorous antitrust enforcement through 
increased funding for the Federal Trade Commission and the 
Antitrust Division of the Department of Justice.
    While GDP increased in real terms by 55 percent between the 
year 2000 and 2022, the budget allocation to the Antitrust 
Division increased just 2.6 percent. If we are going to rely on 
private markets to deliver health care, and on commercial 
insurers to administer the majority of it, we need regulators 
to help protect and promote competition in these markets.
    Third, align Medicare's payment rates across ambulatory 
settings. Stop paying more for the same health care services, 
like routine office visits and lab work, when they are 
delivered in hospital-owned practices or facilities. This 
preference not only increases Medicare and non-Medicare 
spending today, it fuels higher spending tomorrow because it 
drives more integration of hospitals with physicians and 
bolsters the market power of health care systems.
    Adopting any and, ideally, all of these recommendations 
would mitigate the root causes of our nation's high provider 
prices, prices that lead to higher employer-sponsored insurance 
premiums, lower tax revenue, higher subsidies for plans 
purchased through the health insurance marketplaces, and higher 
Medicare spending.
    I urge you to evaluate the recommendations closely, as your 
decisions can help us to achieve higher-value health care with 
a price tag the nation can afford.
    Thank you.
    Chairman Whitehouse. Thank you.
    I'll turn now to Dr. Kurose.
    And I will note that in addition to his full testimony 
being made part of the record in these proceedings, we're also 
going to accept into the record a letter from the National 
Association of ACOs, and several ACOs, including Rhode Island's 
own Coastal and Integra, encouraging Congress to extend 
Alternative Payment Model (APM) bonuses for physicians.\5\
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    \5\ Document submitted by Chairman Whitehouse appars in the 
appendix on page 109.
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    So, that will be made a part of the record, without 
objection.
    Dr. Kurose, please go ahead.

     STATEMENT OF DR. G. ALAN KUROSE, CHAIR, RHODE ISLAND 
     FOUNDATION, AND FORMER PRESIDENT, COASTAL MEDICAL \6\
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    \6\ Prepared statement of Dr. Kurose appears in the appendix on 
page on page 70.
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    Dr. Kurose. Chairman Whitehouse, Ranking Member Grassley, 
and other members of the Committee, thank you for having me 
here today to discuss the topic of managing the care of 
patients and the health of populations to reduce the total 
costs of health care.
    My name is Dr. Al Kurose. For the first 20 years of my 
career I saw patients every day as a practicing primary care 
internist.
    For the last 15 years I've worked as a health care 
executive and community leader on care transformation and 
payment reform. My North Star has been pursuit of the Triple 
Aim of better care and better health at a lower cost. From 2008 
until last year I served as the President of Coastal Medical, a 
large primary care practice in Rhode Island that transformed 
itself into a physician-led ACO that has been one of the top 
performers in the Medicare Shared Savings Program.
    I have three main points I'd like to make today.
    Number one, I believe that as an industry we can transform 
how health care is delivered and paid for in ways that will 
reduce costs and make things better for patients. In many cases 
I'll argue that we already know what to do.
    Number two, primary care is the foundation of any high-
performing health care system. And right now primary care is in 
crisis, and urgent help is needed.
    Number three, advanced primary care by itself is, in my 
view, necessary but not sufficient to sustainably achieve the 
Triple Aim. Continued movement away from fee-for-service and 
toward value-based and prospective payment models is needed, 
particularly for specialists and hospitals where more skin in 
the game is needed when it comes to value-based payment.
    The 2021 National Academy of Sciences, Engineering, and 
Medicine Report on Primary Care concluded that ACOs achieved 
modest cost savings, as well as improvements in quality and 
patient satisfaction. Smaller physician-led ACOs with a greater 
percentage of primary care physicians were the best performers. 
And Coastal Medical was one of them.
    On the poster to your left the green line represents the 
average total cost of care for Coastal's Medicare beneficiaries 
from 2009 through 2019. You can see that upon entry into the 
Medicare Shared Savings Program in 2012, Coastal not only bent 
its curve for total cost of care, it broke it.
    An important question to ask, then, is whether learnings 
from the success of smaller physician-led ACOs like Coastal are 
generalizable to larger systems of care. I will argue that many 
of them are. Coastal's Diabetes Management Program is a good 
example.
    In that program, select patients are equipped with glucose 
meters that use cellular networks to automatically transmit 
blood sugar results in real-time to a multi-disciplinary care 
team that then engages with the patient if, and only if, 
intervention is required for a high or low blood sugar.
    In the old model of care 10 or 15 years ago, a patient with 
a high sugar might have just written it down in their logbook 
and planned to discuss it at their next visit with their doctor 
in a couple of months. Now their phone is going to ring. And 
that proactive outreach by the care team to address the high 
sugar when it's happening may well prevent an emergency room 
visit or hospitalization that might otherwise occur a day or 
two later.
    Clinical programs like this go well beyond what I first 
imagined when we started the ACO work back in 2012. Generally, 
such programs have been the result of cycles of iterative 
learning, which have been a characteristic feature of many of 
the most successful ACOs. It is these types of lessons about 
delivering the right care, in the right place, at the right 
time that I'm referring to when I assert that in many cases we 
already know what to do.
    As I mentioned, primary care is in crisis. We have a 
perfect storm of an aging physician workforce, a shrinking 
pipeline of new primary care physicians (PCPs), widespread 
physician burnout, and a large cohort of baby boomers aging 
into Medicare. Workforce initiatives such as those coming out 
of the Health, Education, Labor, and Pensions (HELP) Committee 
and improved compensation of primary care physicians are 
important next steps.
    I believe we also need to continue experimenting with 
expanding the primary care team, and to pay more attention to 
understanding and mitigating physician burnout.
    Finally, primary care capitation as a payment model may 
help to take primary care teams off the hamster wheel of back-
to-back visits, all day, every day.
    In closing, I will reiterate my initial plea for more 
value-based payment for specialty and hospital care. Primary 
care cannot go it alone in this domain and sustainably succeed. 
That said, I remain cautiously optimistic because I believe 
that in many cases we already know what to do.
    Thank you.
    Chairman Whitehouse. Thank you, Dr. Kurose.
    Mr. Merkel.

  STATEMENT OF THEO MERKEL, DIRECTOR OF PRIVATE HEALTH REFORM 
   INITIATIVE, SENIOR RESEARCH FELLOW AT THE PARAGON HEALTH 
  INSTITUTE, AND SENIOR FELLOW AT THE MANHATTAN INSTITUTE \7\
---------------------------------------------------------------------------

    \7\ Prepared statement of Mr. Merkel appears in the appendix on 
page 79.
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    Mr. Merkel. Thank you, Chairman Whitehouse and Ranking 
Member Grassley, for convening this hearing and giving me the 
opportunity to testify.
    The Federal Government spends more money in health care 
than any other area, exceeding $2 trillion in 2022. For 
context, this is now over twice as much as is spent on defense.
    The pace of growth is unsustainable. The CBO projects 
health care to absorb a larger and larger portion of GDP for 
the foreseeable future. Perhaps most problematic, we do not get 
a good return for our money.
    For instance, Washington actually spent more on improper 
payments for health care, $150 billion last year, than proper 
payments for the Supplemental Nutrition Assistance Program, 
housing assistance, or transportation infrastructure.
    A widely-cited study by the National Academy of Medicine 
estimated that 30 percent of all U.S. health spending does not 
actually improve health. Last year the OECD compared health 
spending in developed nations, and confirmed that the U.S. 
spends more on just about everything, but the key contributors 
to our outsized health spending are payments for hospital and 
physician services. Ironically, given last Congress' action on 
drug prices, we actually spend proportionally less on retail 
pharmaceuticals than every G7 country but the United Kingdom.
    Well-intentioned but ultimately counterproductive 
Government policies increase prices and health spending by both 
inflating demand and decreasing supply haphazardly.
    First, far from being parsimonious with our federal health 
care programs, we are one of the only nations that subsidizes 
health care largely without limit.
    If Medicare is billed for a covered item or service, it 
will pay it.
    If a state makes a Medicaid expenditure, Washington will 
match it.
    If insurers selling Affordable Care Act plans raise 
premiums, the federal taxpayer covers the increase.
    No matter how generous a health plan an employer chooses, 
it receives a tax break. Ultimately, we generously subsidize 
care that Americans need, but we also subsidize a lot of 
inefficient care and waste.
    Second, federal and state policies limit supply by 
restricting who can provide health care items and services, and 
where they can provide them. This insulates providers and 
suppliers from competition, allowing them to command higher 
prices and remain inefficient. It also severely limits 
innovation, as it gives incumbent providers bureaucratic and 
political tools to prevent the type of disruption that we have 
seen in other sectors of the economy.
    With only a few exceptions over the past several decades, 
Congress has either exacerbated these two fundamental issues or 
just tried to work around them with top-down approaches that 
rely on government technocrats to try to manipulate the system 
into efficiency. We are here today because those efforts have 
largely failed.
    Given its size and importance, Medicare is often the 
epicenter of the policy debate. Since 1983 the reform of choice 
has been price controls, starting with hospitals, moving to 
physicians, and recently moving to prescription drugs. But 
price controls largely just attempt to approximate the cost of 
providing a service or producing an item. They avoid whether 
that service or item should be provided, and the value that it 
may offer relative to alternatives.
    Simultaneously, despite the best efforts of the Center for 
Medicare and Medicaid Services, price controls are inevitably 
inaccurate and hugely distort how care is delivered and where 
investment flows.
    The Affordable Care Act put faith in a similarly top-down 
approach that an entirely new agency of well-intentioned 
bureaucrats, insulated from congressional meddling, would be 
able to engineer better payment methods. Yet, the CBO recently 
found that after a decade of work, the Center for Medicare and 
Medicaid Innovation managed to add to the deficit.
    Fortunately, there are many ways to reduce wasteful 
spending while not reducing benefits on enrollees. I have a 
list of proposals in my written testimony. But to highlight a 
few principles:
    One, shift financial risk away from taxpayers. This does 
not mean we need to shift risk to beneficiaries. It could be 
ACOs, other providers, insurers, states, or others. But our 
major health care programs should no longer simply write blank 
checks.
    Two, get the government out of the business of dictating 
who should be paid, how much, and where. Site-neutral payment 
reforms being discussed in Congress would be a good incremental 
step.
    Three, favor bottom-up solutions like enabling patients and 
employers through more coverage options and price transparency, 
instead of the top-down approaches that have repeatedly failed 
over time.
    Thank you again for inviting me to testify. And I look 
forward to your questions.
    Chairman Whitehouse. And, finally, Dr. White.

  STATEMENT OF DR. CHAPIN WHITE, DIRECTOR OF HEALTH ANALYSIS, 
                CONGRESSIONAL BUDGET OFFICE \8\
---------------------------------------------------------------------------

    \8\ Prepared statement of Dr. White appears in the appendix on page 
91.
---------------------------------------------------------------------------
    Dr. White. Chairman Whitehouse, Ranking Member Grassley, 
and members of the Committee, I appreciate the opportunity to 
appear before you today.
    In consultation with Budget Committee staff I've focused 
this testimony on Accountable Care Organizations, Capability 
Maturity Model Integration (CMMI), and the unexpected slowdown 
in federal health care spending.
    Because ACOs voluntarily assume responsibility for the 
quality and costs of care for a defined group of patients, they 
have the potential to reduce unnecessary care, improve care 
coordination and patients' health, and reduce spending. Health 
care providers participating in ACOs, or other value-based 
payment arrangements, receive financial incentives to improve 
the efficiency and quality of care. Such incentives contrast 
with those found in Medicare's traditional fee-for-service 
program in which separate payments are generally made for each 
encounter or service delivered.
    Fee-for-service, as many observers have pointed out, tends 
to create incentives for providers to deliver additional and 
more-complex services.
    CMMI's goal is to identify approaches that reduce spending 
or improve the quality of care. And to do so, it operates 
models that test new ways to deliver and pay for health care, 
including models that establish value-based payment 
arrangements.
    The ACA established a permanent ACO program in Medicare 
known as the Medicare Shared Savings Program (MSSP). CBO has 
reviewed the evidence on the performance of the MSSP, and found 
that the program was associated with small budgetary savings in 
the early years of its operation. The more recent evidence is 
somewhat limited and challenging to interpret. It's become more 
difficult to find reasonable control groups to use. And 
providers have the ability to opt in and out of the ACO 
program.
    What were CMMI's budgetary effects over its first decade of 
operation? As other folks have previewed, CBO has updated its 
estimate of the budgetary effects of CMMI, and currently 
estimates that CMMI's activities increased direct federal 
spending by $5.4 billion, or 0.1 percent of net spending on 
Medicare between 2011 and 2020. Specifically, CMMI spent $7.9 
billion to operate models, and those models reduced spending on 
health care benefits by $2.6 billion.
    That estimate reflects CBO's review of public evaluations 
of 49 models initiated in CMMI's first decade.
    In terms of CBO's projections of CMMI's effects over the 
current baseline projection period from 2024 to 2033, CBO 
projects that CMMI will increase net federal spending by less 
than $50 million, which is a star in CBO's tables.
    Over that period, the estimated effect of CMMI's activities 
transition from an annual net increase to an annual net 
decrease, reflecting ongoing growth in the number of certified 
models that continue to produce savings over time.
    Legislative proposals that would affect CMMI could fall 
into one of three categories: modifications to specific models, 
changes to the parameters within which CMMI operates, and a 
repeal of CMMI's statutory authority, or rescissions of 
unobligated funding.
    In general, CBO would analyze the evidence on specific 
models if the legislation related to a specific model, or when 
data are not available, or if the legislation is more general 
than that, CBO would rely on a general framework using 
information on CMMI's prior activities and performance. And, as 
always, the estimated effects would depend on the details of 
the legislation.
    So, have alternative payment models contributed to the 
slowdown in health care spending?
    The implementation of MSSP and the creation of CMMI have 
occurred during a period of unexpectedly slow growth in federal 
health care spending. Whether that slow growth is related to 
CMMI or other alternative payment models created under the ACA 
is not entirely understood. But, CBO's review of the effects of 
the MSSP and its estimate of the effects of CMMI in its first 
decade of operation suggests that they together were not 
factors in the broader slowdown.
    Still, some researchers have posited that the existence of 
CMMI may have led to broader system-wide changes that are not 
attributable to a specific model.
    Over the past decade, CBO has been tracking the slowdown of 
federal health care spending and has previously pointed to 
several contributing factors. Broader factors include decreases 
in the growth of Medicare's payment rates, reduced spending on 
patients with cardiovascular disease, and a shift in the 
relative importance of technology in fueling the growth of 
health care spending.
    Federal spending on Medicare and Medicaid programs also 
grew more slowly than CBO projected. A key factor underlying 
Medicare's slower-than-expected growth was slower growth in net 
spending on prescription drugs. For Medicaid, a key factor was 
less-than-anticipated spending for long-term services and 
supports.
    Those are my prepared remarks.
    Chairman Whitehouse. Thank you very much, Dr. White.
    Let me start with Dr. Kurose.
    You and I lived through, me much less so than you, all the 
difficulties of transitioning Coastal Medical to an ACO and to 
a very successful ACO. But if you look through all those 
difficulties to the experience of your patients at the end of 
the day, how do you evaluate Coastal Medical's patient 
experience as a result of the successful transition?
    Dr. Kurose. You know, as somebody who practiced primary 
care for 20 years and ended that part of my career just as the 
ACO movement was really getting up and running, the things that 
I've seen happen at Coastal for patients really go way beyond 
what I could have imagined.
    There is a whole variety of centralized clinical programs 
that improve access to care, timeliness of care. There are 
disease management programs for specific chronic conditions. 
There is--there are primary care urgent clinics nights, 
weekends, holidays. There is a whole multi-disciplinary team 
available to many of our patients, with members of the team 
including clinical pharmacists, social workers, navigators, co-
located behavioral health providers.
    And so I look at the movement to accountable care as really 
being the impetus to allow that great expansion of services to 
really deliver a level of care that we just couldn't do when I 
was in practice.
    Chairman Whitehouse. So, in order to save the millions for 
Medicare that Coastal has saved, you were not obliged to cut 
benefits to your patients; indeed, they saw new and improved 
services?
    Dr. Kurose. Yeah, I think that's an accurate statement. And 
we have sort of a truism that we repeated often at Coastal, 
which is that you have to spend more to save more. So, you have 
to invest in the human and technology infrastructure to really 
be able to execute population health management if you want to 
be able to deliver the kinds of services that we're talking 
about.
    But it was the alternative payment models inherent in the 
ACO model that allowed us to generate that additional revenue, 
which we then reinvested to fund all that clinical programming, 
which ultimately improved efficiency, improved care, reduced 
total cost of care.
    Chairman Whitehouse. The bureaucratic system did not always 
entirely support that transition. One of the things that I 
think makes sense in a fee-for-service system is prior 
authorization, just to keep billings from going through the 
roof. But once there is, as you say, skin in the game, the 
rationale for prior approvals in a value-based system appears 
to diminish, if not entirely evaporate.
    Were you obliged nevertheless to continue to see prior 
approvals, and if not, why not? Was that a success?
    Dr. Kurose. We certainly did, and Coastal still does, see 
requirements of that type. The sort of interim solution at 
Coastal was to create teams of people who could assist 
providers in that process so as to reduce the administrative 
burden and the time commitment to that particular aspect of the 
work.
    But I agree completely with the underlying thesis that, 
when you incent provider organizations to be accountable for 
total cost of care, once you have that construct in place, then 
you may not need to have all these administrative processes.
    One thing that I'll add is that it's important, as we try 
to build out and execute on these constructs, that we remember 
that the payment model that an organization sees has to be 
translated into an aligned compensation model for physicians if 
you really want to lock in that mindset that we're counting on 
to sort of control avoidable spending and improve efficiency.
    So, knowing that there is alignment between organizational 
payment models and physician compensation, I think, is 
important if we expect to see the kind of outcomes you're 
alluding to.
    Chairman Whitehouse. Last point.
    If I'm building a house or doing a major renovation, I hire 
a general contractor to manage the project for me. And I expect 
that general contractor to intermediate with electricians, 
drywall folks, carpenters, all the specialists who do the work 
of bringing the project to a successful conclusion.
    Is that the way primary care presently works? And would it 
be useful to try to put primary care providers into more of a 
general contractor model so that they can intermediate between 
the patient and the specialists and coordinate care more 
effectively to the benefit of the patient?
    Dr. Kurose. So, that's an interesting analogy. And I think 
that there is a key role for primary care physicians to 
coordinate care when a patient has multiple complex conditions 
and requires the care of multiple specialists. I'm not sure all 
my specialty colleagues would like the general contractor 
analogy so much, but I think we could at least agree that what 
we need is regular communication.
    And I think the other thing that primary care docs are 
uniquely positioned to do is to have a deeper understanding of 
what the patient's own priorities and goals of care are. And in 
that context, you know, the primary care doctor can really help 
to shepherd the care of a patient through what you alluded to 
earlier, I think correctly, as a very much fragmented system, 
that is also highly complex.
    For those of us who work in health care, even when we have 
to help a family member try to navigate systems, even inside 
baseball players find it challenging at times. And so, I think 
that that's a really, really important aspect of the role of 
primary care that we need to preserve and expand.
    Chairman Whitehouse. Senator Grassley.
    Senator Grassley. Thank you, Mr. Chairman, and thank you 
all for your testimony.
    Common sense supports all of us wanting to get more value 
out of our health care system. I was proud to lead the effort 
to implement Part D, nationwide prescription drug benefit for 
seniors, a long time ago. We used a market-based approach. 
Competition access and affordability has been a key hallmark of 
Part D programs. And I think it--compared to what figures were 
given by CBO at that time, it turns out to be a good steward of 
the taxpayers' dollars, in the first decade costing 50 percent 
less than CBO projected.
    So, Dr. Merkel, what can we learn from Medicare Part D to 
apply to other federal health care programs?
    Mr. Merkel. Thank you for the question, Ranking Member 
Grassley.
    One of my key takeaways from Part D is there is often, 
especially with entitlements, perceived unnecessarily to be 
this tension between providing benefits and getting value for 
both beneficiaries and taxpayers. I think Part D has been able 
to show that this tension does not need to exist.
    How did it do that? It mandated benefits, but it also 
required that financial risk be shared between taxpayers 
through Medicare, but also other entities which are Part D 
plans. And very importantly for accountability, the 
accountability of Part D plans is not just to the Government or 
bureaucrats, but it's also to beneficiaries through choice. 
They can choose plans or switch plans if they're unsatisfied 
with the coverage options, and plans compete for beneficiaries.
    The result has been seeking high value care. There has been 
high utilization of generic drugs. You know, the United States 
has higher utilization of generic drugs than many of our 
international competitors. That's in part because of the way 
that Part D works.
    It's come in under budget, as you've noted, not just in the 
first decade but, as Dr. White noted, it's come in under budget 
again this most recent decade. And there's high beneficiary 
satisfaction.
    Senator Grassley. Yes. Dr. White, let me lead in with this, 
the Center for Medicare and Medicaid Innovation receives $10 
billion of mandatory funding every decade. Despite this 
investment, CBO has found that CMMI has not lowered Medicare 
spending.
    Separately, CBO has found that Medicare's Shared Savings 
Program was not a factor in slower growth of federal health 
care spending.
    Are these models that I just referred to validated by 
independent third parties to determine if they save money?
    And in addition to that question, if there are independent 
analyses, what do they say?
    Dr. White. Thank you, Ranking Member Grassley, for the 
question.
    First, I want to clarify. On CMMI the CBO's conclusion was 
that it added to federal spending. Other researchers have come 
to the same conclusion, including Brad Smith, who is a former 
CMMI administrator, and Health Management Associates did a 
study. Avalere did a study. So, CBO's conclusion on CMMI is 
generally in line with the consensus.
    On MSSP, CBO's conclusion was that it appears to produce 
net savings. And the evidence is fairly clear from the early 
years of the program. The evidence is a little harder to 
interpret in more recent years. But that conclusion, that the 
Medicare Shared Savings Program has produced small net 
budgetary savings, is consistent with and partly based on what 
outside researchers have said.
    So, I think when I said that CMMI and MSSP were not a 
factor in the slowdown, it's more to say that CMMI, over the 
2011 to 2020 period, added a bit to federal health spending. 
MSSP had net savings. Together, they were not a factor in the 
fairly large slowdown during the 2011 to 2020 period.
    Senator Grassley. Thank you, Mr. Chairman.
    Chairman Whitehouse. Senator Van Hollen.

                STATEMENT OF SENATOR VAN HOLLEN

    Senator Van Hollen. Thank you, Mr. Chairman, and thank all 
of you for being here.
    Dr. Dafny, I'm going to start by asking you a question 
related to the collection of data.
    For many years, my state of Maryland has run an innovative 
payment model that started with regulating hospital pricing in 
the 1970s and now includes all-payer global budgets for 
hospitals in the state, with incentives to reduce total cost of 
care and improve efficiency and quality of care. So far, the 
model has been meeting the Medicare savings goals and improving 
care.
    As part of this work, and it's ongoing work on pricing, 
rate setting, and global budgeting, Maryland's All-Payer Claim 
Database has strong hospital-based data. However, as you noted 
in your testimony, many states struggle to obtain data on 
Employee Retirement Income Security Act of 1974 (ERISA) plans 
because these plans are regulated by federal statute and the 
Supreme Court barred states from requiring self-insured plans 
to submit data to address state databases, making obtaining 
plan data more challenging.
    How does greater access to claims data help regulators and 
policymakers address costs and health equity issues?
    And will the U.S. Department of Health and Human Services 
(HHS) pricing transparency rules for insurers help fill the 
gaps in price information that many states experience, or are 
additional steps necessary to make sure that they have the 
information that meets their needs?
    Dr. Dafny. Thank you, Senator Van Hollen, for the question. 
And, also, thank you to the state of Maryland for running some 
very impactful experiments for us researchers to study and to 
act as a laboratory for other states.
    You asked me how does it help for us to have access to a 
national All-Payer Claims Database? It helps enormously because 
we cannot study the effects of mergers and acquisitions without 
health insurance claims.
    Right now, we rely on the largesse and interests of 
commercial insurance companies. That interest has been waning, 
and in order for us to assess the implications of a range of 
phenomena, including private equity consolidation, including 
the expanded geographic footprint of hospital systems, we 
desperately need access to these data.
    You mentioned the critical reason for the Federal 
Government to act, and that is because of that 2016 Supreme 
Court decision that ruled that states cannot compel self-
insured plans, which are regulated under ERISA, to supply their 
claims data. So, we really need your help to enable an All-
Payer Claims Database.
    And finally, you asked whether current efforts on price 
transparency are enough. And my answer to that is simply no, 
the transparency that is out there now. And that's for two 
reasons.
    One is that what is transparent now, to the degree that it 
is transparent, as Senator Grassley mentioned, there are a lot 
of issues with how it's being reported, is just price. And in 
order to understand our nation's spending we need quantity, 
too.
    So, we have the prices for every possible--or could 
theoretically have the prices for every possible combination of 
service, insurance plan, and provider, but we don't know how 
many of those triplets are actually being delivered. And 
without any access to information about the quantity, we're 
swimming in the dark.
    And a second reason is that that data has been extremely 
difficult for researchers to assemble because it is spread out 
in a range of places and not uniformly reported.
    Senator Van Hollen. I appreciate that answer and look 
forward to working with you and others to try to address this 
issue.
    Dr. Fiedler, a question for you about hepatitis C, but 
especially prescription models. And hepatitis C is a growing 
disease with a rate of reported acute cases increasing 400 
percent between 2010 and 2020. There are approximately 2.5 to 3 
million people living with the disease. It also has lots of 
side effects that lead to other complications.
    But it is now curable with oral direct acting antivirals. 
However, even with the competition and generic drugs in the 
market, the cures can be incredibly expensive: $24,000 or more 
for a course of treatment.
    Louisiana, with the support of CMS during the previous 
Administration, implemented an innovative subscription model 
wherein they negotiated a bulk price in order to get unlimited 
doses of medication for Medicaid and incarcerated patients. And 
they also set up a screening and prevention program.
    My question to you is do you agree that that subscription 
model can work generally for diseases like this? And 
specifically, how can we at the federal level learn from that 
with respect to hepatitis C?
    Dr. Fiedler. Thanks for the question.
    I think it generally can make a lot of sense for a payer to 
offer a manufacturer a somewhat larger total payment in 
exchange for a much lower per dose price that facilitates 
broader access. And I think a subscription model, as we've seen 
in Louisiana, can be a very good way of achieving that.
    I also think that there is a particular logic to the sort 
of federally-run subscription model that's currently being 
discussed in the hepatitis C context, given where some of the 
access barriers we've seen here have come from.
    There's something of a collective action problem among 
payers, where society as a whole would be better off if there 
was broad access to these drugs and we avoided the downstream 
complications and the infections that come from active 
infections. But since people bounce from payer to payer over 
time, no particular payer is really that motivated to be the 
one who makes the upfront investment in identifying cases and 
treating them.
    I think it's also relevant that Medicaid is an important 
payer here, and historically, it's been a fairly stingy payer 
across a variety of domains. We have seen that specifically in 
the domain of the sort of coverage policies states have adopted 
with respect to hepatitis C.
    Against that backdrop, I think having the Federal 
Government, you know, adopt the subscription model with respect 
to hepatitis C, and then make the drugs available at very low 
cost to Medicaid or other potential payers, has a strong 
rationale.
    Senator Van Hollen. Thank you. I appreciate that. We may 
draw upon your expertise. We're in the process of putting 
together legislation on that initiative.
    Thank you, Mr. Chairman.
    Chairman Whitehouse. Thanks, Senator Van Hollen.
    Senator Braun.

                   STATEMENT OF SENATOR BRAUN

    Senator Braun. Thank you, Mr. Chairman.
    The amount of time I've spent on this issue before I got to 
the U.S. Senate is a lot. I ran a business that, exactly what 
we're talking about, became the biggest issue once it was of a 
scale where it made a difference. And that started occurring 
back in 2008.
    I was finally sick and tired of hearing how lucky I was 
that my premiums are only going up 5 to 10 percent a year. 
That's the way you measure it in the real world, in a system 
that's built upon remediation with a very inelastic demand once 
you get sick or have a bad accident--with zero, nearly zero 
consumer involvement.
    It's easy to understand why we are where we are.
    As pointed out, and I think very well, in both opening 
statements, we're at that place where it's a tapeworm on the 
economy. The providers are the same, whether it's a government 
payer or a private system payer. So, unless we fix the 
underlying system, don't expect much to change regardless of 
what we do here. Because you can't--when it's that big a part 
of your economy, it's not free market. It's like an unregulated 
utility, if you want to really see what we've got as a health 
care system.
    Until we get our consumers engaged on primary health care 
with their own skin in the game, the ones that can afford it, 
you're probably going to have to have a system for those that 
can't. Because I think in this country everybody ought to 
deserve good health and well-being, but we've got a monstrous 
system that we've evolved into.
    I'm going to hope we have, with the number of people here, 
a second round for questions. Do you think that looks possible, 
Mr. Chair?
    Chairman Whitehouse. It depends, but possible.
    Senator Braun. Okay. So, I'm going to start here.
    The largest sector of our health care economy is now 
hospitals, large corporate hospitals. Back as recently as 10 
years ago that was maybe \1/3\. Practitioners, doctors, and 
nurses were about \1/3\, and the balance being split between 
insurance companies and pharma. Now, hospitals are just under 
50 percent.
    The number of doctors I have spoken to that regret that 
they've gotten into the business because they wanted their own 
enterprise, they never imagined working for a big company 
because they had to due to the arithmetic of their business.
    I'm simply asking for one thing. That is transparency 
throughout the system, like we have in all other markets. Get 
rid of the barriers to entry that we've created here in 
government helping hospitals, keep doctors from owning their 
own hospitals and things like that. But I think that's where we 
need to focus.
    Secondarily are the insurance companies, because they work 
together in an opaque system.
    So, I've had a couple amendments, one recently with direct 
CMS, to publish a list of hospitals not in compliance with the 
price transparency rule that went through the court system to 
even get out there. That was done during the Trump 
administration. The other requires hospitals and insurers to 
share specific prices they negotiate across plans.
    Mr. Merkel, I've got a question for you.
    What other reforms should Congress consider when trying to 
take the biggest part of health care that is more and more 
corporate, embraces none of the aspects of free enterprise? Do 
you like those ideas, number one?
    And what else can we do that would start the clock, at 
least where most of our health care dollars are being spent 
currently?
    Mr. Merkel. Thank you very much for your question.
    I think that you have hit the nail on the head with your 
diagnosis of the problem. We're limiting supply at the same 
time that we're increasing demand through federal programs. And 
we are not enabling consumers and employers because we've just 
put them in the dark.
    I would absolutely start with what you have said: giving 
consumers and employers price information to--basically, we 
have left these powerful tools on the table, which are 
consumers and employers seeking the best value for themselves. 
And as you have noted, unfortunately, what we did in the Trump 
administration, the compliance has been inadequate.
    So, the legislation that you have put forth to codify those 
rules and, I think, increasing enforcement mechanisms to 
require them, as well as being clear who is being transparent 
and who is not, would go a long way.
    Senator Braun. One brief follow-up question, and I'd like 
this to be answered by Dr. Fiedler.
    Obamacare gave us, I think, some things that address the 
fact that everybody should have access. It should be at a price 
that you can afford.
    What about some of the things that have been dysfunctional? 
Like, I think what came from that, too, was that doctors cannot 
own outpatient hospitals, nor can they grow ones that were in 
place.
    Is that something that ought to be changed? Why was that 
ever done in the first place?
    Dr. Fiedler. I do think that there were previsions placing, 
limitations on physician-owned hospitals. I am generally of the 
view that, I think consistent with the question you're asking, 
that there's not a strong rationale for limits on the entry of 
new hospitals into hospital markets and, in particular, limits 
on who can own those hospitals.
    I frankly think that this is probably not the main 
contributor to why hospital markets are as consolidated as they 
are. I think it's probably a fairly marginal factor. I think 
the underlying rationale for the provisions was that physician-
owned hospitals may do a certain amount of cherry picking in 
terms of the patients they treat. And so, other hospitals were 
concerned that they would be left holding the bag.
    I don't view that as a particular concern, and I think 
there's unlikely to be much harm done by removing some of these 
restrictions.
    Senator Braun. Thank you.
    Chairman Whitehouse. Senator Marshall.

                 STATEMENT OF SENATOR MARSHALL

    Senator Marshall. All right. Mr. Chairman, thank you so 
much for hosting this hearing. My first question is for 
Professor Fiddler--Fiedler, probably. My bad. Fiedler, right? 
Okay.
    Prior authorization is the number one administrative 
concern to physicians. It adds to their burden of their day, 
having a patient scheduled for a hip replacement, have them in 
the preoperative area, and then finding out that the insurance 
company has not done the final prior authorization for that 
particular process. I hope--I assume you are familiar with 
prior authorization and how it's being used to ration care.
    What is the prior authorization impact, do you think, on 
health care expenses? Does it actually slow down? Does it make 
it worse?
    Any thoughts on prior authorization?
    Dr. Fiedler. I think prior authorization is very much a 
two-edged sword. On the one hand, I think exactly what you're 
talking about can create a lot of administrative hassles for 
providers but, frankly, for patients as well. If you're the 
patient in that situation where the prior authorization hasn't 
come through, that's a very real burden.
    I think the flipside of this is there are cases where prior 
authorization is used appropriately. We have evidence that it 
meaningfully reduces use of inappropriate services and 
therefore reduces claims spending, and premiums, and cost 
sharing for people.
    Senator Marshall. Appreciate that.
    I think you'd agree with me that if there was a 
streamlined, consistent process, that that would be very 
beneficial to both sides of that coin?
    Dr. Fiedler. I think there likely are opportunities to 
streamline these processes and that's a fruitful place to 
explore.
    Senator Marshall. Okay. I'm going to go to Mr. Merkel next, 
and kind of following up with Senator Braun's questions 
regarding the physician-owned hospitals.
    I may be the only person in the Senate or Congress that's 
ran a hospital, owned a hospital, a private practice, oversaw 
health departments. I understand health care, you know, pretty 
good.
    I always thought to drive down the cost of health care, we 
needed more transparency, more innovation, and consumerism--
making patients consumers again, promoting competition. Whether 
it's insurance companies or whether it's hospitals, Pharmacy 
Benefit Managers (PBMs), we've seen this huge consolidation of 
the industry, partially because of over regulations. And 
basically, there is a moratorium on physicians to expand their 
hospitals or to have any new ones as well.
    I would brag on the physician-owned hospital. They have 
better care, much better quality of care. They actually give 
away more care than most non-profits do, is a sense as well. In 
our particular case, we were the only hospital within 60 miles 
with a, you know, Level 2 emergency room. We took all comers.
    So, Mr. Merkel, what is your experience of physician-owned 
hospitals and do you think that they would help drive the costs 
down or up, at the end of the day?
    Mr. Merkel. Thank you for your question, Doctor.
    I think that, you know, with fee-for-service reimbursement 
and our entitlement programs being basically unlimited in how 
much taxpayer money that they will provide, you know, Congress, 
over the years, has tied themselves into a lot of knots on how 
to try to protect taxpayers while in that system. And industry 
incumbents take advantage of those concerns and will utilize 
those fears to try to block competition from things like 
physician-owned hospitals or through Certificate of Need laws.
    I think both of those restrictions come from the same 
concern and demonstrate how industry incumbents basically use 
them to prevent competition.
    Senator Marshall. Great.
    I want to finish up with a question. Not much time left. 
We'll see if we can get through as many people as we can. We'll 
start with you, Dr. Dafny.
    I'm certainly a believer that our country needs a bigger 
investment in primary care. Everybody--if you have a heart 
attack, if you're in an automobile accident, you go to the 
emergency room you're going to be taken care of, but we don't 
have as much meaningful access to quality primary care. Maybe 
we're spending half as a percentage of investment than many 
other countries are.
    Dr. Dafny, what do you think the impact of more primary 
care would do on the overall costs of health care, the overall 
expenses of health care?
    Dr. Dafny. Thank you for the question, Senator Marshall.
    I would say that as a country, we are extra--we spend far 
less on primary care than they do. That results in pushing more 
spending to specialists, who we know are more expensive.
    I think it would be a tremendously valuable thing.
    We ought to look at the compensation for primary care 
relative to specialists and to encourage more entry into that 
field. And would defer to the primary care physician to my 
left, should you want more detail.
    Senator Marshall. Dr. Kurose, yeah, please go ahead. Okay.
    Dr. Kurose. I concur with all that. And I think that, 
particularly given the complexity and fragmented nature of our 
health care delivery system writ large, it's never been more 
important for the patients, particularly those with complex or 
chronic illnesses, to have a primary care physician that can 
help guide them through that system, make decisions, coordinate 
everything, and have them stay on top of things.
    And you know, to me, that's foundational for a high 
performing health care system of any kind.
    Senator Marshall. Great.
    Certainly, I concur that in this instance we're certainly 
thinking that community health centers are a big part of that, 
an opportunity where you can deliver health care to where the 
patients are. Adding mental health support right there, 
nutrition coaching, those types of things.
    And since there's no one else standing in line, Dr. White, 
what do you think about more primary care? How that would 
impact the costs of health care for this country?
    Dr. White. We have spoken to a number of experts about 
alternative payment models and ACOs. And they have pointed out 
that primary care is really central to ACOs in a very nuts and 
bolts sense. To get patients attributed to an ACO, they have to 
be receiving primary care services, so that's kind of 
foundational.
    But there's also this phenomenon that physician-led ACOs 
are clearly more successful on reducing spending than hospital-
led ACOs. And----
    Senator Marshall. Imagine that.
    Dr. White [continuing]. And what we've gathered is that the 
physician-led ACOs tend to focus on shifting care away from the 
facility settings, the specialty care, imaging services. And 
so, I think that's generally consistent with what you're 
saying.
    Senator Marshall. Okay. Thank you, Chairman. I yield back.
    Chairman Whitehouse. Thank you.
    Senator, while you were in your other hearing, we also had 
a bit of a conversation about prior authorization. And Dr. 
Kurose and, I think, with other heads nodding, made the point 
that when you're in a fee-for-service system, there is some 
rationale for prior authorization to prevent just piling on 
with the billings. But once you move to a value-based system, 
like Accountable Care Organizations run, then the logic, the 
rationale for having prior authorization diminishes, if not 
evaporates.
    So, I appreciated your questions about prior authorization. 
I wanted to fill you in on what the prior testimony had been.
    And I do think that there is room, as we move towards more 
value-based care in our health care system, to make sure that 
the bureaucracies keep up with that, and you're not running 
legacy prior authorization systems that require doctors to 
maintain administrative staff that serve, actually, no real 
purpose because you've reoriented the incentives so that it 
really doesn't make sense to require a prior authorization.
    Maybe there should be prior approvals for prior approvals.
    Senator Marshall. We used to have that.
    So, I certainly agree and concur that we need to go to 
these value-based models, and it would eliminate some of the 
need.
    But in the meantime, 90 percent of the health care system 
is going to fight that, and it will take years to see that 
happening. And I think it's all the more important that we lean 
in on some type of a streamlined fix to the prior authorization 
issues, rather than punishing the 98 percent of physicians that 
are doing the right thing, and focus on those focus--on those 
folks that who indeed are abusing the system.
    So, thank you. I appreciate those comments.
    Chairman Whitehouse. And I'm now delighted to recognize 
Chairman Wyden, who has stepped out of the Finance Committee 
briefly. And I thank you, sir.

                   STATEMENT OF SENATOR WYDEN

    Senator Wyden. I thank my colleague. And this is a very 
good hearing.
    And particularly, what we're trying to do in the Finance 
Committee is look at the ways for the future to build around 
some of the things that just are common sense.
    For example, in the PBM area, we're looking at reducing the 
role of middlemen. I just came from the Medicare, you know, 
hearing, and these marketing middlemen, based on today's 
numbers, are taking $6 billion out of the system, $1,300 a 
patient just on marketing.
    So, I want us to look at the promising models, and that's 
what Chairman Whitehouse has given us a chance to do today. And 
I want to explore with all of you--I'll probably start with 
you, Dr. Kurose--chronic care.
    When I was director of the Gray Panthers, which has now 
been maybe a year or two ago, as I've been saying, Medicare was 
an acute care program. It was--you know, you broke your ankle 
and then you went to the hospital, and that was Part A of 
Medicare. And if you had a horrible case of the flu, you went 
saw your doctor, that was Part B of Medicare.
    That is not Medicare today. Medicare today is 
overwhelmingly chronic care: cancer, diabetes, and heart 
diseases, strokes. And people who have two or more of these 
conditions is now dominating the program.
    And before he retired, Chairman Hatch worked with us--and 
Senator Whitehouse remembers this--on a bill to say, we're 
going to insure those acute care services, and therefore, we're 
going to start building around chronic care. And we passed a 
transformational chronic care bill, which included the 
country's first really big investment on the health side in 
telemedicine, in terms of laying out the infrastructure.
    So, we passed it. And one day, I was sitting in my office 
after Chairman Hatch had moved on to, you know, other matters, 
and the Trump administration called and said, how would you 
feel about our using the telemedicine provisions as the basis 
for telemedicine services in COVID?
    And I said, you're asking me how I feel? This is the 
coolest day I can remember. I've got the Administration asking 
me about something the Democrats and Republicans care about.
    And that, in fact, was how we delivered COVID, COVID-
related services to a great extent during the pandemic is using 
our telemedicine approach.
    So, if you would, tell us why--as I understand, you've been 
interested in this field--why you think that chronic care 
coordination and building on these kind of models makes sense?
    Dr. Kurose. You know, I think when we look at segments of 
the patient population that are older with multiple chronic 
medical illnesses, they certainly have an outsized impact on 
the total cost of care for the broader population. And I think 
there's an opportunity to really both control costs and improve 
patient experience, patient outcomes, efficiency of care.
    I think what you're alluding to in terms of acute versus 
chronic illness goes to some extent to the distinction between 
sort of reactive care models and proactive care models. And I 
think, when you can have a proactive team-based approach to the 
care of chronic illnesses, experience is just demonstrating how 
effective that can be.
    The timeliness of it is important. When you're proactive, 
you can often diagnose a problem earlier when the interventions 
that are required to return, restore wellness to the patient's 
condition--it's much more effective when you intervene early. 
So, right care, in the right place, at the right time is a big 
piece of chronic illness management.
    It's also an opportunity, as I alluded to earlier, to 
incorporate the patient's values and their goals of care. When 
you have an engagement with a patient with multiple chronic 
illnesses, part of--a very important part of that is to 
understand that aspect of their care and give them agency as 
patients and decision-making power. And often, that will 
actually allow you to avoid unnecessary care, or care that the 
patient never wanted.
    So, I think that those aspects of chronic care delivery are 
very much incented and facilitated in an ACO model like the 
Medicare program.
    Senator Wyden. My time is up. And I just wanted to say to 
you that we'll be back to you, because there are really two 
issues here.
    One, Senator Whitehouse and I have been very involved in 
trying to update the Medicare guarantee. You know, Medicare is 
a guarantee. It's not a voucher. It's not a piece of paper. 
It's a guarantee. We've done that now, at least made a start 
with the chronic care additions to Medicare.
    But I think, as we learn more about what chronic conditions 
are all about and how to treat them, maybe we're going to learn 
some things about how to prevent them in the first place. And 
I'm going to want to talk to you about that relationship as 
well.
    Mr. Chairman, good work, as always, and your leadership on 
health care is long, long noted. And I look forward to working 
with you on the things we're talking about today.
    Chairman Whitehouse. Thank you, Chairman Wyden.
    I have a number of questions I'll ask Dr. White. That 
creates a second round, so I'll recognize Senator Braun. And 
then I have another hearing to get off to, so I will close the 
hearing after those two rounds.
    Dr. White, CMMI looked at some programs that were cost 
saving failures and others that were cost saving successes. 
Your CMMI report notes models that produced statistically 
significant savings, and that a third of the CMMI models that 
have produced statistically significant savings were ACO 
models--your colleague Dr. Kurose on the panel being one 
example.
    You noted also that certain features of the pioneer ACO 
model have been incorporated now into the Medicare Shared 
Savings Program and that, beginning next year, CMS has 
announced that the Medicare Shared Savings program will also 
incorporate aspects of the other successful ACO model, the ACO 
investment model.
    What are the qualities of those successful models that led 
to their success, and where did those ACO models succeed in 
achieving savings?
    Dr. White. Thank you for the question, Chairman.
    At a high level, MSSP has operated----
    Chairman Whitehouse. Let me interrupt you for one second to 
say that Senator Kaine has arrived. And I amend my previous 
order for proceeding so that after Senator Braun, we'll 
recognize Senator Kaine.
    Dr. White. MSSP has operated one-side models for 
participating providers may earn shared savings, and also two-
sided models, where providers can also incur financial 
penalties. And a key feature of the pioneer ACO model was that 
it incorporated a two-sided risk arrangement for all 
participants by the second performance year. And the main MSSP 
program is moving toward those two-sided models.
    With the ACO investment model, one of its key features was 
that it provided prepaid shared savings, which was intended to 
support investment in infrastructure and the formation of ACOs, 
and especially in rural areas and underserved areas.
    Now, our report was at a fairly high level focusing on 
budgetary impacts, so we didn't dig into the specific 
operational details of those models. But the two-sidedness and 
the funding for infrastructure investments are the features of 
those two ACO models that stood out to us.
    Chairman Whitehouse. There were winners in those ACO 
models. And the winning features of those models are now being 
propagated further into the Shared Savings Program; correct?
    Dr. White. That's fair to say.
    Chairman Whitehouse. What do experts that CBO hears from 
say about the importance of primary care in the context of 
successful delivery system reforms?
    Dr. White. Sure. I'll reiterate the fact that primary care 
is key to patient attribution in ACOs, but then, more broadly, 
physician-led organizations have the ability and the incentives 
to move care away from high cost specialty care facility 
settings and focus on management of chronic conditions. That is 
consistent with the ability to save money and reduce spending.
    Chairman Whitehouse. And, finally, is it correct that CBO 
communicated in a letter to our committee in March of this year 
that CBO now projects that the United States will have spent 
$6.3 trillion less between 2010 and 2033 than CBO's original 
projections proposed in its 2010 baseline?
    Dr. White. Yes.
    And just to unpack that a little bit, this is from the 
letter that we sent in March of this year.
    Over the 2010 to 2020 period, we spent $1.1 trillion less 
on health care than we projected in August of 2010. And looking 
forward from 2021 to 2033, we now project we will spend $5.2 
trillion less on major health programs than we projected in the 
summer of 2010. That sums to the $6.3 trillion.
    Chairman Whitehouse. Great. With that, I will make that 
letter a matter of record. (insert footnote in editing)
    Chairman Whitehouse. And I will turn to Senator Braun, and 
then Senator Kaine.
    Senator Braun. Thank you, Mr. Chairman.
    We talked about hospitals earlier. They now occupy the 
biggest percentage of the health care dollar.
    Insurance, though, cannot go unmentioned. When I redesigned 
my plan to make it to where we haven't had premium increases in 
15 years, and threw the kitchen sink and everything at 
wellness, creating health care consumers at the time, insurance 
was never intended to take care of minor health care. Just like 
to doesn't work in any other area of insurance, it's for 
indemnification of a critical, unusual incident or issue. I 
don't think it was ever intended, just evolved that way, to 
cover everything.
    Do we need insurance for primary health care? Or should it 
go back to what it was intended for: indemnification against 
critical illness or an accident?
    I'm going to start with Dr. Fiedler. And why is that still 
a part of the system? It's kind of like the Darth Vader that 
keeps the glue of lack of transparency and everything there.
    And then Dr. Dafny and Dr. Kurose. So, keep your answers at 
about a minute or so, so we respect the time.
    Dr. Fiedler, you can start.
    Dr. Fiedler. I think one of the rationales for coverage of 
some of these more routine services is that they have the 
potential to prevent the need for more expensive services down 
the road. And so, I think----
    Senator Braun. Prevention is worth--an ounce of that is 
worth a pound of cure.
    Dr. Fiedler. Right. And it may not be that there are cost 
savings, but it may be that the sort of benefits that they 
provide, together with the cost savings they generate, means 
they're worth it on net.
    So, I think that is----
    Senator Braun. But that doesn't work in any other arena of 
insurance on minor stuff. Then you're mixing indemnification 
and the cash flow that goes with it, and you're doing other 
things. Well, why couldn't that be done directly between 
patient and the provider and get rid of all the red tape and 
costs of processing a claim?
    Dr. Fiedler. I think another important reason that many of 
these services are being covered through insurance is because 
the insurer is actually playing a very important price 
negotiation function in the private market.
    Senator Braun. So, I want to stop there. You've made your 
point. I think that is totally off base.
    You've gotten rid of what works in every other market. 
People shop around to save 50 bucks on a big screen T.V. 
They're not doing any of that.
    When I put that into my insurance plan, costs started going 
down by 50 percent. You throw the wellness tools, you have your 
cake and eat it, too. Dr. Dafny.
    Dr. Dafny. Thank you for the opportunity, Senator Braun, to 
answer this question.
    I agree with you that insurance ideally does not have first 
dollar coverage. Right? It's supposed to protect against the 
unanticipable risks that one has.
    However, what data show us is that when consumers have high 
deductibles, that they cut back on their care, but they cut 
back indiscriminately. They cut back on care that could reduce 
spending later on. And to the extent that employers and 
government payers then end up having to spend more because of 
those decisions early on, that's a reason to subsidize that 
kind of care.
    Dr. Kurose. To me, your question at least in part--and I'll 
see if you agree--raises a question of how should primary care 
be compensated?
    And it seems like when you're moving away from the purpose 
of insurance as you described it, you could think about 
capitated models of payment for primary care that gives you a 
predictability on what the cost is.
    Exactly how that gets funded and what the incentives are 
for patients is sort of a different question, but I think that 
the costs of primary care should be relatively predictable, and 
that paying prospectively on a per member per month, per member 
per year basis for primary care makes sense.
    One of the things that I would add is that I think there is 
value in having primary care have skin in the game in terms of 
managing total cost of care because I believe that they play an 
important role in that, although they can't do it alone.
    Senator Braun. I think there, that is a dilemma because you 
do, then, eliminate the market in that skin in the game.
    And we've evolved that way. All I can tell you is I'm 
seeing more and more, unless you're saying people would not 
take care of their own well-being just because that's the way 
it's been, I think you're sticking to a model that's broken. 
And it has gotten us where we are today.
    We need to get creative there. You bring health care costs 
down. I did it, and it's been working for 15 years. And we've 
got to be more creative and entrepreneurial in areas like that.
    Mr. Merkel, do you want to weigh in quickly?
    Mr. Merkel. Yes. I would say that you're right. Insurers' 
raison d'etre is to insure against financial risk, and to the 
extent that we have required them to do more, they do that 
inefficiently. And while yes, currently, they're playing a role 
to negotiate prices, I think that they haven't done that 
particularly well.
    And if we put more people--put more pressure on through 
giving consumers, and patients, and providers a more active 
role in doing that, I think we'd probably see better results in 
the long run.
    Senator Braun. Thank you.

                   STATEMENT OF SENATOR KAINE

    Senator Kaine [presiding]. Thank you to all the witnesses 
for being here today and helping the committee examine ways to 
both maintain quality, but reduce costs as we're doing so.
    I care very deeply about this topic. I have a bill with 
Senator Bennett that I call the `Medicare-X Choice Act.' And I 
want to talk about it a second.
    Dr. Fiedler, I'll ask you a question about it.
    Medicare-X Choice Act would create a public option that 
would expand upon the successes of the Affordable Care Act, 
making affordable coverage available for families, individuals, 
and small businesses.
    It would direct CMS to devise an insurance policy that 
would cover the ACA essential benefits, and offer that policy 
on the exchange for individuals and small businesses.
    An individual choosing to purchase that policy, if they 
qualified for the ACA subsidy, could apply that subsidy to 
bring down the cost of the premium. Because the CMS-devised 
policy would not need to cover a profit margin, fancy salaries, 
ads on T.V., return to shareholders, it would likely be a very 
affordable option for people. Wouldn't force people to buy a 
government policy, but I think folks looking at the exchange 
would find it to be a very attractive option.
    The proposal would increase access to health care services 
in parts of our country that have historically faced challenges 
accessing care: rural Virginia, rural America, where often 
there's inadequate options or choice on the exchanges.
    People--because CMS exists in every ZIP Code in the 
country, it could be available on every exchange in the 
country. Somebody moving from Virginia to Oregon, not knowing 
whether the insurance company that insures them in Virginia 
even offers policies in Oregon, wouldn't need to worry about 
whether the Medicare-X policy would be available because 
Medicare already operates in every ZIP Code.
    My colleagues and I have differing opinions about how to 
achieve the goal of broadened access and reduced costs, but I 
do think we have the common goal of doing those things. And 
that was why I was so gratified when the Urban Institute issued 
a report last year stating that, if implemented, the Medicare-X 
Choice Act would reduce the number of uninsured people by about 
1.1 million, save households about $10.9 billion a year, save 
the Federal Government $20.3 billion a year, and cut total 
spending on health care by $456 billion over a 10-year period.
    Increased access to care is not only good for individuals. 
It's good for communities.
    Dr. Fiedler, I'd like to ask you to speak about how the 
mechanics of Medicare-X would both increase access to care and 
reduce health care spending over the long term.
    Dr. Fiedler. Thank you for the question.
    This is something that Dr. Dafny alluded to in her 
testimony, but a striking feature of our health care system is 
that private insurers pay much higher prices for the same 
health care services than Medicare does.
    And that's a reflection of the fact that private insurers 
have to negotiate these prices with providers. And providers, 
in many markets, wield a lot of market power, whereas Medicare 
is able to pay lower prices by setting prices administratively.
    Medicare-X would introduce a Medicare-like plan into the 
individual and small group markets. And because Medicare-X 
would pay these lower prices, it would offer lower premiums 
than existing plans. It would probably be due to the lack of a 
profit margin and probably somewhat lower administrative costs 
that would add to the premium reductions. That's where the cost 
savings would come from.
    You also asked about access. In terms of access, there 
would be sort of two main effects to think about.
    One is that the lower premiums would cause some people who 
are uninsured today to take up coverage, which would improve 
their access to care.
    And then, another is that the Federal Government would save 
a lot of money on the subsidies delivered to people who are 
currently insured. And the bill would then use some of those 
federal savings to enhance the subsidies available to people 
who have private coverage on the marketplace. And that would 
pull additional people into the market in coverage, and improve 
access to care.
    Senator Kaine. Thank you, Dr. Fiedler.
    You know, we don't have the votes to do Medicare-X yet, but 
I believe it's the next step forward, that we started on a path 
with the Affordable Care Act. I don't think we should just go 
on a different path, but I think we should take the next step 
forward on the path we began. And I think offering a Medicare-X 
policy on the exchanges and allowing people, as they shop, to 
do what Senator Braun said, to shop and try to find the most 
economical plans, I think that would be a good thing.
    I want to--Dr. White, I have a question for you, and then 
we will close the hearing.
    At a Budget Committee Hearing last month, I asked Dr. 
Marilyn Moon about a New York Times article that caught my 
attention. And I heard Senator Whitehouse referring to it.
    The article was entitled `A Huge Threat to the U.S. Budget 
Has Receded. And No One Is Sure Why.' And it was sharing the 
work of the CBO that between 2010 and 2020, Medicare costs were 
9 percent lower than expected.
    The article was interesting in advancing different 
scenarios. I asked Dr. Moon if she had thoughts about why this 
happened, and she speculated two factors.
    One, that passage of the Affordable Care Act and an 
increase in people having insurance prior to joining Medicare 
might mean that people are a little bit healthier when they 
joined Medicare, and thus, their expenses might have been 
lower, at least initially.
    And then, she also pointed out that there is a demographic 
aging bubble of a lot of people turning 65 at once--baby 
boomers like me, I turned 65 in February--and younger seniors 
tend to be healthier than older seniors. So, if you have a huge 
bubble of young seniors coming into Medicare, that can also 
affect costs.
    Given that CBO was responsible for the work that has led to 
this, this interesting phenomenon and speculation, can you talk 
about the factors that CBO took into consideration when doing 
the analysis and how those factors could potentially change 
over the next 10-year budget cycle?
    Dr. White. Sure.
    There's a lot to unpack in that question, but let me start 
with the baby boomers aging into Medicare. That's a demographic 
phenomenon that's very well understood. It's very predictable, 
and it's baked into our demographic factors. So, that is pretty 
straightforward to have a handle on.
    In terms of people having health insurance under age 65 
because of the ACA and then aging into Medicare, that sounds 
plausible. We haven't dug into that and pinned down the size of 
that. The ACA did so many other things, big things in Medicare, 
that that phenomenon, my sense is, is relatively small.
    But one thing that I want to draw out is that the 
unexpected slowdown in Medicare spending actually started 
appearing well before 2014, when the coverage expansions went 
into effect. And so, this is really a long-running slowdown 
phenomenon.
    And we know that we overestimated Part D spending. We know 
that Medicaid spending on long-term services and supports has 
turned down. We're taking those factors into account when we 
project going forward.
    And I want to make a general point that we use the most 
recent historical evidence as our jumping off point. We look at 
our misses. We scrutinize those misses. When we come to 
understand our misses better, we explain for the world why 
we've updated our thinking.
    That showed up in the CMMI report in a big way, and our 
predictions now, as always, we're trying to be in the middle of 
the distribution. It's as likely to be too high as too low. The 
future is always uncertain, but we're trying to take what we've 
learned and really dig into the phenomenon that Dr. Moon 
highlighted.
    Senator Kaine. Great.
    Well, thank you, Dr. White. The fact that the CBO manages 
to make Democrats happy or unhappy, and Republicans happy or 
unhappy--you know, I've railed at some CBO studies and been 
entirely comforted by others, and everyone around this table 
feels the same way. I think you're approaching the work that 
you do in this space with, you know, with intellectual 
integrity and an attempt to be evenhanded, and I appreciate 
that.
    And I do think it's important. I applaud analyzing your 
misses because when you miss something, going back and trying 
to understand why gives you the ability to calibrate and then, 
you know, hopefully do a better job. I think the Samuel Beckett 
line is `Ever tried. Ever failed. No matter. Try again. Fail 
better.'
    And so, it sounds like that's the method that you follow.
    The hearing is now concluded. I want to thank the witnesses 
for hearing--appearing before the committee. Your written 
statements wholly will be included in the record.
    Without objection, I submit statements for the record from 
Milbank Memorial Fund, the Rhode Island Quality Institute, the 
National Association of Accountable Care Organizations, from 
Professor David Cutler and Nikhil Sahni, and a preprint 
publication in Health Affairs titled ``Active steps to reduce 
administrative spending associated with financial transactions 
in US healthcare''.\9\
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    \9\ Documents submitted for the Record appear in the appendix on 
page 109.
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    Information for all senators, questions for the record are 
due by noon tomorrow, with signed hard copies delivered to the 
Committee clerk in Dirksen 624. Emailed copies will also be 
accepted.
    We'll ask witnesses, if there are questions for the record 
that are submitted, to respond to those questions within seven 
days of receipt.
    With no further business before the Committee, this hearing 
is adjourned.
    [Whereupon, at 11:43 a.m., Wednesday, October 18, 2023 the 
hearing was adjourned.]

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