[Senate Hearing 118-256]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-256

                       HOW PRIMARY CARE IMPROVES
                         HEALTH CARE EFFICIENCY

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

                                HEARING

                               BEFORE THE

                        COMMITTEE ON THE BUDGET
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             SECOND SESSION
                               __________

                             March 6, 2024
                               __________

           Printed for the use of the Committee on the Budget


                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                            www.govinfo.gov
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
55-277                     WASHINGTON : 2024  


                        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, MARCH 6, 2024
                OPENING STATEMENTS BY COMMITTEE MEMBERS

                                                                   Page
Senator Sheldon Whitehouse, Chairman.............................     1
    Prepared Statement...........................................    31
Senator Charles E. Grassley, Ranking Member......................     3
    Prepared Statement...........................................    34

                    STATEMENTS BY COMMITTEE MEMBERS

Senator Ron Wyden................................................     5
Senator Ron Johnson..............................................    18
Senator Chris Van Hollen.........................................    21
Senator Alex Padilla.............................................    24
Senator Tim Kaine................................................    26
Senator Mike Braun...............................................    27

                               WITNESSES

Mr. Christopher Koller, President, Milbank Memorial Fund.........     7
    Prepared Statement...........................................    37
Dr. Amol Navathe, Associate Professor, Perelman School of 
  Medicine and The Wharton School, University of Pennsylvania....     9
    Prepared Statement...........................................    46
Dr. Bob Rauner, President, Partnership for Healthy Nebraska, and 
  Representative, American Academy of Family Physicians..........    10
    Prepared Statement...........................................    60
Ms. Lisa M. Grabert, Visiting Research Professor, Marquette 
  University College of Nursing..................................    12
    Prepared Statement...........................................    68
Dr. Christina Taylor, Chief Medical Officer, Value Based Care, 
  Clover Health, and President-Elect, Iowa Medical Society.......    13
    Prepared Statement...........................................    78

                                APPENDIX

Responses to post-hearing questions for the Record
    Mr. Koller...................................................    82
    Dr. Navathe..................................................    86
    Dr. Rauner...................................................    94
    Ms. Grabert..................................................   100
    Dr. Taylor...................................................   103
Statement submitted for the Record by AARP.......................   108
Statement submitted for the Record by American Academy of PAs....   112
Statement submitted for the Record by American Association of 
  Child and Adolescent Psychiatry................................   113
Statement submitted for the Record by American College of 
  Osteopathic Family Physicians..................................   115
Statement submitted for the Record by American College of 
  Physicians.....................................................   116
Statement submitted for the Record by Arnold Ventures............   118
Statement submitted for the Record by the Commonwealth Fund......   121
Statement submitted for the Record by Families USA...............   125
Statement submitted for the Record by the National Association of 
  ACOs...........................................................   129
Statement submitted for the Record by National Partnership for 
  Women and Families.............................................   133
Statement submitted for the Record by Primary Care Collaborative 
  and Better Health Now..........................................   136
Statement submitted for the Record by Rhode Island Health Center 
  Association....................................................   139
Statement submitted for the Record by Society of General Internal 
  Medicine.......................................................   141
Statement submitted for the Record by United States of Care......   145

 
                       HOW PRIMARY CARE IMPROVES
                         HEALTH CARE EFFICIENCY

                              ----------                              


                        WEDNESDAY, MARCH 6, 2024

                                           Committee on the Budget,
                                                       U.S. Senate,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:07 
a.m., in the Dirksen Senate Office Building, Hon. Sheldon 
Whitehouse, Chairman of the Committee, presiding.
    Present: Senators Whitehouse, Murray, Wyden, Kaine, Van 
Hollen, Lujan, Padilla, Grassley, Johnson, Marshall, Braun, and 
R. Scott.
    Also present: Democratic staff: Dan Dudis, Majority Staff 
Director; Anirudh Srirangam, Healthcare Policy Advisor.
    Republican staff: Chris Conlin, Deputy Staff Director; 
Krisann Pearce, General Counsel; Nic Pottebaum, Professional 
Staff Member; Ryan Flynn, Staff Assistant.
    Witnesses:
    Mr. Christopher Koller, President, Milbank Memorial Fund
    Dr. Amol Navathe, Associate Professor, Perelman School of 
Medicine, and The Wharton School, University of Pennsylvania
    Dr. Bob Rauner, President, Partnership for Healthy 
Nebraska, and Representative, American Academy of Family 
Physicians
    Ms. Lisa M. Grabert, Visiting Research Professor, Marquette 
University College of Nursing
    Dr. Christina Taylor, Chief Medical Officer, Value Based 
Care, Clover Health, and President-Elect, Iowa Medical Society

          OPENING STATEMENT OF CHAIRMAN WHITEHOUSE \1\
---------------------------------------------------------------------------

    \1\ Prepared statement of Chairman Whitehouse appears in the 
appendix on page 31.
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    Chairman Whitehouse. All right, let me call our Committee 
back to order for purposes of the hearing, which I hope will 
open some healthy bipartisan conversations on ways that we can 
save money in our healthcare system by improving the quality of 
care for patients. Members of the Committee may recognize this 
chart, certainly members of the Finance Committee may recognize 
this chart, which I've used for years to show the enormous 
opportunity that we have in healthcare in America.
    It graphs healthcare spending as a percentage of Gross 
Domestic Product (GDP) against life expectancy. And as you can 
see, we are outliers in exactly the wrong direction. That's the 
bad news. The good news is there's lots of room for improvement 
and the numbers are big. U.S. health spending makes up 17 
percent of GDP. As you can see, it's a far higher percentage 
than in peer nations. Yet, U.S. life expectancy is below peer 
nations and even falling. Indeed, it's now fallen to its lowest 
in two decades.
    By contrast, Germany's health spending represents 12.5 
percent of that nation's GDP with longer life expectancy. If 
America's healthcare spending went from 17 percent to 12.5 
percent of GDP, it would save our budget nearly a trillion 
dollars a year, $10 trillion dollars in our customary 10-year 
budget window. So, we are dealing with potentially very, very 
big savings.
    Why is American healthcare spending so inefficient? One 
answer is how badly we fund primary care. In our Budget 
Committee hearing last October, we heard that despite 
overwhelming evidence that primary care is associated with 
longer life expectancy and lower downstream health costs, the 
U.S. continues to spend less on primary care as a share of 
total healthcare spending than any other peer Organisation for 
Economic Co-operation and Development (OECD) country. In fact, 
average primary care spending across our peer nations is nearly 
double ours.
    U.S. percentage spending on primary care actually declined 
from a sad 6.5 percent in 2002 to a truly woeful 4.7 percent in 
2019. Today, three in ten Americans report not having a usual 
source of primary care. In some areas, often rural areas, the 
situation is much worse.
    At our October hearing, we also heard how accountable care 
organizations (ACOs), and other payment models have improved 
the quality of care while lowering the cost of care. We've seen 
that in Rhode Island through two primary care ACOs, Coastal 
Medical and Integra. So, today's hearing is about how to do 
more of that. How to deliver better care at a lower cost with 
better outcomes for patients.
    This is often pretty straightforward stuff. Primary care 
doctors and nurses know their patients. They know what they 
need to stay healthy, whether it's home visits or telehealth 
options or better coordination of their medications or better 
diets or moving that slippery rug at the bottom of the stairs. 
Letting primary care doctors and nurses out of the handcuffs of 
fee for service payment frees up these simple innovations and 
patients love it.
    We'll hear from experts today how to get there, not 
complicated. First, make high quality primary care more 
available. Second, fix how we pay for primary care. We are 
releasing a discussion draft of a bill tasking Centers for 
Medicare and Medicaid Services (CMS) to accelerate value-based 
primary care by creating hybrid payment models for Medicare 
primary care providers. Hybrid payment start to move away from 
the failed fee-for-service treadmill by at least partially 
paying primary care providers based on their patient mix.
    These hybrid payment models reward providers who provide 
the best care to their patients. Care that reduces the 
patient's emergency visits, hospitalizations, excess specialist 
services, and other big-cost drivers. And these hybrid payment 
models reward patients with better health.
    My discussion draft proposes a Technical Advisory Committee 
to improve how CMS sets Medicare's physician fee schedule. The 
existing fee schedule has under resourced both primary care 
services and primary care provider pay, leading to few primary 
care physicians. One report projects that in a decade the U.S. 
will face a shortage of between 17 and 45,000 primary care 
doctors. If good primary care reduces overall costs, as the 
data suggests, that will be a very expensive primary care 
physician shortage. One to which the existing fee schedule is 
leading us.
    On the reform side, even good alternative payment models 
stand on the existing fee schedule, hampering the new model's 
ability to hit that triple aim of better patient experience, 
better outcomes, and lower costs. Fee schedule reforms could 
head off that very expensive primary care shortage and at the 
same time help current primary care providers lower health 
costs by improving Medicare beneficiaries' health outcomes.
    So, I encourage my colleagues to work with me as we develop 
these policies further. Today we'll hear from Chris Koller, the 
nation's first state health insurance commissioner who put 
primary care at the center of health spending in Rhode Island 
and saw lower costs and better outcomes result. He'll explain 
how reliance on a broken fee-for-service healthcare system 
limits our potential to scale primary care reforms.
    We'll hear from Dr. Amol Navathe about how hybrid payment 
models can strengthen primary care by helping providers 
innovate, improve care, and lower costs. And we'll hear from 
Dr. Bob Rauner, a frontline primary care physician, about how 
payment models affect the care he provides his patients.
    We've learned a lot since passing the Affordable Care Act 
about how delivery system reforms can unlock improvements in 
our healthcare system that drive meaningful cost savings from 
better care. Now, we can use that learning to make improved 
care for patients and lower costs for the budget an everyday 
thing.
    The reforms contained in my discussion draft would help 
doctors deliver high quality primary care to many more 
Americans and improve their health outcomes and lower total 
healthcare spending because more and better primary care 
reduces the need for expensive specialty and hospital care. 
These are savings we achieve with no, none, zero benefit cuts. 
Let's be very clear about that. These are savings we achieve 
because patients are healthier. Patients are healthier because 
they get better primary care and doctors provide better primary 
care because we reward them for that.
    Simple tools, but we need to put them to work, and I hope 
this hearing helps begin that process. And with that, I turn to 
my distinguished Ranking Member, Senator Grassley.
    Senator Grassley. Thank you.
    Chairman Whitehouse. And I will, at the conclusion of 
Senator Grassley's remarks, I'd like to recognize the Chairman 
of the Finance Committee who has important jurisdiction in this 
space for a few remarks as well, Senator Wyden, then we'll 
proceed to the witnesses.

           OPENING STATEMENT OF SENATOR GRASSLEY \2\
---------------------------------------------------------------------------

    \2\ Prepared statement of Senator Grassley appears in the appendix 
on page 34.
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    Senator Grassley. Well, thank you for holding today's 
hearing on strengthening primary care. Americans spend more 
than $4.3 trillion annually on health. Our spending has more 
than tripled as a percentage of Gross Domestic Product since 
1960. Growing healthcare costs don't just strain the American 
pocketbooks, these costs also are a major driver of widening 
budget deficits in the federal government's unsustainable 
fiscal outlook. And it's clear that we're not getting our 
money's worth for all of this spending.
    Major healthcare programs spending eats up 32 percent of 
the federal revenue today and will be 45 percent mid-century. 
Our healthcare 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 
where we ought to find a bipartisan start.
    We can also do a better job reducing clinical waste by 
focusing more on prevention and early intervention, reducing 
inappropriate care, and also improving care coordination. 
Having access to primary care is key to being able to do all of 
these things I mentioned. When patients have access to timely 
primary care, they have better health outcomes and live longer. 
We're blessed with millions of dedicated and qualified 
healthcare providers. These individuals care deeply about the 
quality of care that they provide.
    I'm proud that Iowa is home to several great institutions 
that train primary care doctors, physician assistants, nurses, 
therapists, and too many more to mention. Rural primary care 
depends on a suite of providers, meaning doctors, physician 
assistants, nurse practitioners, along with telehealth and 
other innovations to deliver timely care. To make primary care 
more accessible and effective, we need to remove federal 
government barriers, lean on consumer choice and price 
transparency, and be outcomes based.
    To often Medicare regulations and payment systems are 
overly burdensome for physicians. Government driven approaches 
haven't moved our healthcare system to be more outcome based. 
The future of Medicare payments to providers and improving 
access to primary care lies outside of the fee-for-service, so 
patients and taxpayers can get better value. The key question 
is how do we actually do that, who's in control, and what can 
lower costs and at the same time improve health outcomes.
    Last October, this Committee held a hearing of reducing 
excess costs in healthcare. I'm glad that we took an accurate 
account of what's working and not working in reducing our 
nation's healthcare costs at that hearing. Now, the 
Congressional Budget Office (CBO) has found the Center for 
Medicare and Medicaid Innovation, a program created to lower 
costs has not lowered Medicare costs. That's not my judgment. 
That's CBO.
    CBO told us what is lowering healthcare spending in 
Medicare is the Part D program. In the past decade, existing 
brand name drugs lost their patent protection. As a result of 
new competition from generic drugs patients are shifting to 
less expensive generic formulas. This is in line with what we 
already know from CBO. In the first decade of Part D, it ended 
up costing taxpayers 36 percent less than projected by CBO and 
that doesn't happen very often.
    As then Chairman of the Senate Finance Committee, I was 
proud to author Medicare Part D. Prescription drug costs are 
still too high. We need to reform the role of the very opaque 
middlemen and you know them as PBMs or Pharmacy Benefit 
Managers, and we need to enact more competition into the drug 
market. We know that market-based solutions are effective in 
lowering costs and improving care as we have seen, as I just 
stated, in Medicare Part D.
    We should build on these policies, while seniors should get 
a choice between fee-for-service Medicare and Medicare 
Advantage. We know that Medicare Advantage (MA) is a growing 
choice of many seniors. Medicare Advantage can be effective at 
promoting value in the healthcare by directing resources in 
primary care and higher quality care. As Medicare Advantage 
adds more patients and spreads billions of dollars of 
taxpayers' money, aggressive oversight is needed to root out 
fraud, waste, and abuse that's been a focus of mine for many 
years.
    Finally, we can't talk about waste and inefficiency in 
healthcare without discussing our country's fiscal situation. 
According to CBO, the federal budget deficit in the fiscal year 
that most recently ended clocked in at two trillion dollars and 
future deficits are projected to be even larger. Growing 
healthcare spending is a major reason. Healthcare spending can 
be made more efficient without compromising the quality of care 
and reducing access, especially in rural areas where access is 
a major problem.
    I look forward to this hearing, from our witnesses, and 
thank them for appearing because this issue of more primary 
care is very necessary to be solved if we're going to reduce 
costs.
    Chairman Whitehouse. We recognize Chairman Wyden for his 
remarks and then I'll introduce the witnesses.

                   STATEMENT OF SENATOR WYDEN

    Senator Wyden. Thank you very much, Mr. Chairman. And 
colleagues, thank you for allowing me this imposition. I'm 
going to be very brief. Particularly, the Finance members 
recall that before he retired, we all worked with Chairman 
Hatch to begin to move Medicare away from being just an acute 
care program to being one that will deal with chronic illness. 
The reason that Senator Whitehouse's work is so important is 
that when we did that, and it was a crucial transformation.
    When I was coming up, I remember Medicaid was for acute 
care. You broke your ankle or something like that, you went to 
the hospital. Now, Medicare, to a great extent, there's cancer 
and diabetes and heart disease and strokes, and all these 
chronic illnesses, and primary care, what Chairman Whitehouse 
is going after here has a key role, colleagues, to play in 
managing chronic illness. In effect, this is the next step, and 
I would just say, whether it is grab bars in showers, whether 
it's transportation assistance, whether it's air conditioning, 
you can go on and on, but all of it relates to this primary 
care issue that Senator Whitehouse, who, in addition to his 
role here as Chairman of the Budget Committee, wears another 
very valuable hat on the Finance Committee.
    I think we can all work together and this is the future and 
Dr. Rauner, I'm going to try and get back. We're working on the 
tax bill this morning and sort of around the clock, but your 
point of saying, in particular, that a lot of these primary 
care services should apply to traditional Medicare, not just 
MA, is very much in sync with, I think, the forward-thinking 
work that's going on in healthcare. Chairman Whitehouse is 
going to lead this effort and we're going to work really 
closely with him.
    Colleagues, apologies for the bad manners.
    Chairman Whitehouse. No, no, when the Chairman of Finance 
wants to talk about healthcare reforms, we're all ears. First, 
we'll hear from Chris Koller. Mr. Koller is the president of 
Milbank Memorial Fund, 115-year operating foundation that works 
to improve population health and health equity.
    As I mentioned, he was the country's first health insurance 
commissioner from Rhode Island from 2005 to 2013. He's a member 
of the National Academy of Sciences, Engineering, and Medicine 
and on the faculty of Brown University School of Public Health.
    We'll then hear from Dr. Amol Navathe. Dr. Navathe is an 
Associate Professor of Medicine and Health Policy at the 
University of Pennsylvania. He's a practicing internal medicine 
physician and a health economics researcher. His research 
focuses on improving the quality and cost efficiency of 
healthcare through better payment approaches. He currently 
serves as Vice Chair of the Medicare Payment Advisory 
Commission. He's previously served at the Council of Economic 
Advisors and as a leader of the Comparative Effectiveness 
Research Portfolio for the Department of Health and Human 
Services.
    We'll then hear from Dr. Bob Rauner. Dr. Rauner is a family 
physician who spent the first 15 years of career caring for 
rural and underserved patients in Nebraska and then spent the 
past 12 years starting two primary care physician-led 
accountable care organizations, the Southeast Rural Physicians 
Alliance ACO in 2012, and then One Health Nebraska ACO in 2016.
    He serves as president of the Partnership for Healthy 
Nebraska, a group that works with organizations and communities 
in Nebraska to address health-related issues impacting those 
they serve. And he's appearing today as a representative of the 
American Academy of Family Physicians.
    We're also joined by Ms. Lisa Grabert. Ms. Grabert is a 
Visiting Research Professor at Marquette University College of 
Nursing. Previously, she's worked at the House of 
Representatives Committee on Ways and Means, the American 
Hospital Association, and the Centers for Medicare and Medicaid 
Services.
    And our final witness today will be Dr. Christina Taylor. 
Dr. Taylor is the Chief Medical Officer for Value Based Care 
for Clover Health. She is also President-Elect of the Iowa 
Medical Society. Preivously, Dr. Taylor served as Chief Medical 
Officer at the McFarland Clinic in Ames, Iowa, where she 
oversaw the population and value-based healthcare efforts. Dr. 
Taylor earned her medical degree from the University of Iowa, 
Carver College of Medicine and completed her internal medicine 
residency in Des Moines, Iowa. We welcome all of you. Mr. 
Koller, please proceed. I've got to remember I'm an official 
here and I can't call you by your first name.

 STATEMENT OF CHRISTOPHER KOLLER, PRESIDENT, NILBANK MEMORIAL 
                            FUND \3\
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    \3\ Prepared statement of Mr. Koller appears in the appendix on 
page 37.
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    Mr. Koller. Thank you. Chairman Whitehouse, Ranking Member 
Grassley, and distinguished members of the Committee, thank you 
for the opportunity to testify today.
    As you hammer out details this week of a spending bill that 
contained sorely needed funding for community health centers, 
the National Health Service Corp and teaching health centers, I 
wanted to focus on the essential nature of primary care and 
Medicare's role in shaping the country's healthcare system.
    As Senator Whitehouse noted, in 2005, I assumed the newly 
created role of Health Insurance Commissioner for the State of 
Rhode Island. My job was to direct commercial insurers to 
improve the accessibility, quality, and affordability of the 
healthcare system. I convened an advisory council of consumers 
and providers to look at the drivers of healthcare 
unaffordability in Rhode Island. They found a gravely out of 
balance healthcare delivery system that depended heavily on 
specialty care providers and underfunded primary care providers 
who, when adequately supported, deliver cost effective, 
preventive urgent, routine, and chronic care. These issues also 
cripple the Medicare Program and the U.S. healthcare system, in 
general.
    As Senator Whitehouse noted, overall, the U.S. spends 50 
percent more of its GDP on healthcare than any other country 
and in return we have somewhere between the 45th and 50th 
longest life expectancy at birth in the world. In Rhode Island, 
we implemented a strategy to help rebalance our delivery 
system. This included a cap on the rate of growth in hospital 
prices and a requirement that insurers increase the portion of 
their healthcare spending going to primary care by 1 percentage 
point a year for five years.
    By making delivery system rebalancing a priority, since 
then Rhode Island had catalyzed Medicare ACOs and new ways of 
paying primary care practices, maintained one of the highest 
levels of primary care providers per capita in the country, 
which left the state better prepared to face the COVID-19 
pandemic, supported a network of community health centers that 
serves one in six state residents, inspired 21 other states to 
report on or increase primary care spending, and we've improved 
our ranking in the Commonwealth Fund's state health system 
scorecard to fourth.
    But most importantly, Rhode Island has greatly improved its 
health insurance affordability relative to neighboring states. 
Yet, these efforts amount to sandbags against the relentless 
flood. Rhode Island is still subject to the grave primary care 
prices facing the country. The Milbank Memorial Fund's annual 
health review as a primary care scorecard released last week 
documented that almost one in three Americans report they lack 
access to a source of regular care. This figure is increasing 
most dramatically for children.
    The number of primary care physicians per person is 
declining, the share of healthcare dollars going to primary 
care is less than 1 in 20 and is dropping, and a grim future 
lies ahead. About one in seven physicians is practicing primary 
care five years after medical residency. That's not enough to 
replace those retiring, let alone to match the levels found in 
other countries. Medicare's fee schedule has created this 
unbalanced delivery system and primary care crisis. How much 
and how it pays is not delivering value for the Medicare 
program or its beneficiaries. Medicare is the benchmark for all 
of their payers, so this inefficiency has rippled through our 
entire healthcare system.
    In 2021, the National Academy of Science, Engineering, and 
Medicine issued a report on implementing high quality primary 
care. I was privileged to serve on that committee and in it we 
studied Medicare's method of healthcare services valuation in 
the role of the Relative Value Utilization Committee (RUC), an 
advisory committee appointed by the American Medical 
Association that assigns value to all physician services paid 
by Medicare.
    The nation report concluded 90 percent of the RUC's 
recommendations are accepted by the Centers for Medicare and 
Medicaid Services. The fee schedule implemented by Medicare 
systematically devalues primary care services relative to other 
services. This results in a compensation gap between primary 
care and other physicians that is widened, driving what 
specialty medical students chose and what graduate medical 
education programs hospitals offer.
    Given the five to one ratio of specialists to primary care 
physicians on the RUC, these findings are not surprising. The 
Government Accountability Office and numerous commentators have 
pointed out the conflicts of interest in this arrangement. How 
Medicare pays also contributes to the problem. Paying for each 
service encourages the provision of care more highly valued by 
the RUC members, procedures and testing, and discourages lower 
price services and those with no fee valuation that are often 
used by primary care clinicians, such as patient education, 
care planning, and services delivered by non-licensed 
clinicians, all of which help with the chronic conditions cited 
by Senator Wyden.
    Fee-for-service payments also discourage investments to 
improved care, as we'll hear from Dr. Rauner, and leave 
providers financially vulnerable in times of reduced demand for 
in-person services, such as during the pandemic. This is a 
self-perpetuating cycle. A committee dominated by specialists 
systematically values specialty care over primary care. 
Commercial payers follow suit. Specialists' income increase, 
attracting a greater share of medical school students and 
further destabilizing our delivery system. Medicare and the 
country spend more and get less.
    Given this, I offer four recommendations for Congress to 
improve the effectiveness and efficiency of the Medicare 
physicians fee schedule. First, revise the Medicare physician 
fee schedule valuation process in the role of the RUC. Second, 
direct CMS to annually report primary care spending levels 
across all programs. Third, implement a hybrid payment 
methodology, a blend of pre-enrollee and fee-for-service 
payments in the Medicare fee schedule for primary care 
clinicians and services. And finally, direct CMS to waive Part 
B cost sharing for all services provided by whomever the 
beneficiary has designated as their usual source of care.
    Chairman Whitehouse. Thank you, Mr. Koller. Let me turn now 
to Dr. Navathe.

 STATEMENT OF DR. AMOL NAVATHE, ASSOCIATE PROFESSOR, PERELMAN 
   SCHOOL OF MEDICINE, AND THE WHARTON SCHOOL, UNIVERSITY OF 
                        PENNSYLVANIA \4\
---------------------------------------------------------------------------

    \4\ Prepared statement of Dr. Navathe appears in the appendix on 
page 46.
---------------------------------------------------------------------------
    Dr. Navathe. Chairman Whitehouse, Ranking Member Grassley, 
and distinguished members of the Committee, thank you for the 
opportunity to testify today.
    Before I begin my substantive remarks, I would like to 
emphasize that my comments reflect solely my beliefs and not 
the opinions of any organization I'm affiliated with, including 
Medicare Payment Advisory Commission (MedPAC), the University 
of Pennsylvania Health System or Perelman School of Medicine.
    Today I would like to highlight how Congress can enable 
much needed transformation of primary care delivery in our 
country. I've dedicated a substantial portion of my career to 
this effort. I led the design of a new primary care payment 
model, together with Blue Cross Blue Shield of Hawaii. In 2016, 
we shifted to a hybrid model with a predictable monthly 
payment, adjusted for the level of patient illness while 
continuing to pay some services fee-for-service. This gave 
primary care providers or PCPs flexibility to practice more 
patient-centered care while streamlining operations. The 
model's success led the plan to expand it statewide.
    I would like to share four key points in support of 
reforming primary care and physician payment. First, there's 
near consensus amongst health policy experts that robust 
primary care is required for cost efficient healthcare. 
Medicare spends only 4 percent of its total spending on primary 
care, which is far less, proportionally, than other high-income 
countries.
    Geographic regions within the U.S. that have more PCPs 
achieve greater health with lower spending. For example, 
Medicare spends 25 percent less per beneficiary in states with 
many PCPs compared to those with few. Second, the current fee-
for-service payment system produces a misalignment between 
provider incentives and patient health. This leads to 
systematic under investment in primary care. In particular, the 
payment rates in Medicare's physician fee schedule undervalue 
diagnostic services in favor of procedural ones. This is an 
issue throughout the fee schedule and exacerbates the incentive 
to provide more services by shifting towards costly ones; thus, 
Medicare spending goes up without producing additional health 
benefits.
    Third, granting CMS the authority to pay primary care 
practices through a hybrid payment model is imperative to 
strengthen primary care. A hybrid payment model would allow 
practices to deliver more patient-centered care, change to more 
efficient staffing models, and use technology like telehealth 
when it is efficient and effective. The evidence for hybrid 
payments is promising. In Hawaii, there were marked 
improvements in quality. This included increased rates of cost-
effective prevention like cancer screening, as well as greater 
cost saving care, such as end of life care planning.
    To complement quality gains, there was greater use of 
telehealth that predated the pandemic. In fact, unlike other 
states where primary care practice finances were massively 
disrupted by the COVID-19 pandemic, practices in Hawaii were 
protected, financially. The success in Hawaii underscores the 
stability that hybrid payments can impart to primary care.
    Fourth, a hybrid primary care payment system is a linchpin 
for reducing federal spending on healthcare. While not every 
test of primary care payment reform has yielded overall 
savings, key leading indicators are positive. Examples of 
success include a 5 percent reduction in spending on outpatient 
imaging among Medicare Advantage beneficiaries enrolled in 
Hawaii's Blue Cross plan. To get a sense of magnitude, this 
would translate to $368 million in savings if results 
replicated across the Medicare program. CMS demonstrations lead 
to reductions in use of expensive hospital care and emergency 
department visits. The magnitude here reflects $5.4 billion in 
annual savings if results replicated across traditional 
Medicare.
    The ability for primary care to drive savings is also 
evident through the performance of accountable care 
organizations or ACOs in the Medicare Shared Savings Program or 
MSSP. Physician led ACOs are more successful than other ACOs. 
To date, the MSSP has saved $1.8 billion, but when advanced 
primary care models with hybrid payments have overlapped with 
ACOs, the synergies have yielded even larger savings.
    Hybrid primary care payments cannot be implemented at scale 
without congressional action. Notably, CMS has conducted 
demonstration projects with hybrid payments. It also has the 
authority to implement hybrid payments in the MSSP, which is a 
step that it should take. However, what we need now must be 
nationwide and permanent. Demonstration projects, by nature, 
are time limited and uncertain. This has led to under 
investment by physician practices and lack of participation 
from private payers; thus, the full benefits of hybrid payments 
have not been realized. Only through congressional action can 
CMS scale hybrid payments pass this tipping point of 
transformation across the nation. Thank you for the opportunity 
to share my testimony with you today.
    Chairman Whitehouse. Thank you very much. Dr. Rauner.

STATEMENT OF DR. BOB RAUNER, PRESIDENT, PARTNERSHIP FOR HEALTHY 
   NEBRASKA, AND REPRESENTATIVE, AMERICAN ACADEMY OF FAMILY 
                         PHYSICIANS \5\
---------------------------------------------------------------------------

    \5\ Prepared statement of Dr. Rauner appears in the appendix on 
page 60.
---------------------------------------------------------------------------
    Dr. Rauner. Chairman Whitehouse, Ranking Member Grassley, 
and distinguished members of the Committee, thank you for the 
opportunity to testify today. As a family physician from 
Nebraska, I'm honored to be here today representing the 129,600 
physicians and student members at The American Academy of 
Family Physicians, including myself.
    I spent the first portion of my career practicing in my 
hometown of Sydney, Nebraska, which is far out west, closer to 
Wyoming, along with my wife, Lisa, who is also a family 
physician. We moved there, in part, to replace my family 
doctor, Doc O'Halloran, who, when I was in medical school, was 
always telling my mom when is Bob going to come back so I can 
retire?
    The next phase of my career, we went to teaching at a 
family medicine residency program so we could teach others how 
to become rural family physicians. During that time is when the 
electronic medical records were coming out and we installed one 
and joined a research network across the country where we 
started studying what was working in terms of systematic 
quality in clinics. The problem was it was really hard to 
sustain with the fee-for-service payment system. It took extra 
work and there was no reward for it through fee-for-service.
    So, I was happy in 2012 when the Medicare Shared Saving 
Program came out with an advanced payment ACO contract. So, I 
switched careers again and I recruited nine clinics to join 
that advanced payment ACO, then we took what I learned from our 
research networks and employed one of those nine clinics across 
Nebraska. Within the first two years, we were one of the Top 10 
highest quality scoring ACOs in the country as a group of 
mostly rural family physicians, but we ran into sustainability 
challenges when the advance payment money ran out, so we 
started a second ACO in 2016. We started three clinics in 
Lincoln and then grew that to 23 clinics in four communities.
    In 2022, we were one of only 11 out of 482 ACOs across the 
country that had greater than 90 percentile reductions in 
costs, while also greater than 90 percentile quality numbers. 
I'd like to point out one of the figures I include in my 
testimony, and it's our savings over time since our first 
contract. We had net savings for the first three years, but in 
those three years we didn't meet the shared savings threshold, 
so we received no money from Medicare Shared Savings Program. 
We finally hit it in the fourth year, in 2020, but the 
reconciliation takes another nine months. So, we actually 
didn't get our first shared savings payment until the latter 
half of 2021, a full five years after we started.
    But we were able to sustain that for two reasons. Number 
one, Nebraska was one of the Comprehensive Primary Care (CPC) 
Plus intervention states. That meant for our Medicare patients 
we got a risk adjustment per member per month payment that was 
used to hire our care coordinators and fund our operations 
during that time. In addition, it was a multi-payer option, so 
Blue Cross/Blue Shield Nebraska also provided a per member per 
month similar quality metrics, which is why in both the funding 
and the quality goes across almost half of our payer mix, and 
it was that investment that got us to the point now where we're 
10 percent under budget in Medicare and over 20 percent under 
budget on our Blue Cross contracts.
    Shared Savings are possible in year one and two, but 
sometimes those are false savings due to risk coding or 
sometimes even denied and delayed care, which can come back to 
bite you later on. I'm proud to say that One Health Nebraska 
ACO did it the right way. We achieved true savings by focusing 
on better chronic disease management, post discharge visits, 
and increasing our annual wellness visit rates to 85 percent.
    The combination of fee-for-service, per member per month 
payments and shared savings actually gets us on those two 
contracts to a 12 to 13 percent primary care spend rate, the 
kind of spending that Chris Koller mentions is needed to 
sustain this kind of high-quality care. I think future ACO 
contracts should measure primary spend rates as one of the core 
metrics to make sure the money is actually going to the right 
place on these contracts.
    And just like our experience before, I think to recruit 
more primary care physicians in the ACO contracts we need a 
model under MSSP that includes both the upfront funding to get 
you off the ground, but the population-based payments to 
sustain your operations over time. Thank you for the time to 
offer this testimony.
    Chairman Whitehouse. Thank you very much, Dr. Rauner. I've 
got to say you've got my competitive juices flowing talking 
about the success of your ACOs because Rhode Island has a 
couple of superstar ones also. Ms. Grabert, please proceed.

  STATEMENT OF LISA M. GRABERT, VISITING RESEARCH PROFESSOR, 
          MARQUETTE UNIVERSITY COLLEGE OF NURSING \6\
---------------------------------------------------------------------------

    \6\ Prepared statement of Ms. Grabert appears in the appendix on 
page 68.
---------------------------------------------------------------------------
    Ms. Grabert. Chairman Whitehouse, Ranking Member Grassley, 
and distinguished members of the Committee, I am Lisa Grabert, 
a Visiting Research Professor in the College of Nursing at 
Marquette University located in the good land of Milwaukee, 
Wisconsin. I'm a former congressional staffer for the U.S. 
House of Representatives Committee on Ways and Means and I'm 
honored to testify before the Committee today on the Medicare 
Program, a policy area where I've worked for over 20 years.
    I applaud the Committee for addressing the important topic 
of primary care. My written testimony includes several examples 
from fee-for-service Medicare that were well intentioned, but 
unfortunately, did not turn out the way many of us had hoped. 
These programs include Accountable Care Organizations or ACOs, 
the Center for Medicare and Medicaid Innovation or the CMII, 
and the Independent Provider Advisory Board or IPAB. But I'm a 
glass half full kind of person, so I will concentrate my oral 
testimony on a virtual slam dunk, the expansion of telehealth 
services.
    To understand why telehealth was successful, we must first 
spend time on the economic structure of Medicare Advantage or 
the MA Program. The Medicare Program relies on a benchmark 
system for MA plans. The benchmark is set on an annual basis 
and represents a range of 95 to 115 percent of expected costs 
and fee-for-service Medicare. A different benchmark is set for 
each county in the U.S. based on a statutory formula. Each plan 
submits an annual bid. The bid is reflexive of the services the 
MA Plan intends to deliver to Medicare beneficiaries and these 
services must include, at a minimum, what is covered by fee-
for-services. These minimum services are referred to as the 
basic benefit.
    If an MA plan submits a bid that is lower than the 
benchmark, the plan receives a rebate. MA plans are required to 
reinvest a portion of the rebate and plans typically reinvest 
in premium reductions, reduced cost sharing, and supplemental 
benefits. These supplemental benefits are key to understanding 
why telehealth is such an important example to guide future 
Medicare reform. The bipartisan Budget Act of 2018 included a 
policy that allows MA plans to offer telehealth as a basic 
benefit rather than as a supplemental benefit.
    This bipartisan policy achieved two key things. The first 
achievement was less taxpayer spending, which manifests as 
lower annual bids. The Congressional Budget Office, or CBO, 
estimated the MA telehealth policy saves taxpayers $80 million 
and the Centers for Medicare and Medicaid Services, or CMS, 
estimated this policy saved beneficiaries $557 million.
    The second achievement of the policy was freeing up capital 
within the category of supplement benefits. This economic 
incentive allows plans to offer new benefits, such as enhanced 
primary care. In a peer-reviewed study in press, my coauthors, 
Dr. Grace McCormick, Dr. Erin Trish of the USC Brooking Schafer 
Center, and Dr. Catherine Wagner of the Marquette College of 
Business and I concluded that this switch from the supplemental 
to the basic package is the first of its kind in the Medicare 
statute.
    This seemingly small, bipartisan policy change is lightning 
in a bottle. A similar telehealth policy was implemented on the 
fee-for-service side. Like the ACO, CMMI, and IPAP examples in 
the case of fee-for-service telehealth it spends roughly five 
billion dollars a year. The detailed research I've done on this 
topic has convinced me that policymakers should solely focus 
their limited time and resources in Medicare on MA changes, not 
fee-for-service.
    If my telehealth example is not convincing enough, just 
listen to the footsteps of Medicare beneficiaries. They are 
quickly moving towards MA. Just last year the proverbial scale 
tipped, and the Medicare Program now consists of more MA 
beneficiaries than fee-for-service beneficiaries. $13 million 
new beneficiaries will be added to Medicare over the next 10 
years. At a pace of nearly 10,000 Baby Boomers a day, MA is 
projected to grow 42 percent while for fee-for-service is 
projected to shrink.
    The answer to enhancing primary care lies squarely within 
the Medicare Advantage benefit. Any attempts to force change 
within fee-for-service are misaligned with the future momentum 
of the program. I thank you for the opportunity to offer my 
perspective and I look forward to your questions.
    Chairman Whitehouse. Thank you very much, and last, but not 
least, Dr. Taylor. Delighted that you're here.

STATEMENT OF DR. CHRISTINA TAYLOR, CHIEF MEDICAL OFFICER, VALUE 
  BASED CARE, CLOVER HEALTH AND PRESIDENT-ELECT, IOWA MEDICAL 
                          SOCIETY \7\
---------------------------------------------------------------------------

    \7\ Prepared statement of Dr. Taylor appears in the appendix on 
page 78.
---------------------------------------------------------------------------
    Dr. Taylor. I'm Dr. Christy Taylor and I'm an internal 
medicine physician from Iowa. I practiced for nearly 20 years. 
I started out in a physician-owned multispecialty clinic, the 
Iowa Clinic, and I was their first Chief Quality Officer and 
then I was the Chief Medical Officer, McFarland Clinic where we 
served both rural and urban patients. And throughout this time, 
I've also served as the medical director of a multi-state ACO. 
So, in my career, I've been deeply involved in transitioning 
our organizations from fee-for-service to value-based care.
    I've been blessed to work at organizations that 
historically delivered exceptional care, but even we had to 
change our focus from that of volume to patient access and 
coordinating care to deliver the right care to the right 
patients at the right time. And now, I'm the Chief Medical 
Officer of the Value Division of Clover Health, an organization 
which brings support and actionable patient information to 
primary care providers.
    So, in all of these settings, a fundamental aspect we 
focused on is the critical role of primary care providers in 
coordinating care. Patients who see primary care physicians 
absolutely have lower overall total cost of care. In my clinic, 
we focused on both patient access and engagement. We actually 
improved quality of care and had significantly lower costs and 
we were successful in our value-based contracts. We received 
shared savings every single year.
    The most meaningful results, however, were what we saw in 
our patient outcomes, both in prevention and in disease 
management. And most of this work was done by primary care 
physicians and then we collaborated with other groups around 
the country to share best practices and challenge ourselves 
further. Our preventive care increased, things such as vaccines 
and cancer screenings, and with actionable data and additional 
personnel we manage chronic disease patients better, such as 
those with hypertension and diabetes to help them get and stay 
in better control. This resulted in healthier patients and 
fewer Emergency Room (ER) and hospital admissions.
    But along the way to value several investments were 
necessary. We added additional personnel, such as care 
managers, plus the technological and analytical resources to 
make the data actionable. And these resources are outside the 
scope of what we would call traditional care or regular 
practice. For example, we put people and processes in place so 
that we could get real time hospital discharge information so 
that we could reach out to patients during these vulnerable 
times in their healthcare and it required both timely data and 
care managers in place to actually result in true care 
coordination so that we could have good follow up, reduced 
medical error, and readmissions prevented.
    So, across multiple organizations, I've seen the positive 
impacts that primary care providers who actually focus on value 
have made. With the right resources we have safer, better care 
at lower costs. But despite these successes, significant 
challenges remain; namely, those of investment, administrative 
burden, and lack of predictability. Transforming care does 
require significant investment, which small or rural practices 
either can't afford or accomplish at their scale. There's just 
a base cost to personnel and then the patient and analytic 
tools that you need are unaffordable for the small practices, 
but without these important solutions we don't have the 
critical information that we need to better care for patients 
or avoid duplicate services.
    This is frankly what drew me to my work at Clover so that 
we could work with the primary care practices and provide them 
these additional resources so they could serve their patients.
    In the last several years, providers have experienced a 
drastic uptick in administrative burden beyond the good medical 
recordkeeping that you'd normally expect. There's additional 
recording of information that's not impactful to patient care 
and this burden is definitely heavier on the primary care 
physician. We're taking precious time away from patient care 
duties. Intentionally or not, we are adding strain to a 
shrinking primary care workforce. We must decrease the 
administrative burdens that are not directly impacting care.
    And finally, we need more predictability. Frequent changes 
in federal requirements and unstable payment arrangements are 
challenging for all providers, more so the smaller ones. In 
order for practices to be able to move to value and provide 
coordination beyond traditional care, we need predictable and 
sustainable reimbursement models.
    In summary, primary care providers are the frontline of 
coordinating care. Patients who see primary care physicians are 
healthy and at a lower cost. We need to assist the primary care 
providers to enter and remain in value-based programs. Thank 
you very much.
    Chairman Whitehouse. Thank you very much. After the hearing 
is over, Dr. Taylor, I would invite you to sit down and make me 
a punch list of the administrative burdens that you think are 
least helpful and most aggravating and send that to Ranking 
Member Grassley and myself for us to have in hand as we 
proceed. And hearing your testimony and Dr. Rauner's testimony 
makes me want to take you both out for a beer with Dr. Al 
Puerini, who was the founding Chief Marketing Officer (CMO) of 
Integra ACO Rhode Island and Dr. Al Kurose who was the founding 
CMO of Coastal Medical and just let you tell me what we need to 
do to continue to make those improvements. I really appreciate, 
Dr. Rauner, particularly your success with the ACOs because I 
think Coastal and Integra are right up there with you in that 
uppermost performance corner.
    Some ACOs were less successful than others and sometimes 
the ACO program gets, I think, under appreciated because there 
were unsuccessful programs. There were characteristics, I 
think, to the very successful program. Dr. Navathe suggested 
that where there was hybrid payment overlap with the ACO, that 
boosted success. You said that where it's a primary care 
physician ACO, uncomplicated existing practice, they were more 
successful. That is my experience as well and I'd invite you to 
think about and send in after the hearing, if you like, or if 
you have a quick answer now, as you look at the whole ACO 
experiment, what are the things we should take out of it where 
we got the best wins? What are the things we really need to 
replicate?
    And I'll add that I had long wars with the Obama 
Administration CMS folks about precisely the concerns that you 
had. I used to tell them that the way you're dealing with 
shared savings you are starving your lead dogs. You don't want 
to do that. You want to feed your lead dogs. You want to 
encourage that kind of behavior and thankfully they did a lot 
of listening and we were able to make a lot of improvements off 
where they initially were. So, I take a very keen interest in 
ACO wellbeing. Any thoughts on that?
    Dr. Rauner. Yes, a couple of things that shake out and the 
studies have shown all the way back to 2016 that the ACOs that 
were achieving the most success were the primary care led ACOs, 
so this is not new information. That is probably the most 
fundamental thing and I think a couple things. One is, if a 
primary care physician led ACO, those primary care doctors are 
all involved, and they know what they're doing.
    I've actually talked to colleagues who were employed who 
don't even know they're in an ACO. So, if you don't know you're 
in an ACO, you're probably not going to do very well. A key 
portion of what you're doing, honestly, is behavior change and 
that takes relationship with the primary care doctor to get 
your blood pressure and diabetes under control. Without that 
relationship engagement of primary care physicians, it's really 
hard to make happy, successful. A second factor is that you're 
not necessarily locked into anything.
    So, unfortunately, if you're in a narrow network, they're 
locked into that narrow network. We're not. So, I can look in 
Lincoln and actually do know that, for example, sometimes the 
high-value cardiology in this system while the high-value 
orthopedist is in another system and someone who's in radiology 
is in an independent system that's wholly different from the 
others. Because we're not locked in, we can send them to any of 
those places and always do the best.
    One of our first principles in our ACO, when we started it, 
was we're going to send patients to the same place we're going 
to send our mom or our kids and we're not going to sign a 
contract that doesn't let us do that. I'm going to send my mom 
and our kids to the place where I know is the highest value 
stuff. And so, I think that's one of the other major things.
    The third thing is because we're only a primary care led 
ACO, when the money comes in it stays in the ACO. It gets 
reinvested in the business. We just keep hiring more and more 
care coordinators. If I had $200,000, I don't want to buy more 
technology. I want to hire three more social workers or a 
couple diabetes educators. Having that team wrapped around you 
is the core thing. And the other things I see in some employ 
models the primary care doctors are just plain understaffed. 
The care coordinators are centralized, and you don't have the 
relationship when it's a central phonebank person. But once the 
nurse that you know at the clinic when Lupe calls, you're going 
to listen to Lupe, and so I think those are kind of the three 
main things that made the difference for us.
    Chairman Whitehouse. Mr. Koller, when you were leading the 
transformation in Rhode Island towards primary care, you were 
dealing with a lot of statistics and tracking a lot of 
statistics and seeing how that rolled out into insurance costs 
and all of that. Did you also have occasion to take on or 
absorb any of the more sort of experiential gains that Dr. 
Rauner is talking about, about that improved patient 
relationship between the primary care doctor and the patient 
once they're in a mode like that where they're getting these 
various supports?
    And it's been my experience that people absolutely loved it 
when their patients have all these new opportunities that the 
ACO format and the primary care relationship provided, some of 
which just doesn't get quantified because it's hard to 
quantify, but Rhode Island is a small state and I expect you 
heard a lot of feedback. What was it like?
    Mr. Koller. Thank you, Senator Whitehouse. I think we did 
balance this notion of evidence in relationships that you're 
talking about. So, the evidence is what we talked about here 
around the value of primary care, but at the core of what Dr. 
Rauner and Dr. Taylor is describing is a relationship that 
people have with their clinician and that relationship, that 
trust that emerges is so important for the patient themselves. 
And so, that's really what motivated us when we were trying to 
do this work in Rhode Island. We had the benefit of a strong 
community health center system with a lot of folks with that 
kind of trust.
    We had leading ACOs, as you talked about. Our primary care 
efforts were really an effort to kickstart those in the way 
that Dr. Rauner is talking about, to give them upstart funding 
so they could build those sorts of relationships and it pays 
off.
    I also want to note it's especially important when we're 
concerned about disparities in healthcare because often the 
source of those disparities is a lack of a trusting 
relationship. What brings me to this discussion is we're losing 
those relationships. Almost a third of the folks in the country 
say they don't have it right now and if we don't rebuild that 
trusting relationship, Medicare is in deep trouble from a 
financial and a security standpoint.
    Chairman Whitehouse. Senator Grassley.
    Senator Grassley. Dr. Taylor, we heard about how you've 
achieved results in primary care clinics there. You mentioned 
achieving increase in vaccines given, cancer screenings that 
are completed and improved management of high blood pressure 
patients, Emergency Room patients count is down, so explain to 
us how we could scale your effective model, so prevention and 
care coordination happens across the country? And specifically, 
are physicians empowered to do this now or are there federal 
barriers?
    Dr. Taylor. Thank you, Senator Grassley for the question 
and appreciate the opportunity to answer that. So, there's 
really two parts to your question. And one is regarding how we 
scale these efforts and I think there is always difficulty in 
scaling something you do locally because healthcare and how we 
deliver it is local, so you have to have different solutions in 
different places for what makes sense for the patients and 
their communities. So, you have to have the flexibility and 
agility to put forth a solution in one community versus 
another.
    In a particular area in urban Iowa, we don't have a lot of 
transportation issues, but you get to rural Iowa or rural 
Midwest, or other parts of the country and you have significant 
issues getting people to their doctor's appointments. So, 
simply stating that transportation is something everyone needs 
to work on, as an example, would not be something that you 
would say everyone needs to do the same thing. The point is you 
have to have flexibility in what your efforts are.
    We really need a handful of things, universally, across our 
country for the physicians locally to be able to put forth 
their initiatives. And that is, we need data and then you need 
your own tool, regardless of what that is, whether it's 
telehealth or care managers or technological tools, that you 
need data, tools, and then you need time, which means you need 
personnel. You need doctors and nurses to be able to respond 
and do the outreach in these extra things that are important 
for coordinating care beyond what's done in just the office 
visits. And so, these extra things that we're having doctors do 
that take up more time for paperwork and phone calls that are 
not patient care, we need to relieve them of those burdens so 
they can spend the time coordinating the care instead.
    Senator Grassley. Are there any federal red tape problems 
to do what you just said?
    Dr. Taylor. Well, there are several, one of which is that 
we don't have a reimbursement model currently in the fee-for-
service side, which does appropriately reimburse physicians to 
do these extra things beyond office visit care. At least in 
Medicare Advantage and sometimes in the ACOs, we have more 
flexibility there. There's supplemental benefits. There's 
incentives that you can provide to primary care offices, and 
so, when I've worked with various Medicare Advantage companies 
over the years, they incentivize primary care offices to make 
sure that your patients were seen to work on preventive 
measures, to make sure the quality of care was ensured.
    And so, making sure that we have a predictable, but yet, 
able to reimburse us for the extra things beyond office care is 
one of those. And then there are multiple, which we'll be happy 
to work with you afterward, and provide a detailed list of the 
small details which just take up an enormous amount of 
physician and nursing time.
    Senator Grassley. Thank you. And then I want to ask Ms. 
Grabert, your testimony spoke about 2018 expansion to 
telehealth in Medicare Advantage, saved Medicare money and laid 
the groundwork for expanding telehealth utilization during the 
pandemic. In fee-for-service Medicare telehealth expansion 
costs money. Is Medicare Advantage an effective model for 
expanding primary care benefits for seniors while also lowering 
Medicare spending?
    Ms. Grabert. Thank you for the question, Senator Grassley. 
Yes, I do think that Medicare Advantage is the program to look 
at for expanding primary care. One of the things I mentioned in 
my written testimony is that Medicare uses what's called value-
based insurance design or VBID, for Medicare Advantage plans. 
And in those experiments, which are similar to ACOs on the fee-
for-service side, they've identified a number of services that 
you may want to think about potentially treating in the same 
way you looked at telehealth in the 2018 bill.
    Some of those examples under VBID for Medicare Advantage 
are cost sharing reductions for medications, non-emergency 
transport, which has been mentioned a few times already, 
healthy food and grocery options, annual wellness and routine 
physicals, smartphones, broadband, and Internet, roadside 
assistance, and minor home repairs. These are services that 
Medicare beneficiaries are getting under MA through the VBID 
model, but those are small in nature, and they should be 
considered for a nationwide expansion.
    Senator Grassley. Thank you.
    Chairman Whitehouse. Senator Johnson.

                  STATEMENT OF SENATOR JOHNSON

    Senator Johnson. Thank you, Mr. Chairman. You know when I 
was growing up, we had primary care physicians. We called them 
family doctors and those doctors would doctor to the parents 
and then the children as the children became adults. We don't 
have that anymore and I guess what drives me nuts about these 
hearings is we're just now looking at the root cause. We're not 
going back in history and examining how did we go from family 
doctors to a hearing right now where we're saying what we need 
is family doctors. And I guess I would argue what changed is 
the third-party payer system.
    We have a completely broken healthcare financing system 
which incentivizes specialties, that disincentivizes primary 
care physicians, family doctors and until we recognize that 
reality, we're not going to fix the problem. It wasn't that 
many decades ago that the patients paid about 90 cents on the 
dollar. Now, they pay 10 cents, so we've taken consumerism out 
of this. We have physicians--80 percent used to be independent. 
Now, 80 percent are part of organizations, and they are told 
how to practice medicine.
    They follow protocols. They follow guidelines. And I think 
we saw during COVID if they have a different perspective, 
they're vilified, and their careers are destroyed at times. So, 
I think the solution here is we have to put physicians again at 
the top of the treatment pyramid as opposed to being crushed at 
the bottom by all the bureaucracy.
    We've talked about chronic disease. I'll ask you, Dr. 
Rauner, what research is being done to determine what is the 
root cause of the chronic disease? Again, I've heard that we've 
gone from something like 6 percent of the population to chronic 
disease to the Rand Study saying 60. I don't know what the 
start point is, but I think you'd probably agree. I think most 
people agree we've really got a real problem with chronic 
disease. What are we doing to figure out what caused it as 
opposed to how do we treat it? We need to figure out how to 
treat it, but the best thing is how to prevent it.
    Dr. Rauner. Well, a couple things. We actually still do 
have family doctors and then in Lincoln, Nebraska we're back to 
almost 75, 80 percent are independent because of these 
contracts, so we're actually reversing the trend in Lincoln. 
And my niece, Brenna, is finishing up her family medicine 
residency in Milwaukee, Wisconsin. I hear, unfortunately, she 
might be staying in Wisconsin, so there's still some in 
Wisconsin.
    Senator Johnson. God's country.
    Dr. Rauner. And then, we actually know exactly what's 
causing the increased chronic disease is lack of exercise, poor 
nutrition, and obesity. That's what's driving it. One of my 
biggest fears, honestly, is the burden of the disease is 
growing while our primary care workforce is shrinking, which is 
a recipe for disaster in the next 10 years, so we need to 
figure out----
    Senator Johnson. Let me stop right there, okay, obesity. 
You say lack of exercise. What about what we're putting into 
our foods?
    Dr. Rauner. Oh, yes.
    Senator Johnson. I'm reading more and more pretty scary 
information, for example, on glyphosate. It used to be used as 
a pre-emergent weed killer. Now, we find out it's a desiccant 
and now we're spraying it on food and it's in our food. I mean, 
are we really seriously researching some of these issues?
    Dr. Rauner. Yes. And it's actually something we're working 
on. And so, you drink basically coffee in the morning and water 
during the day, and maybe a beer in the evening, but it's all 
the stuff in the beverages we drink, the sugar, the sweeteners, 
all the additives. So, it's partly the calories. The calories 
we drink are actually the biggest problem in obesity, but it's 
the processed food. You should eat the food that, frankly, your 
great grandmother recognized as food. A lot of what we buy off 
the counter your great grandmother would not recognize it as 
food. She'd say what the heck is that. And then, on top of 
that, we just don't have people walking as much. I mean two of 
my daughters live overseas and when we go visit them it's hard 
not to walk 12 or 15,000 steps a day. In Lincoln, Nebraska, you 
can get by with 4,000 and so those are the root causes.
    Senator Johnson. Doctor, real quick, do you know what 
percentage of drugs being prescribed are being prescribed off 
label? It's a significant percentage. Correct?
    Dr. Taylor. A significant percentage, yes. I can't give you 
a precise number.
    Senator Johnson. I held an event on Monday and one of the 
doctors who testified at that event just talked about the 
molecules, all these generic drugs that there were studies, 
observational studies proved to be effective in treating COVID. 
None of those were recommended. Actually, a lot of them were 
sabotaged by the federal health officials all in favor of the 
patentable drugs that are extremely expensive and the point 
being is there's just no avenue for us to explore and do 
research on generic drugs for different conditions than what 
they're originally designed for. Would you think that's a 
problem?
    Dr. Taylor. Well, I think, as a physician, you're brought 
back to our first responsibility is to do no harm and we all 
live by that. And frankly, I don't prescribe a medicine if I 
don't feel that I have to prescribe a medicine. The best 
medicine is no medicine if you don't need it. And then, 
frankly, we use lifestyle interventions and try to find things 
beyond or before prescribing medicines. And then, you have to 
look at the side effect profile in the individual patient, so 
truly, you need to match the disease to the cure. And I don't 
know that I can give you an answer in terms of how much work is 
being done on generic----
    Senator Johnson. I would like to think that most doctors 
take your approach to like not use the medicines, but I don't 
think that's really the reality. I think we're pushing 
pharmaceutical drugs and products to treat these chronic 
diseases left and right and really not paying attention to 
adverse events the way we should, but that's my own personal 
opinion, but thank you, Mr. Chairman.
    Chairman Whitehouse. Let me drop in one question as Senator 
Van Hollen gets settled. And if I may ask, Dr. Navathe, what 
started the Hawaii hybrid? What's its origin story and who had 
to approve it?
    Dr. Navathe. Thank you, Senator, for the question. So, 
there was an enterprising CEO at the Blue Cross/Blue Shield of 
Hawaii named Mike Gold, who, as he was planning his retirement, 
who said I want to do something that will really change the 
health and the course of health in Hawaii. Just like the rest 
of the country, there was increasing obesity, there was 
increasing diabetes because of it and so he convened a set of 
national experts and local folks, including physicians, 
including current Governor Josh Green was there as well. And we 
debated, basically, what are the best ways to really catalyze 
health system change.
    And the leading candidate was let's really invest in 
primary care and let's change the system toward one that 
provided more stability and robust infrastructure. And luckily, 
Blue Cross/Blue Shield Hawaii actually has something like 60 
percent market share, so when they said, hey, we're going to 
shift over it really did catalyze some system transformation 
and that's what kind of set the foundation.
    Chairman Whitehouse. My Ranking Member has to leave and has 
asked to ask one more question before he goes. Senator Van 
Hollen has very courteously agreed to that, so let me turn to 
Senator Grassley and then Senator Van Hollen.
    Senator Grassley. Thank you for your deference. Just one 
question to Dr. Taylor, and it's not a long one. But you talked 
about supporting small and rural primary care practices as very 
important. So, tell me how can partnerships between Medicare 
Advantage plans and primary care practices improve access to 
primary care?
    Dr. Taylor. Thank you, Senator, for that question regarding 
rural physicians, which are absolutely crucial for providing 
patient care across this country. There's a couple of things 
that Medicare Advantage companies and, frankly, all pairs. In 
this case, you asked about Medicare Advantage companies. 
There's a few things that you can do to help provide the 
relationship or encourage the relationship between patients and 
primary care. And that's, first of all, having an open 
relationship where the pairs are able to actually talk with the 
doctor practices, or at least their administration, to let them 
know here's who your patients are. Sometimes it's just as 
simple as that, is letting the physicians know here is who your 
patients are and they provide information to the patients to 
help encourage a visit with the primary care doctor.
    So, first and foremost, it's literally trying to encourage 
the patient to have a personal relationship with their 
physician. In the Medicare Advantage sites, specifically, we 
also have incentives for primary care physicians. Please get 
your patients in for a primary care visit this year. Those 
incentives work. They allow you to have the ability to hire 
additional staff to do outreach to your patients and bring 
these people in for their necessary preventive treatments.
    Chairman Whitehouse. Thank you, Ranking Member Grassley. 
Senator Van Hollen.

                STATEMENT OF SENATOR VAN HOLLEN

    Senator Van Hollen. Thank you, Mr. Chairman. Thank all of 
you for your testimony today. I appreciate the good comments 
about Hawaii's innovative systems for addressing some of these 
issues. As many of you know, Maryland has also developed some 
innovative models to reduce health spending while improving the 
quality of care, including the State's all payer model and what 
we have now, which is the total cost of care model, a key 
component of which is the Maryland Primary Care Program.
    In fact, according to a recent Journal of the American 
Medical Association (JAMA) study, the Maryland Primary Care 
Program had outcomes when it came to treating Medicare patients 
and COVID that not only lowered the COVID-19 caseload, reduced 
hospitalization death rates, but also found that the office 
visits did not decrease because of the prospective payment 
model.
    So, Mr. Koller, I know, at least in your written testimony, 
you mentioned the Maryland model. Can you elaborate on how more 
efficient health spending and care delivery results from models 
like Maryland's, the aim, of course, as I said, to reduce 
hospital spending and incentivizing high quality primary care.
    Mr. Koller. Thank you, Senator Van Hollen, and you're 
absolutely right. Maryland has been an innovator in this area. 
We're very familiar with the Maryland work. We salute it. We've 
actually published some of the findings there. What's important 
in the Maryland work, is as you note, the idea of putting the 
entire system on a budget, a budget which actually benefits 
health systems and hospitals because it gives them an assured 
revenue, much as what we're talking about today for primary 
care physicians. And that, as you note, the Maryland Primary 
Care Program. It has been a partnership between CMS.
    And to Dr. Navathe's comments, a large Blue Cross 
organization, so you have dominant payers and the results have 
been really significant, specifically in the JAMA study that 
you cited, we also published it, a 20 percent lower mortality 
rate during COVID for practices that were enrolled in that 
Primary Care Program. It is a sterling example of what a 
combination of hybrid payments, care transformation, and 
persistence can produce that has saved lives in Maryland and 
it's what we're trying to replicate for the entire Medicaid 
beneficiaries.
    Senator Van Hollen. Well, thank you for those comments 
because I do believe that it, and maybe Hawaii. I'm less 
familiar with the Hawaii model, but those kinds of models can 
be important.
    Dr. Navathe, could you just take a moment to pick up on 
what Mr. Koller was discussing and how hybrid primary care 
payment models work to mitigate against the challenges that we 
find in a solo fee-for-service model and how the hybrid models 
can better support a whole patient and team-based care?
    Dr. Navathe. Thank you, Senator, for the question. So, I 
think as the Maryland model very nicely exhibits, the hybrid 
payments with a fixed perspective payment that's going to the 
practices it allows them to invest in infrastructure, allows 
them to staff in a way that reflects what is most efficient to 
deliver care and meet the patients where they are. So, for 
example, telehealth for a patient who wants to do a telehealth 
visit or an in-person visit for somebody who wants to do that, 
it allows them to use technology most efficiently.
    But one thing I'd also like to highlight right alongside 
that is it reduces administrative burden, right? Instead of 
getting these tickie-tack codes where I have to code this and 
code that where actually coding is more costly than the payment 
you receive. It unshackles them from that system. It allows 
them to invest in ways, as you highlighted, that can really 
improve preventive care.
    Senator Van Hollen. Got it. Thank you very much. Thank you 
all for your testimony. Thank you, Mr. Chairman.
    Chairman Whitehouse. Let me follow up on that, if I may, 
because a number of you have mentioned the administrative 
burdens. Folks like Dr. Rauner, who started an ACO, had to live 
in an even worse environment where they had to run the fee-for-
service system while they built the ACO system. So, the 
administrative burden actually went up during that process. 
You're suggesting that a proper hybrid system drops a lot of 
that reporting and coding out. That has been the experience in 
the Hawaii hybrid.
    Dr. Navathe. Yes. Thank you, Senator, for that question. 
Yes, that's absolutely right. So, because the Blue Cross/Blue 
Shield of Hawaii maintains so much market share, it's able to 
push past that tipping point where practices can actually shift 
over their operations.
    Chairman Whitehouse. And just count on that one payment 
model, basically.
    Dr. Navathe. Correct. And so, they don't have to worry so 
much about coding the Transitional Care Management (TCM) code 
or Chronic Care Management (CCM) code or whatever that code is. 
They can really focus on caring for patients because the 
revenue is coming in the door.
    Chairman Whitehouse. I'm told that we have another member 
coming, so I get to indulge in a few more questions. So, this 
may not be quite the right way to think about it, but the way I 
think about it is that if you were building a house you would 
hire your general contractor and your general contractor would 
deal with the electrician, the plumber, the tile person, the 
carpenters, and all of that. And if you had a problem, you'd go 
to the general contractor and say could you please fix it.
    That is a pretty basic and efficient and effective model. 
And it strikes me that trying to move primary care physicians 
into the general contractor model so that you go through the 
primary care practice to get to the specialist would provide a 
much better handle on the over deployment of specialists care. 
And also, as you said, Dr. Rauner, lets you have a little bit 
of a better-quality judgment about where the best places are to 
send patients to.
    This gets particularly interesting with ACOs because I can 
remember Dr. Kurose and Dr. Puerini saying we actually bill 
about 14 percent, I think was the number, of our patient cost 
of care. That's the part that we directly control. The other 86 
percent is specialists, it's hospitals, it's stuff that we 
don't control. So, when we take on these risks, we're way 
leveraged with stuff that is beyond our control. So, 
presumably, not only could better general contractor status for 
primary care folks reduce the excess utilization of specialist 
services, but it could also deleverage the risk for ACOs. So, I 
don't know if that makes sense to you all as a model, but let 
me ask Dr. Rauner first and then Dr. Navathe, and Mr. Koller 
what you think about that, and I'll turn to Dr. Taylor if 
there's time.
    Dr. Rauner. I think a lot of primary care doctors would 
agree with that model, that they are basically kind of the 
general contractor when done right. Now, some people just don't 
have one and they do get random people from everywhere. I think 
that's one of the problems is how do you know that it's the 
right orthopedic surgeon or the right oncologist and that's why 
we started with our principles. I'll send them to the same 
place I would send my mom or my kids. So, the orthopedic 
surgeon I'd encourage, I know the group he's with, and 
literally, I got operated on there and so did my mom. But one 
thing the ACO gives----
    Chairman Whitehouse. But how do you reward your patients 
for going to the provider of your recommendation and should the 
system, in some way, encourage primary care selected specialist 
rather than people who just go to their cousin's friend, the 
specialist, and start their care there?
    Dr. Rauner. Well, I think most of the time you just don't 
need that, honestly. So, like there was a time where people 
liked the, gatekeeper model, which we didn't really like at all 
because I don't like being in that position to tell you, no, 
you can't see that person. But most people, if they've been 
seeing you for years, they trust your judgment and really 
that's how you say it. It's like this is where I'd send my mom. 
They're like, okay, I'm good with that.
    I don't have to give them a lot of data. Although, in the 
past, I'd say most of us physicians had no data to go by. I 
think with these models now we actually do have data. I've got 
a spreadsheet on my laptop where I literally have the 
orthopedic surgeons in town with observed to expected outcomes. 
It tends to confirm what I already knew, thankfully. But 
there's a big difference, unfortunately. I wish I could say 
every physician in the United States was equally good, but I 
can't say that. And so, we (A) have the data to know and (B) 
like Dr. Taylor said, every community's healthcare is local. 
And if you don't know the specifics about this community--
Lincoln and Omaha are only 60 miles away, but they're totally 
different medical communities. And knowing that, having that 
local knowledge is really essential.
    Chairman Whitehouse. Let me hold off on that with Senator 
Padilla here and recognize Senator Padilla for his questioning. 
We'll probably wrap up after that, so while I'm thinking of it, 
if Dr. Navathe or Mr. Koller would like to respond to that and 
take my question as a question for the record and put any 
thoughts in writing about how to improve on the primary care 
general contractor model that would be helpful to me, anyway. 
Senator Padilla.

                  STATEMENT OF SENATOR PADILLA

    Senator Padilla. Thank you, Mr. Chairman and thank you to 
the witnesses for our participation today.
    During and following the COVID pandemic, we witnessed 
dramatic increases in emergency department visits for mental 
health emergencies of all types, including suspected suicide 
attempts. This uptick has been particularly pronounced among 
children. I'm sure you've all read the reporting that I have. 
To properly address the crisis, mental health professionals, 
including child and adolescent psychiatrists need to meet 
children where they are. The thing is as professionals, we all 
can agree to that. This includes in primary care settings, in 
pediatricians' offices, many times in schools, but I understand 
that providers have faced difficulties in aligning mental 
health services with existing billing codes.
    However, I also understand that there's many innovative 
models out there, including the collaborative care model that 
offer primary care providers a way to both bill and be 
reimbursed for the integration of behavioral health managers 
and psychiatrists into their practice. The question is for Mr. 
Koller. How can integrative behavioral care models such as 
collaborative care and child psychiatry access programs help 
increase access to mental and behavioral health providers, 
particularly for underserved populations?
    Mr. Koller. Thank you very much, Senator. I would second 
your remarks about, first, the behavioral health crisis and 
then the ability of primary care to contribute to that. And 
there are numerous demonstrations that properly trained, and 
properly resourced primary care clinicians can both provide 
frontline behavioral healthcare and then the collaborative care 
model that you're talking about.
    A number of the things that we've talked about today, the 
idea of a hybrid payment or paying on a per-patient fee allows 
primary care practices to build the capacity to hire social 
workers to develop other staff to do the kind of screening 
necessary to implement behavioral health model. And I guess the 
other piece I would add is that we have numerous examples 
within the community health centers which have not been 
shackled by Medicare fee schedule where they've been able to 
build exactly that capacity to meet the needs of kids that 
you've been so adamant about. Thank you.
    Senator Padilla. And just a couple of follow ups for you, 
do you see any benefit these models present in addressing the 
workforce shortages, both in the physical and the mental areas?
    Mr. Koller. Yes, we're extremely concerned about workforce 
shortage. We, being the Milbank Memorial Fund. We think, to 
Senator Whitehouse's comments, we're worried that there aren't 
going to be enough general contractors. We support the model. 
We just don't think we're training enough general contractors 
and the root of that is the Medicare fee schedule. We have to 
create incentives for physicians, clinicians, advanced 
practitioners who are training to choose primary care so that 
we can build the kind of capacity that you're talking about.
    Senator Padilla. So, that increased efficiency through the 
collaborative model for your much needed resources.
    Mr. Koller. Absolutely.
    Senator Padilla. And then, another follow up. There's 33 
states that have adopted some sort of collaborative care model. 
What can we do to encourage those that haven't yet to do so?
    Mr. Koller. Well, particularly given your concern, and it's 
entirely appropriate about underserved populations, I would 
look at the catalytic role of Medicaid programs. Medicaid 
serves almost one half of the kids in the country. Congress has 
authority over that and can work with Center for Medicaid and 
CHIP Services (CMCS) to create incentives for states to develop 
that kind of capacity, whether it's through managed care 
programs through their fee-for-service. So, I think Medicaid is 
a powerful lever to spread the kind of work that you're talking 
about.
    Senator Padilla. Thank you very much. Thank you, Mr. Chair.
    Chairman Whitehouse. Senator Kaine.

                   STATEMENT OF SENATOR KAINE

    Senator Kaine. Thank you, Mr. Chair. And to the Chair and 
Senator Grassley for having this important hearing. I want to 
ask a question about the way to support diverse healthcare 
providers in innovative models that we are rolling out, value-
based models. And let me talk about a primary care physician 
who practices in Richmond named Lerla Joseph. I've known Dr. 
Joseph since I was on the City Council and Mayor. She's an 
African American woman. She serves predominantly African 
American community in Richmond, Virginia. Her patients are more 
likely to be uninsured or underinsured and they're more likely 
to have multiple chronic conditions that require significantly 
complex management.
    When the Affordable Care Act (ACA) was passed, Dr. Joseph 
saw the growth of value-based care movement as an opportunity 
to look for new ways to provide care for her patients. And 
since then, she has successfully participated in accountable 
care models, resulting both in cost savings, but also improved 
patient outcomes. But as part of this journey, she's realized 
that we, as Congress, but also the CMMI could do more to 
support diverse providers, rural providers, small providers. As 
she says, equality is one thing, but equity is another. She 
believes a lot of the focus on building these value-based care 
models have focused on larger providers and not necessarily 
those serving rural or minority communities.
    Not every provider is starting from the same starting 
point. Some need more support than others to make the 
transition of value-based care. And it seems obvious to me that 
we could do more to support diverse providers and we should. 
So, perhaps I'll just start with you, Dr. Navathe. What more 
can Congress in the Center for Medicare and Medicaid Innovation 
do to support diverse providers serving their communities when 
it comes to these value-based care innovations?
    Dr. Navathe. Thank you, Senator, for this very important 
question. So, I think, just taking one quick step into the root 
cause might help understand. So, when CMMI typically tests 
modeling, it tests in a voluntary framework where providers 
have to raise their hand and say I want to join. Perhaps it's 
not surprising then that well-resourced providers who can bear 
risks and can make investments end up joining and so we don't 
get a representative population.
    We then look at the results and the practice innovations 
for those models and we try to scale them and that doesn't 
always work for diverse populations. So, I think as we think 
about what CMMI and others can do to help kind of boils down to 
maybe three things. One, we need models that are really truly 
directed towards safety net providers, toward rural providers, 
toward providers that take care of diverse populations so 
there's increased investment in technical support for them.
    Secondly, when we do voluntary models, we have to check for 
representativeness. We have to make sure that we're actually 
getting participation from those or create better incentives 
for that to happen. And third, rethink this paradigm of 
voluntary to mandatory. This idea of we're just going to let 
whoever raises their hand then scale what happens. We may have 
to rethink that to begin with.
    Senator Kaine. Can I then, Mr. Chairman, get on a soapbox 
here that I wasn't intending to get on, but based on Dr. 
Navathe's answer, this equality versus equity thing some people 
seem to be really worried about the word ``equity.'' And yet, 
you've just given a perfect example. Participation in a program 
first-come-first-served, raise your hand, that is as equal as 
can be, but it's not going to produce the right health outcome. 
It's not. When we started to finally deploy vaccines that were 
developed in COVID, we said anybody over 65 can get them. 
That's as equal as can be, but we found after about three 
months of that was some people over 65 don't know how to use a 
computer. And in my neighborhood, they were searching 
Walgreen's has it today and then it's the CVS across town. 
Those had the computer and the time to use it, they were 
getting vaccines. And those who didn't have the computer or 
didn't have the time to use it or had a day job, even if they 
were over 65 and didn't have the time to spend, they were not 
getting vaccinated and then 90 days into the vaccination 
rollout, the communities that were getting hit hardest with 
COVID were being under vaccinated compared to others.
    Now, everyone is eligible if you're age 65. That is an 
equality policy. There's nothing unequal about that, but it was 
producing an inequitable result that was actually hurting the 
health outcomes of the people who were most affected by COVID. 
So, we actually learned as we're then in the deployment of 
vaccines and we switched to models where we're going to do 
vaccine clinics in public housing communities. We're going to 
do vaccine clinics in rural places where folks might not have 
the CVS so close to them that somebody else does. And then, 
over time, the vaccination rates started to sort of more 
equalize among the population, but to do that we had to be 
intentional about it. And in the health space, I can think of 
about 50 examples of this where the policy that is an equality 
policy is not going to produce an equitable result. But maybe 
more importantly, it's not going to produce the result that's 
right in terms of health outcomes that we're seeking. And so, I 
really appreciate you sharing that answer. And Mr. Chair, I'll 
yield back to you.
    Chairman Whitehouse. Senator Braun.

                   STATEMENT OF SENATOR BRAUN

    Senator Braun. Thank you, Mr. Chairman. I've got a variety 
of subjects to talk about. Sixteen years ago, this whole 
malaise that encompasses the healthcare part of our economy was 
sick and tired of how lucky I was that my costs are only going 
up 5 to 10 percent a year, had a business that had nearly 300 
employees then. For 17 years prior, probably had 20 to 25. It 
was a much smaller part of our GDP. Didn't have to worry very 
much about it. But to really get a grip on it, I was large 
enough to self-insure, which they didn't tell me the year 
before because they were making so much on the prior plan. And 
then I poured everything and the kitchen sink at prevention and 
wellness and then did what it took then to create healthcare 
consumers out of my employees. You know what happened? We've 
not had a premium increase for my employees in over 15 years. 
That's unheard of, but it was so simple to do. So, my first 
question is going to be on a particular part of healthcare 
reform that involves hospitals.
    And I'm going to start with Ms. Grabert. Site-neutral 
pricing, you know what that is. You know how the big hospital 
chains end up buying all these other places, all of a sudden 
jack up the costs based on overhead factors. This is very 
simple here. What is that doing in our healthcare costs when 
they buy places that were doing it for less money and for no 
reason end up jacking up the prices and keep the competitive 
prices that were in place all of a sudden, they're gone. 
Explain what site-neutral is to people out there who may not 
understand it clearly.
    Ms. Grabert. Thank you for the question, Senator Braun. I'm 
a big fan of your Site-based Invoicing and Transparency 
Enhancement (SITE) Act. It's a bipartisan bill that's been 
introduced in the Senate and it targets a payment peculiarity 
within fee-for-service Medicare. I call it a peculiarity where 
outpatient offices receive what's called a facility fee for the 
services they provide. The same services could be provided in 
an independent primary care office, and they do not receive the 
facility fee, so there's a discrepancy in the reimbursement 
rates that Medicare pays, and it hurts the competition, it 
incentivizes things like consolidation, which are not good for 
the healthcare system, and it costs Medicare beneficiaries 
more.
    Medicare beneficiaries pay a percentage of cost sharing for 
every service that they have. If a facility fee is something 
that they're exposed to, they pay more out-of-pocket every time 
they go to that outpatient facility versus an alternative like 
the physician office. So, it's not good for the healthcare 
system, it's not good for competition, and it's not good for 
Medicare beneficiaries.
    Senator Braun. Well put. And with all that, I've got a 
Democratic sponsor, Senator Hassan, and Senator Kennedy on my 
side. Every senator ought to be on that if we're wanting to 
lower costs.
    Ms. Grabert. I agree. I think every senator should be on 
that bill.
    Senator Braun. Okay. I knew you would. Dr. Taylor, when it 
comes to healthcare transparency and competition, which was the 
hallmark of what I did. I've got another bill out there that 
was introduced, believe it or not, with me and Chairman Sanders 
of the Health, Education, Labor, and Pensions Committee, with 
the simple idea that if we are going to bring costs down for 
the government or through the private pay plans, we've got to 
have information that everyone can see to make an educated 
decision on what kind of healthcare they want. What do you 
think for hospitals and insurers; is it going to be wise to 
have them list, in not a cryptic form, prices of everything 
they're doing, even some of the agreements they make between 
themselves to try to cloak all of it to keep us from being 
healthcare consumers?
    Dr. Taylor. Thanks, Senator Braun, I appreciate the 
opportunity here. First of all, I guess I would applaud your 
shining a light on the need for cost transparency. The first 
thing I think we do is we start with our medical students and 
our residents in training and teach them about cost of care. 
It's often not even part of our training to understand costs, 
even as physicians. So, one of the things you've heard 
throughout testimony today is we've each talked about the 
importance of their being either a physician led something, 
physician led ACO, a physician led organization. So, you need 
to bring providers to the center of the organization and expect 
us to pay attention to costs. And when you have a physician led 
ACO or organization, then you're putting that in the driver's 
seat there. So, it helps when we all know that we are supposed 
to be caring about costs.
    And then on the transparency side, I'll use your site 
neutrality as a perfect example. Most people, general 
population, laypersons are not aware that getting their 
screening colonoscopy in an outpatient center would be a 
different cost than doing it in a hospital. It's not quite as 
simple as saying it's just listing the costs, but they should 
be aware that there is a cost difference and then they should 
be educated to ask is there a reason that I need to get this at 
a higher cost site of services?
    Senator Braun. One of the other things we did was a pre-
biometric screening, and it was one of the best investments I 
ever made. Dr. Rauner, would you want to briefly weigh in on 
this topic as well?
    Dr. Rauner. Yes, I tell people my single biggest surprise 
taking on this role is I knew there was price variation and I 
always thought it was 20, 30 percent. In Lincoln, Nebraska, 
it's tenfold, and one of our biggest challenges was figuring it 
out, actually. And so, although it took us a while for 
Medicare, we actually saved money pretty quickly with our 
commercial plan because we figured it out, but we didn't do it 
with information they gave us. We did it with information on 
our Explanation of Benefits (EOB) for our own family members 
because they have to tell us what they asked us to pay. And so, 
we quickly realized, for example, in my own EOBs and other 
colleagues, we started looking at how much--because it's $1,800 
to $8,000 for a colonoscopy, depending on where you went, same 
gastroenterologist, same scope, same meds. It's simply the 
site. The lab was a tenfold difference. So, if you could figure 
that out, and what consumer wouldn't want to figure that out, 
the problem is we found that the insurance companies had often 
had gag clauses where they couldn't share the information with 
us, so we had to find creative ways to figure that out. But 
boy, you can save a lot of money, and then the biometrics are 
huge. There's some employee wellness that's done right and 
there's some employee wellness that's done wrong, so I 
congratulate you for going the biometric route. That's really 
how you have to make----
    Senator Braun. Thank you so much. It's prevention, 
wellness, competition, transparency. Everybody else lives with 
competition and transparency. The healthcare industry ought to 
as well.
    Dr. Rauner. Amen.
    Senator Braun. Thank you.
    Chairman Whitehouse. Thank you all. I very much hope that 
your testimony and all of the responses and engagement from my 
colleagues create a platform for some really important 
bipartisan work. I think it is very clear, almost indubitably 
clear, that by reforming the payment system we can free up 
innovation and better patient response to primary care 
providers. We can reward them better so that the primary care 
cost reduction effect has more sway through the healthcare 
system, that patients will enjoy better outcomes, and a way 
better patient experience in that environment, and that the 
shackles of a pure fee-for-service system are not helpful as we 
move forward. And each of you from different academic, policy, 
practitioner, and legislative backgrounds, I think, have 
contributed to that message. So, I hope that we can continue to 
go forward to build bipartisan legislation that will achieve 
those goals.
    And to those of you who I asked to provide a response to a 
question for the record in writing, you have a chance to 
deliberate about it, please do so. We would ask that they be 
answered as quickly as possible. If there are other questions 
for the record that members would like to ask, we'll send them 
to you. Those are due by noon tomorrow or else forget it. So, 
if anybody comes in by noon, we'll let you know. If not, you're 
off the hook with only the questions that are pending. Let me 
thank you very much for appearing before the Committee today. 
You provided very, very thoughtful and helpful full written 
statements and those will be part of the record of the hearing. 
Thank you for the diligence of the long, full statements that 
you prepared. And again, if we do get you question, if you 
could get answers back to us within seven days that helps us 
conclude the process of this hearing.
    With no further business before the Committee, the hearing 
is adjourned.
    [Whereupon, at 11:44 a.m., Wednesday, March 6, 2024, the 
hearing was adjourned.]

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