    [Senate Hearing 118-781]
    [From the U.S. Government Publishing Office]

                                                         S. Hrg. 118-781

                      BOLSTERING CHRONIC CARE THROUGH
                         MEDICARE PHYSICIAN PAYMENT
    =======================================================================

                                    HEARING

                                   BEFORE THE

                              COMMITTEE ON FINANCE
                              UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 APRIL 11, 2024

                                   __________

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                Printed for the use of the Committee on Finance

                                   __________

                         U.S. GOVERNMENT PUBLISHING OFFICE
    63-287-PDF                  WASHINGTON : 2026
    =======================================================================

                              COMMITTEE ON FINANCE

                          RON WYDEN, Oregon, Chairman

    DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
    MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
    ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
    THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
    BENJAMIN L. CARDIN, Maryland         TIM SCOTT, South Carolina
    SHERROD BROWN, Ohio                  BILL CASSIDY, Louisiana
    MICHAEL F. BENNET, Colorado          JAMES LANKFORD, Oklahoma
    ROBERT P. CASEY, Jr., Pennsylvania   STEVE DAINES, Montana
    MARK R. WARNER, Virginia             TODD YOUNG, Indiana
    SHELDON WHITEHOUSE, Rhode Island     JOHN BARRASSO, Wyoming
    MAGGIE HASSAN, New Hampshire         RON JOHNSON, Wisconsin
    CATHERINE CORTEZ MASTO, Nevada       THOM TILLIS, North Carolina
    ELIZABETH WARREN, Massachusetts      MARSHA BLACKBURN, Tennessee

                        Joshua Sheinkman, Staff Director

                    Gregg Richard, Republican Staff Director

                                      (II)

                                C O N T E N T S

                                  ----------

                               OPENING STATEMENTS

                                                                       Page
    Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
      on Finance.....................................................     1
    Crapo, Hon. Mike, a U.S. Senator from Idaho......................     4

                                   WITNESSES

    Navathe, Amol S., M.D., Ph.D., professor of health policy,
      medicine, and healthcare management, Perelman School of
      Medicine and The Wharton School, University of Pennsylvania,
      Philadelphia, PA...............................................     6
    Furr, Steven P., M.D., FAAFP, president, American Academy of
      Family Physicians, Jackson, AL.................................     7
    Turner, Patricia L., M.D., MBA, FACS, executive director and
      chief executive officer, American College of Surgeons, Chicago,
      IL.............................................................     9
    Matthews, Melanie, MSN, chief executive officer, Physicians of
      Southwest Washington; and president, MultiCare Connected Care,
      Olympia, WA....................................................    11

                   ALPHABETICAL LISTING AND APPENDIX MATERIAL

    Crapo, Hon. Mike:
        Opening statement............................................     4
        Prepared statement...........................................    35
    Furr, Steven P., M.D., FAAFP:
        Testimony....................................................     7
        Prepared statement...........................................    36
        Responses to questions from committee members................    43
    Matthews, Melanie:
        Testimony....................................................    11
        Prepared statement...........................................    55
        Responses to questions from committee members................    59
    Navathe, Amol S., M.D., Ph.D.:
        Testimony....................................................     6
        Prepared statement...........................................    73
        Responses to questions from committee members................    82
    Turner, Patricia L., M.D., MBA, FACS:
        Testimony....................................................     9
        Prepared statement...........................................   100
        Responses to questions from committee members................   106
    Wyden, Hon. Ron:
        Opening statement............................................     1
        Prepared statement...........................................   117

                                 Communications

    Alliance for Home Dialysis.......................................   121
    Alliance for Women's Health and Prevention.......................   123
    Alliance of Specialty Medicine...................................   124
    American Academy of Dermatology Association......................   132
    American Academy of Home Care Medicine...........................   136
    American Academy of Ophthalmology................................   142
    American Academy of Orthopaedic Surgeons and American Association
      of Orthopaedic Surgeons........................................   146
    American Academy of Otolaryngology--Head and Neck Surgery........   161
    American Association of Clinical Urologists......................   165
    American Association of Hip and Knee Surgeons....................   165
    American Association of Nurse Practitioners......................   171
    American Association of Orthopaedic Surgeons.....................   178
    American Clinical Neurophysiology Society........................   183
    American College of Allergy, Asthma, and Immunology Advocacy
      Council........................................................   186
    American College of Lifestyle Medicine...........................   188
    American College of Physicians...................................   193
    American College of Radiology....................................   197
    American College of Surgeons.....................................   199
    American Diabetes Association....................................   200
    American Geriatrics Society......................................   202
    American Medical Association.....................................   205
    American Medical Women's Association.............................   211
    American Nurses Association......................................   212
    American Occupational Therapy Association........................   215
    American Osteopathic Association.................................   221
    American Physical Therapy Association............................   225
    American Psychological Association Services, Inc.................   232
    American Society of Health-System Pharmacists....................   235
    American Society of Pediatric Nephrology.........................   236
    American Society of Retina Specialists...........................   238
    American Urological Association..................................   243
    Association for Clinical Oncology................................   245
    Borelli, A. Joseph, Jr., M.D.....................................   249
    Coalition of State Rheumatology Organizations....................   250
    College of American Pathologists.................................   252
    Emergency Department Practice Management Association.............   259
    Healthy Aging Coalition..........................................   261
    Infectious Diseases Society of America...........................   262
    Medical Group Management Association.............................   265
    National Academy of Neuropsychology..............................   268
    National Association of ACOs.....................................   271
    Obesity Care Advocacy Network....................................   274
    Primary Care Collaborative and Better Health--NOW................   277
    Society of General Internal Medicine.............................   280
    Society of Gynecologic Oncology..................................   282
    UsAgainstAlzheimer's.............................................   284

           BOLSTERING CHRONIC CARE THROUGH MEDICARE PHYSICIAN PAYMENT

                                  ----------

                            THURSDAY, APRIL 11, 2024

                                           U.S. Senate,
                                          Committee on Finance,
                                                        Washington, DC.
        The hearing was convened, pursuant to notice, at 10:04
    a.m., in Room SD-215, Dirksen Senate Office Building, Hon. Ron
    Wyden (chairman of the committee) presiding.
        Present: Senators Stabenow, Warner, Whitehouse, Hassan,
    Warren, Crapo, Grassley, Lankford, Johnson, Tillis, and
    Blackburn.
        Also present: Democratic staff: Shawn Bishop, Chief Health
    Advisor; Eva DuGoff, Senior Health Advisor; Marisa Salemme,
    Senior Health Advisor; Joshua Sheinkman, Staff Director; and
    Tiffany Smith, Deputy Staff Director and Chief Counsel.
    Republican staff: Kellie McConnell, Health Policy Director;
    Gregg Richard, Staff Director; and Conor Sheehey, Senior Health
    Policy Advisor.

       OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
                 OREGON, CHAIRMAN, COMMITTEE ON FINANCE

        The Chairman. The committee will come to order, and today
    we are going to discuss how to update and strengthen Medicare's
    guarantee of high-quality health benefits for the next
    generation of America's seniors. To be clear from the outset,
    traditional Medicare, now used by millions of older people to
    secure the vital services of Medicare, is falling behind when
    it comes to helping seniors manage their health when they are
    living with multiple chronic conditions.
        I know members of the committee are interested in reforms
    to the way physicians and nonphysician practitioners are paid.
    In my view, any update to the way physicians are paid by
    traditional Medicare has to provide a lifeline to those older
    folks that I was talking about: the millions of seniors who
    live with chronic conditions and who are struggling to
    coordinate their health care in a fragmented system, in a
    peculiar, crazy quilt of services that just does not put
    seniors' health first. This hearing is going to jump-start that
    debate.
        The Finance Committee has had a special interest in this. I
    believe this was before our colleague from New Hampshire joined
    us, but we delivered a wake-up call to the country when we
    passed our first round of reforms to care for chronic
    conditions in Medicare. I remember those days like it was
    yesterday, because the late Orrin Hatch, the chairman of our
    committee, had some concerns about the original idea, and
    Johnny Isakson of Georgia and Senator Warner and I and others
    were kind of the agitators, and the chairman agreed to work
    closely with us. And we made the point that--and it's critical
    today--Medicare is no longer just an acute care program.
        Back in the days when I was director of the Gray Panthers
    and I had a full head of hair and rugged good looks, that was
    Medicare. You know, you broke your ankle, and that was Part A
    of Medicare. You went to the hospital. If you had a really
    horrendous case of the flu, that was Part B of Medicare. That
    was the ballgame. In our gerontology classes, we taught that:
    Part A, Part B, the end.
        That is no longer Medicare. Today, Medicare is
    overwhelmingly about chronic conditions: cancer, diabetes,
    heart disease, strokes, COPD--you all know the list. And what
    we know is that if you do not figure out ways to pull these
    services together, as I mentioned, you have this crazy quilt of
    appointments and prescriptions and care plans that lead to
    confusion and, particularly, worse health care.
        When a senior's health gets this complicated, care
    coordination is not an option. Recent events have underlined
    the growing cost of chronic disease in America. Even before the
    COVID-19 pandemic, life expectancy began to dip in the United
    States from a 2014 peak of 79 years old. The pandemic led to a
    backlog of preventive care that may only accelerate chronic
    illness in our country.
        The way traditional Medicare pays physicians to manage and
    treat these conditions has not kept up with the times.
    Democrats and Republicans were right to tackle the problem
    earlier. It is now time to act once more. In contrast to
    traditional Medicare in the past decade, Medicare Advantage
    plans have been given a host of tools to incorporate chronic
    disease management into their plan choices.
        We talked about it, and it is all about giving flexibility
    to plans. And the irony of course is, a lot of these additions
    were really quite expensive in terms of their cost, but they
    could make a difference for seniors--even grab bars in showers.
        Now, I have people who run ambulance systems who say
    ``thank goodness for those grab bars,'' because we do not see
    as many older people who have hips that are shattered getting
    out of bathtubs. So, these are important kinds of health-care
    issues, and ones that can be addressed with services that are
    not particularly expensive.
        So, MA was built from the ground up to offer more flexible
    benefits, to give seniors the option to choose a Medicare plan
    that was tailored to their needs. Plans are able to use
    rebates, growing from $12 billion in 2014 to $67 billion in
    2024, to support this idea of the flexibilities and the added
    benefits. Unfortunately, it is increasingly clear that too many
    insurance companies are playing too many games with these
    rules, particularly in terms of coding games with Medicare's
    payment rules to maximize their bottom line but do little or
    nothing for seniors. MA plans seem, in too many instances, to
    be using more of these extra dollars to juice marketing and
    enrollment.
        We have been told by experts that MA plans are now spending
    $6 billion per year on marketing middlemen. Get that number,
    colleagues: $6 billion on marketing middlemen who sell their
    plans to seniors. Just last week at our request, the Centers
    for Medicare and Medicaid Services announced they are cracking
    down on these insurance middlemen selling seniors' personal
    information over and over again. So what this means,
    colleagues, is an insurance plan gets some personal data from
    somebody and then, after they get their data from the consumer,
    they just sell it over and over again. We pushed to get that
    outlawed, and that is in fact going to be done.
        Now, there is plenty more that we need to do in terms of
    getting traditional Medicare to keep up with the needs of
    seniors when it comes to care coordination, nonmedical
    determinations of health, and the like. This could include
    steps such as reducing or eliminating cost sharing for care
    coordination services. Seniors should not have to pick up the
    tab when their primary care doctor works with their
    cardiologist or physical therapist to coordinate a care plan
    for high blood pressure. It also has to include empowering
    primary care. The physicians and the providers who do that play
    a critical role in managing chronic illness.
        We also have a persistent shortage of primary care
    providers in many parts of the country. That is because there
    are out-of-whack payment rules that make primary care a less
    appealing specialty than other fields. Primary care providers
    need to be valued and compensated more fully by Medicare.
        Finally, the challenge before the Finance Committee is to
    improve the way Medicare pays for services delivered in the
    doctor's office or at home, so there is a real focus on
    managing those chronic conditions that dominate the health of
    seniors.
        Last point I want to make, colleagues, is when we got the
    original bill passed--and it shows what we can do here in this
    committee working in a bipartisan way, with a bit of
    imagination--a major section of our chronic care bill was
    devoted to telehealth services. They were big, and they just
    sat there plopped right in the center of the bill, and for a
    year or two nobody paid a lot of attention. One day I was
    sitting in my office, and President Trump's director of CMS
    called me up and said, ``How would you feel if we were to use
    your telemedicine provisions as the basis for dealing with
    COVID?'' I said, ``Are you kidding me? How would I feel? I am
    going to go and have two hot fudge sundaes. This is
    wonderful.'' This is an indication that the Finance Committee,
    on a bipartisan basis, can make a difference.
        We are still building on that model. So I am going to turn
    this over to Senator Crapo, but I just bring this up by way of
    saying that this committee, working in a bipartisan way, did
    something historic with this change to make Medicare focus as
    much on chronic care as it does on acute care. We have to keep
    building on it, and it really speaks to what these four
    witnesses are going to be talking about today, so we thank you.
        Senator Crapo?
        [The prepared statement of Chairman Wyden appears in the
    appendix.]

                 OPENING STATEMENT OF HON. MIKE CRAPO,
                       A U.S. SENATOR FROM IDAHO

        Senator Crapo. Thank you, Mr. Chairman, and thank you for
    holding this important hearing. We can build strong
    bipartisanship and have done so in this area many, many times.
        Across the country, more than 60 million Americans rely on
    Medicare to meet their health-care needs. Over the next decade,
    this population will grow by more than 20 percent. Medicare's
    coverage and payment policies play a dominant role in setting
    benchmarks and baseline rules of the road, not just for the
    program itself, but also for countless other payers, affecting
    hundreds of millions of working families.
        In short, ensuring a resilient and robust Medicare program
    has become more vital than ever. Unfortunately, our current
    policies seem poised to fall short of that goal. Today's
    hearing highlights the urgency of advancing durable clinician
    payment reforms, both for front-line medical providers and,
    more importantly, for patients.
        In the absence of proactive policy changes, tens of
    millions of seniors will suffer the consequences. The risks of
    inaction range from surges in wait times and delays including
    for critical care, to clinician office closures and cutbacks in
    provider participation.
        Our committee has an obligation to strengthen the Medicare
    program and avert these unacceptable outcomes. A successful
    legislative initiative must reckon with the range of challenges
    under the current paradigm, which has served to devalue and
    distort payments for vital services, as well as to exacerbate
    administrative burdens.
        In inflation-adjusted terms, Medicare Physician Fee
    Schedule payments have declined by more than 25 percent over
    the past 2 decades, even as clinicians continue to face
    skyrocketing costs for overhead, equipment, supplies, and
    staffing needs. As the Medicare trustees cautioned last year,
    the colossal gap between stagnant fees and steep inflation
    poses a dire threat to long-term patient access. The current
    conversion factor update schedule cannot sustain an effective
    or even adequate clinical workforce moving forward.
        For many specialists, recent regulatory changes have
    further intensified these issues, as new billing codes and
    valuation shifts have triggered drastic cuts under the
    program's budget-neutrality rules. Based on inflexible cost-
    containment measures, a payment bump for primary care prompts
    payment reductions for entirely unrelated procedures and
    services, from brain surgery to advanced cancer care.
        From 2014 to 2023, for instance, even before adjusting for
    inflation, the fees for chemotherapy administration and IV
    infusions declined. Under these conditions, it should come as
    no surprise that many physicians have opted to sell their
    practices, join health systems, or limit new Medicare patients.
        Structural fee schedule reforms should shift away from the
    status quo--which forces clinicians to vie for ever-dwindling
    resources--and move forward to models that promote and reward
    team-based, patient-centered approaches. Nine years ago,
    Congress took concerted action to repeal the draconian
    Sustainable Growth Rate system, which had threatened cascades
    of dramatic cuts. In enacting the Medicare Access and CHIP
    Reauthorization Act, policymakers sought to stabilize the fee
    schedule and incentivize value-based care. In practice, these
    reforms have largely failed. The Merit-based Incentive Payment
    System aimed to establish an accessible on-ramp to
    participation in quality-driven alternative payment models, or
    APMs.
        Instead, this system has buried clinicians in dozens of
    hours of paperwork each year, all in exchange for potential
    marginal payment bumps based on ambiguous metrics that lack
    meaningful value for patients. A number of primary-care-focused
    APMs have shown promise, but countless specialties lack access
    to any clinically relevant models at all.
        While the MACRA-established committee to translate
    clinician-developed APM concepts into concrete policy options
    has worked through dozens of viable proposals, the Centers for
    Medicare and Medicaid Services have largely rejected these
    opportunities. Reforms to advance value-based care thus demand
    a focus not just on financial incentives, but also on
    structural improvements that ensure meaningful options informed
    by clinical experience and aligned with patient needs.
        I look forward to building on this committee's bipartisan
    work to bolster and modernize our clinician payment systems.
    The program's current and future enrollees depend on it.
        Thank you to our witnesses for being here today, and thank
    you, Mr. Chairman.
        [The prepared statement of Senator Crapo appears in the
    appendix.]
        The Chairman. Thank you, and we have four individuals who,
    by any objective assessment, are real experts in chronic care.
    So we thank you, and we have some brief introductions. We will
    go right to your testimony.
        Dr. Amol Navathe is a practicing primary care physician,
    and an associate professor of health policy and medicine at the
    University of Pennsylvania. He is also vice chairman of MedPAC,
    the Medicare Payment Advisory Commission.
        Dr. Steve Furr is here. He is a family physician and
    president of the American Academy of Family Physicians. He also
    cofounded a clinic as well in Jackson, AL to serve folks there.
        Dr. Patricia Turner is a general surgeon and chief
    executive officer of the American College of Surgeons, and she
    is also a professor at the University of Chicago. We welcome
    you.
        And then, Melanie Matthews is chief executive officer of
    Physicians of Southwest Washington and president of MultiCare
    Connected Care.
        To all of our witnesses, we thank you for speaking with the
    Finance Committee about these extraordinarily important
    issues--chronic care and particularly the Medicare physician
    payment system. Please go ahead with your remarks. As you know,
    we are trying to keep everybody at 5 minutes, because we think
    members--it is going to be a hectic morning here in the
    Senate--are very interested in these issues.
        Dr. Navathe, please start.

    STATEMENT OF AMOL S. NAVATHE, M.D., Ph.D., PROFESSOR OF HEALTH
    POLICY, MEDICINE, AND HEALTHCARE MANAGEMENT, PERELMAN SCHOOL OF
     MEDICINE AND THE WHARTON SCHOOL, UNIVERSITY OF PENNSYLVANIA,
                            PHILADELPHIA, PA

        Dr. Navathe. Chairman Wyden, Ranking Member Crapo, and
    distinguished members of the committee, thank you for the
    opportunity to testify. My name is Amol Navathe. I am a general
    internist, physician, and health economist.
        Before I begin my remarks, I would like to emphasize that
    my comments reflect solely my beliefs, and not the opinions of
    any organization I am affiliated with, including MedPAC, the
    University of Pennsylvania Health System, or Perelman School of
    Medicine.
        Today, I would like to highlight why the Medicare program
    needs to better address chronic disease care, and why this
    cannot happen without changes to physician payment. As a
    practicing physician, I have witnessed firsthand the challenges
    that Medicare beneficiaries face in getting optimal care for
    chronic conditions.
        Take for example my patient Mr. L, a wonderful gentleman
    suffering from diabetes, heart failure, and kidney disease. Mr.
    L has to manage his chronic conditions on his own, spending an
    average of 2 hours a day coordinating his medications,
    traveling to clinics, and attending appointments. He is one of
    so many patients who would benefit from a more proactive
    patient-centered model of care, a model that could have
    prevented his recent hospitalization for kidney failure. In
    reflecting upon Mr. L's situation, I would like to share three
    key points.
        First, chronic disease may be the single most important
    challenge affecting the Medicare program. More than two-thirds
    of the Medicare population has two or more chronic conditions.
    The 15 percent of beneficiaries with six or more chronic
    conditions cost Medicare more than three times the average.
        Second, dramatic fragmentation plagues chronic disease
    care. Medicare beneficiaries with chronic conditions see more
    than five physicians concurrently. My colleague Matt Press
    found that over just 3 months, it takes a PCP over 50
    interactions--let me say that again--50 interactions with other
    clinicians and the patient, to actively coordinate care for
    just one important clinical condition. It is pretty astounding
    how much time and effort this takes.
        What does this have to do with physician payment? That
    leads me to my third point. Unfortunately, the status quo fee-
    for-service system is a key factor in producing fragmentation.
    The focus is not on producing more health, just on producing
    more health care. Each clinician has their head down, focused
    on doing more visits and procedures, while the critical task of
    coordinating care often gets overlooked.
        With good intentions, CMS has attempted to fill this gap by
    adding more billing codes. But reducing the important work of
    clinicians to a list of codes is a fraught task. The result is
    an administratively complex system of ticky-tack codes that are
    underused because the cost of billing them is itself
    unprofitable. For example, the administrative cost to bill for
    a visit is about $20. That is more than the $15 physicians get
    paid for a virtual check-in visit. I sometimes call this death
    from a thousand codes.
        So what is the path forward? Addressing fragmentation will
    require a new way of delivering chronic disease care, which in
    turn will require substantial changes to physician payment.
    Simply adding more dollars to the current system will not be
    enough. Physician groups need to be able to invest in new
    capabilities; use technologies like telehealth when safe,
    efficient, and effective; and staff practices differently.
        A natural place to start is investing in primary care. One
    promising path is to provide PCPs with steady monthly payments
    per beneficiary, in addition to certain fee-for-service
    payments. This would balance the roles of preserving access,
    while enabling PCPs to practice more patient-centered care. An
    additional benefit would be unshackling PCPs from a system that
    requires billing for each and every task.
        Another promising approach is to continue expansion of
    alternative payment models, which place accountability for cost
    and quality outcomes onto providers. This will require
    continued support from the CMS Innovation Center. Alternative
    payment models can improve care for patients with both high and
    low burdens of chronic disease. A great example has been the
    Accountable Care Organization model. However, alternative
    payment models still rely on the Physician Fee Schedule,
    creating conflicting incentives for some physicians. This leads
    me to point out that CMS needs more tools to manage the fee-
    for-service program effectively.
        There are many factors to consider in improving physician
    payment, and no single entity has all the required expertise.
    This effort will benefit from the input of multidisciplinary
    experts, who could be convened as an advisory panel to CMS.
    Ultimately, CMS needs the ability to catalyze a new care model,
    and that will require adapting the fee schedule to accommodate
    new approaches, such as for primary care. This will require
    action. Unlike in Medicare Advantage, where we have seen
    substantial innovation to meet beneficiary needs on a near
    real-time basis, traditional Medicare requires congressional
    action to stay up to date. Hence, CMS needs more tools and
    authorities to better address chronic disease among Medicare
    beneficiaries.
        Thank you.
        [The prepared statement of Dr. Navathe appears in the
    appendix.]
        The Chairman. Dr. Navathe, we have had some jaw-dropping
    testimony around here over the years, but to hear that one
    patient had 50 interventions--was that your word, or
    interactions?
        Dr. Navathe. Interactions.
        The Chairman. Yes. Fifty interactions over a 3-month
    period. I am going to be replacing my jaw or something. That
    was really extraordinary, and I think that also gives us a
    wake-up call like we had years earlier when we started down
    this path. And I thank you.
        Dr. Furr?

     STATEMENT OF STEVEN P. FURR, M.D., FAAFP, PRESIDENT, AMERICAN
               ACADEMY OF FAMILY PHYSICIANS, JACKSON, AL

        Dr. Furr. Good morning, Chairman Wyden, Ranking Member
    Crapo, and members of the committee; I am Steve Furr. I am a
    practicing family physician from Jackson, AL, population
    slightly less than 5,000. I am the president of the American
    Academy of Family Physicians. I am honored to be with you here
    today, representing our 130,000 members, physicians, and
    medical students who faithfully serve their patients and your
    constituents.
        I have delivered primary care in a rural community for more
    than 35 years. In my time, I have seen firsthand how my
    patients are getting sicker and more complex. Meeting the
    current and future needs of our patients with chronic
    conditions requires our Nation to better leverage primary care.
        On March the 21st, Carolyn, my long-term patient, came to
    my office complaining that she had a blister on her right great
    toe. Carolyn and I were born in the very same year, but our
    life paths are very different. But we have walked them together
    as physician and patient. She is a diabetic on short- and long-
    acting insulin, and between her diabetes and her hypertension,
    her kidneys failed. She was on dialysis and then was fortunate
    enough to get a kidney transplant. Now she is on chronic
    immunosuppressive therapy. She comes to my office and as I
    examine her, I can smell the putrid odor from her toe, and I
    know that she has a necrotic foot.
        I clean and debride the wound, get the x-ray confirming
    infection has not moved into the bone. The vascular studies
    showed what we suspected. She has no blood flow from the knee
    down to the rest of her foot. She saw the vascular surgeon on
    Tuesday this week, and will hopefully get a revascularization
    procedure that will save that leg. If she is not treated in
    time, she would get a very different procedure, a left above-
    the-knee amputation, leaving more morbidity and mortality. One
    of the most impactful aspects of primary care is the trusting
    relationship we develop with our patients.
        Evidence suggests that the longitudinal relationships that
    I and other primary care physicians foster with our patients
    lead to better control of chronic conditions, fewer emergency
    department visits and hospital stays, and improved patient
    outcomes. But traditional Medicare underinvests in primary care
    and these relationships. Lower primary care payment rates and a
    system that rewards volume over value means physicians are
    pressured to see as many patients as possible.
        Meanwhile, overwhelming administrative burden takes
    significant time away from our patient care. This is leading
    current primary care physicians to leave the field, and
    discouraging medical students from pursuing primary care
    specialties. This in turn is having severe impacts on patient
    access. Among peer nations, the patients in our country are the
    least likely to have a longstanding relationship with a primary
    care physician. Our health-care system has steered people away
    from high-value, low-cost services like preventive screenings
    and primary care office visits.
        By not investing more up-front dollars in primary care, we
    are paying an even higher price, and we are not prioritizing
    what really matters: patient outcomes and experience. One of
    the major factors contributing to our national underinvestment
    in primary care is a relative undervaluation of primary care in
    fee-for-service payment. In general, Medicare values procedural
    services higher than it does office visits and other cognitive
    services most often delivered by primary care physicians. This
    devaluation is not limited to Medicare. As mentioned earlier,
    most payers tie their payment rates to Medicare or use
    Medicare-relative values.
        Fee-for-service does not just underinvest in primary care;
    it also makes it hard to get paid. We must submit multiple
    unique codes for each service we provide, documenting both what
    we did and why we did it. That does not fit with the
    continuous, comprehensive nature of the primary care that we
    provide.
        That is why we must accelerate the transition to value-
    based payment for primary care, using alternative payment
    models, or APMs, that provide prospective population-based
    payments. However, it is important to realize APMs are often
    designed based on fee-for-service payment rates. Therefore,
    improving fee-for-service payment for primary care is one
    essential strategy to support the transition into value-based
    care.
        I am encouraged by the recent policy changes to better
    value primary care Medicare. Unfortunately, Medicare's budget-
    neutrality requirements for physician payment are severely
    undermining these investments. CMS is forced to offset
    increases anywhere in the fee schedule with across-the-board
    cuts to all services, including primary care. This means
    Medicare cannot appropriately pay for all the services a
    patient might need.
        So, as a first step forward, I would ask that Congress
    revise current budget-neutrality requirements. Additionally,
    Congress should waive patient cost-sharing requirements for
    chronic care management and other primary care services. In
    closing, I urge Congress to prioritize policies that would
    better support patients with chronic conditions and the family
    physicians who care for them. We all have the same goal: to
    improve the lives of the people we serve.
        Thank you for the opportunity to provide this testimony. I
    look forward to trying to answer your questions.
        [The prepared statement of Dr. Furr appears in the
    appendix.]
        The Chairman. Doctor, thank you, and good for you for
    taking the principles that you have advocated and putting them
    into action there at home. Nice to have you.
        Dr. Turner?

      STATEMENT OF PATRICIA L. TURNER, M.D., MBA, FACS, EXECUTIVE
       DIRECTOR AND CHIEF EXECUTIVE OFFICER, AMERICAN COLLEGE OF
                         SURGEONS, CHICAGO, IL

        Dr. Turner. Chairman Wyden, Ranking Member Crapo, and
    members of the committee, thank you for inviting the American
    College of Surgeons to testify at this important hearing on
    ``Bolstering Chronic Care Through Medicare Payment.'' The ACS
    and its 90,000 members remain committed to improving care for
    all surgical patients, including those living with chronic
    conditions, and to ensuring that Medicare beneficiaries receive
    the highest quality of care.
        Quality improvement in surgery has been the cornerstone of
    the ACS since its founding 110 years ago, and with 13 quality
    programs, the ACS has set the standards for high-quality
    surgical care. In some cases, it has collaborated with other
    specialty societies to develop others. Patients seek out our
    programs for definitive quality measurement and evidence-based
    practice. We believe that medicine should be advancing toward a
    system that rewards high quality and enhances the value basis
    of care. This transformation is underway and would benefit from
    efficient investments in the partnerships between CMS and
    subject matter experts committed to improving the way quality
    is measured and incentivized, and by improving the calculus of
    the Physician Fee Schedule.
        The ACS envisions quality as a comprehensive program which
    centers on the patient and is inclusive of the entire team
    involved in providing care. Truly team-based care requires
    coordination with our primary care colleagues and other
    specialists to ensure that a patient's chronic conditions are
    managed appropriately to achieve the best possible outcome.
    This commitment to team-based care is evident in our
    verification programs, which include standards related to
    disease management. Most physicians in the current fee-for-
    service system, however, are evaluated on measures that do not
    necessarily reflect the care they deliver or the conditions
    they treat. Unfortunately, the current model of individual,
    disconnected measures is insufficient to achieve coordinated
    patient-centered high-value care, and provides little
    actionable information for continuous physician improvement or
    patient decision-making autonomy at point of care.
        Programmatic measures developed by the ACS exhibit
    applicability to diverse care settings, cause a limited burden
    on care providers, and deliver demonstrably better results. The
    ACS believes that addressing the shortcomings of traditional
    Medicare fee-for-service payments will require new types of
    quality measures, facilitated by increased flexibility in the
    facility-based scoring option in the Merit-based Incentive
    Payment System.
        However, Medicare cannot transform into a system which
    functions to reward value without immediate and lasting
    stability in the physician payment system. To create this
    stability, Congress should immediately address the payment
    reductions already anticipated in 2025. Under current law, it
    would take decades for the fee schedule conversion factor to
    return to adjusted 2000 levels. The implementation of positive
    annual updates to the conversion factor reflecting the
    inflation in practice costs is an essential step necessary to
    enhance patient access to care and to improved quality.
        Yearly reductions to the Medicare conversion factor
    continue to be problematic for surgeons and physicians of all
    specialties, due to the budget-neutrality requirements for any
    change in the Physician Fee Schedule expected to increase
    expenditure by as little as $20 million annually. This trigger
    amount has remained the same since its implementation in 1992.
    Updating the trigger for budget-neutrality adjustments would
    help to ensure that comparatively minor changes to the fee
    schedule do not always require across-the-board cuts. Congress
    should, at a minimum, increase the budget-neutrality trigger
    threshold from $20 million to $100 million and index it
    annually to account for inflation. This will create a stable
    base from which physicians can incorporate payment models
    involving risk, and will reduce unhelpful competition between
    specialties when other sectors of the health-care system have
    none of the same constraints.
        Finally, Congress can do more to make alternative payment
    models available to physicians. Along with dozens of other
    specialty societies, the ACS developed and submitted proposals
    that were reviewed, revised, and evaluated by the Physician-
    Focused Payment Model Technical Advisory Committee created by
    MACRA. Fourteen were recommended for testing or implementation
    by the PTAC, but CMS has not tested any as proposed. This
    bottleneck has created a disincentive for stakeholder
    investment into the development of APMs. These innovative and
    value-driven proposals are some of the best ways to incorporate
    data into this conversation in a way that enhances patient
    outcomes and ultimately bends the cost curve.
        Congress should require that at a minimum, some portion of
    the Innovation Center's budget be dedicated to testing
    physician- and specialist-developed APMs recommended by the
    PTAC. These are relatively modest reform ideas that would
    stabilize the Physician Fee Schedule and build upon MACRA to
    focus on providing high-value care to our patients.
        Surgeons are devoted to their patients, and we look forward
    to working with you to solve these thorny problems. Thank you
    for the opportunity to participate, and we look forward to
    answering your questions.
        [The prepared statement of Dr. Turner appears in the
    appendix.]
        The Chairman. You are going to get some momentarily. Thank
    you.
        Ms. Matthews, welcome.

     STATEMENT OF MELANIE MATTHEWS, MSN, CHIEF EXECUTIVE OFFICER,
     PHYSICIANS OF SOUTHWEST WASHINGTON; AND PRESIDENT, MULTICARE
                      CONNECTED CARE, OLYMPIA, WA

        Ms. Matthews. Thank you, Chairman Wyden, Ranking Member
    Crapo, and distinguished members of the committee. I appreciate
    this opportunity to discuss ways to enhance care for
    individuals with chronic conditions. My name is Melanie
    Matthews, and I am honored to serve as the chief executive
    officer, PSW, and the president of MultiCare Connected Care. I
    have over 2 decades of experience in health care, and have
    strong focus in value-based care.
        PSW is an independent physician practice association formed
    in 1995. We participate in Accountable Care Organizations,
    including the Medicare Shared Savings Program and the ACO
    Realizing Equity, Access, and Community Health (REACH) model.
    Across our partnerships, we provide care to over 400,000 people
    in Washington, Idaho, and Oregon. Collectively, our
    partnerships have saved $120 million in Medicare by maintaining
    an average quality score of 96 percent.
        Accountable Care Organizations sit at the intersection of
    today's topics of both physician payment and care coordination.
    ACOs deliver strategies that are particularly important for
    individuals with chronic conditions, who frequently see
    numerous providers across multiple settings. To better care for
    populations, Congress should lean into Accountable Care
    Organizations, which offer the best pathway for health outcomes
    at a lower cost.
        I would like to share three themes with you today. First,
    accountable care is working. It is working for patients, and it
    is working for Medicare. Over the past decade, ACOs have
    collectively saved $22 billion. While cost savings have been a
    headline, the underlying strategies that we deploy to achieve
    shared savings improve care for people.
        Essentially, we wrap services around people to improve
    their health-care delivery experience by expanding access to
    care coordination and ensuring the right care at the right time
    in the right care setting. While we call that accountable care,
    you may think about that as the type of care that you would
    want for yourself, your family, and your community.
        Second, these strategies are particularly impactful for
    chronically ill populations. For example, a registered nurse
    plays a pivotal role in the care coordination by developing and
    executing personalized care plans. These nurses collaborate
    closely with their patients, their families, and the
    interdisciplinary teams of physicians, social workers,
    pharmacists, and other health-care professionals as needed.
    These programs would not be possible under the fee-for-service
    model.
        Third, we are focused on greater engagement of
    beneficiaries and communities. This includes providing
    incentives for beneficiaries such as a cost-sharing relief to
    increase access to services that otherwise may be avoided or
    foregone. An example in our ACO is, a rural critical access
    provider built a chronic care management program for Chronic
    Obstructive Pulmonary Disease. Despite the potential benefits
    of the program, there was low enrollment because of the
    beneficiary coinsurance payment. This was a hurdle. Within our
    ACO reach, we implemented a cost-sharing waiver to remedy the
    issue. This flexibility was a game-changer in increasing access
    and enhancing quality of life.
        There are key policy levers to accelerate this
    transformation, including creating clear and strong incentives
    for participation in accountable care by extending Advanced
    Alternative Payment Model bonuses, strengthening the data
    infrastructure needed to facilitate information sharing, and
    simplifying and supporting provider participation in
    alternative payment models.
        I would like to leave you with a story to help illustrate
    the importance of this work. Many of you know firsthand--or at
    least secondhand--how frightening and overwhelming it can be to
    be discharged from the hospital or any other post-acute care
    setting. Often when this happens in a fee-for-service
    environment, people are alone with complex instructions, and
    far too often this experience leads to readmissions that are
    preventable.
        The experience is different in ACOs. We had a patient who
    was sent home from a skilled nursing facility with instructions
    for wound care. After returning home, it became clear that the
    health care home health provider did not have the proper
    supplies. The patient was planning to return to the emergency
    department to have the wound addressed. At our ACO, the nurse
    care manager checked in with the patient on the phone,
    identified the issue, and was able to refer her to another home
    health provider who had the supplies and could get there
    immediately. The patient's experience was far superior,
    avoiding an unnecessary trip to the emergency department and
    addressing her health-care needs at home. The health-care
    system avoided the cost of the hospital. This is a win-win.
        In conclusion, I extend my gratitude for the opportunity to
    share these impactful stories and advocate for advancements in
    health-care delivery. PSW and MultiCare Connected Care remain
    steadfast in our commitment to collaborate with Congress to
    achieve better outcomes for all patients.
        Thank you.
        [The prepared statement of Ms. Matthews appears in the
    appendix.]
        The Chairman. Thank you very much. And I am going to start
    with you, Dr. Navathe, because I want to understand a bit more
    about these 50 interactions that you talked about as it related
    to one patient in a 3-month period. I sense what you are
    talking about here--and I do not want to put words in your
    mouth--is that if this patient was taken care of in a different
    kind of way, that for example, Medicare would pay every month a
    flat sum for this patient to a primary care doctor, that
    primary care doctor would coordinate things. Is that something
    resembling English in terms of what you are talking about here?
        Dr. Navathe. Thank you, Senator, for the question. So, I
    think there are two aspects. I think the first part is, some of
    those 50 interactions, probably the majority honestly, would
    need to happen regardless. This is just a PCP, a primary care
    doctor, having to talk to a specialist, contact the patient,
    make sure that everything is translated and coordinated, and
    the patient is getting the right care.
        The second point that you are making is absolutely right.
    Some portion of those interactions would probably not need to
    happen in a type of payment model that you are suggesting,
    because the primary care practice would be able to staff nurse
    practitioners and physician's assistants and pharmacists, and
    change the way that it is caring for that patient in a more
    effective and efficient way.
        The Chairman. So, have you made a list of these
    interactions in terms of, say two or three different patients?
    I assume not in every case are there 50 interactions, but there
    would be different numbers, and you would see different people,
    and that sort of thing. But have you made a list that would be
    sort of a representative model?
        I mean, as you know, physician payment is discussed around
    here like the weather. You know, everybody says, ``Physician
    payment, oh my goodness, we have got to change it. It is not
    doing what we need to do. We are not spending the money
    effectively. We are not getting providers for this particular
    field and that.''
        So, I like your idea very much, because we have been
    looking--I see my colleagues, particularly Senator Stabenow and
    Senator Whitehouse, who have specialized in this. We have been
    talking about what to do about traditional Medicare for ages
    and ages, and in fact, the legendary New York Times journalist
    Robert Pear, who was the most authoritative reporter on health
    care, he did his last article on chronic care and our bill, and
    he had been covering it forever. And we all walked away saying,
    ``We have to do more for traditional Medicare.'' And so, we
    want to get more details from you about how to do that with
    your idea of the per-month per-patient kind of payment for
    coordination.
        There is one other question. I have a little bit of time
    left for the entire panel. So, apropos of that piece that
    Robert Pear wrote--he went through grab bars and nutritional
    assistance and all of this kind of stuff. What do you four
    experts in the field think are the lessons learned from the
    jump-start we had doing this for MA?
        In other words, MA was better positioned at the beginning,
    because it already coordinated services in a constructive kind
    of fashion. But you cannot leave 50 percent of the elderly
    population behind that is using traditional Medicare.
        So let's just use my time, go right down the table. What do
    you think the lessons are learned from the MA experience, which
    has produced some examples that I have given, and what can we
    apply to traditional Medicare now? Dr. Navathe, let us just go
    right down the row.
        Dr. Navathe. Thank you, Senator. I will try to keep my
    comments brief. So, I think what we have learned is that there
    is a big gap between what traditional Medicare provides and
    patient needs, because Medicare Advantage plans have provided
    supplemental benefits like transportation. They have
    flexibility to reduce cost sharing. As we have heard, that can
    be very important.
        So, I think we have to meet the patients where they are,
    and that has been a key lesson, right? And I think one of the
    big challenges is, in Medicare Advantage they have the
    flexibility to innovate their benefits. They have that
    flexibility to do some of this on their own. In traditional
    Medicare, there are a lot more constraints, and we need
    Congress to give CMS the authorities to make that happen.
        The Chairman. That is way too logical for government--meet
    the patients where they are. Good for you.
        Dr. Furr?
        Dr. Furr. So, there are medical advantages of Medicare
    Advantage, but I will say there are also some downsides. The
    rise of prior authorization coincides with the rise of the
    Medicare Advantage plans. It is a huge hassle for our doctors
    trying to take care of patients. To give you an example, when I
    try to send a patient and I need a stress test, my nurses tell
    me it is easier for me to do the referral to the cardiologist
    than it is to get the stress test set up. I do not need to
    refer to the cardiologist; I just need the stress test.
        It is not just tests; it is even the drugs--the change of
    plan, doing a different formulary. I have a diabetic who is
    completely controlled, hypertension is controlled. If I have to
    change the medication, there are some hassles with that.
    Medicare is much easier as far as getting services. They do not
    have the umbrella services. As far as getting referrals and
    taking care of them, there is ease there doing that.
        The Chairman. Well, thank you also for mentioning the prior
    authorizations, because a good chunk of these talented staffers
    here on the podium are working on it now, because some of the
    stuff is outrageous, just literally outrageous.
        Dr. Turner, your thoughts, lessons learned?
        Dr. Turner. Thank you for the question, Senator. I agree
    that there are two sides to nearly everything, and when we
    think about Medicare Advantage, there are some advantages. The
    flexibility is encouraging. The additional burden of prior
    authorization can be a problem.
        But when we think about innovation, that allows us to
    consider prehabilitation. What are the elements of that that
    can help patients do better with chronic conditions before
    their surgical procedures? We have a geriatric surgery program
    that allows us to think about all of the elements that can be
    incorporated to enhance the care of the older patient with
    chronic conditions. What are the elements that can be
    integrated into that so that their outcomes are better, so
    there is minimal readmission to the hospital, minimal
    recidivism, incorporating all of the members of the health-care
    team and recognizing that there is a complexity to the care of
    the chronic conditions of our patients that requires a holistic
    approach to the patient, meeting them where they are and making
    sure that they have the best outcome in an evidence-based
    fashion?
        The Chairman. Great. We will wrap up with you, Ms.
    Matthews. I am over my time, but----
        Ms. Matthews. Thank you. The only thing I would add would
    be----
        The Chairman. We want to be partial to people in the
    Northwest.
        Ms. Matthews [continuing]. Just engaging beneficiaries in
    their plan of care. I think there is a lot of flexibility in
    continuing to support those and both the alternative payment
    models as well as Medicare Advantage programs. Thank you.
        The Chairman. Thank you.
        Senator Crapo?
        Senator Crapo. Thank you, Mr. Chairman.
        This will be a question for Dr. Furr and Dr. Turner.
    Seniors with chronic conditions can face severe access
    barriers, particularly for prescription medications. The Better
    Act, which our committee advanced unanimously this year, would
    help to bridge affordability gaps by dragging down out-of-
    pocket costs for a wide range of chronic disease treatments.
        That said, clinicians and patients report record-high
    growth in the use of prior authorization, step therapy, and
    other policies that risk imposing costly burdens on providers
    and impeding care quality for patients. Recent studies have
    shown a dramatic increase in the use of these restrictions,
    which clinicians often cite as most pervasive in the context of
    medicines.
        Regulations finalized earlier this year aim to streamline
    prior authorization timelines and processes for numerous
    services, but the complete exclusion of both physician-
    administered and pharmacy-dispensed prescription drugs seems
    likely to limit the effects of the final rule.
        Dr. Furr and Dr. Turner, how do prior authorization and
    step therapy affect physicians' ability to address patient
    needs, and what steps should policymakers take to improve these
    processes?
        Dr. Furr. The realization of how prior authorization
    started out was that it was for high-cost things, such as a PET
    scan or something like that. But now this has been ratcheted
    down. First it was procedures. Then it was things like CAT
    scans, and now it has gone down to drugs. And the first strange
    thing is, when I have a patient who is controlled with their
    diabetes or hypertension, we do not need to be changing their
    drugs. But yet, if they move to another plan or the plan
    changes their formulary, they are required to change their
    plan.
        Just to give you an example, the other day I had a diabetic
    who came in. I had a better diabetic drug for him that he
    needed, but he said, ``I want this drug, which has more side
    effects, because I can get it for zero copay for a 90-day
    supply.'' It is a diabetic drug, but not a better drug, and not
    the best drug for him. But he chose that drug, because he did
    not want to pay a little bit more.
        And just out-of-pocket costs are a huge issue. Our patients
    are having to decide between getting drugs and getting food.
    And as I mentioned the patient earlier, she was on chronic care
    management for 2 years, the lady with the foot. She stopped
    doing chronic care management because of the $13 to $15 copay
    per month, and she was no longer doing that.
        Senator Crapo. Thank you.
        Dr. Turner?
        Dr. Turner. Thank you for the question. There is no
    question that prior authorization can create a roadblock for
    patients to get the evidence-based care that they need, and we
    are concerned about the onerous burden that it also places on
    the physicians, and it can delay access to care. So, one of the
    significant concerns is that prior authorization, which adds a
    tremendous administrative burden, requires lots of back and
    forth between the physician's office trying to get approval for
    what we know is the right thing to do for the patient.
        The patient's care is delayed, and ultimately our goal is
    to provide timely and evidence-based high-quality care. So, if
    prior authorization creates these unreasonable burdens for the
    physician and the patient, it can be incredibly complex to
    deliver the care that we know that they deserve and they need.
        So we would agree that anything that smooths that process,
    that allows the evidence base to be an opportunity to provide
    the care that we know that they need, an electronic interface
    that minimizes the amount of time that physicians' offices have
    to spend on the phone, that is time they are preparing for and
    seeing the next patient.
        It often adds to the expense, because their practices must
    hire additional people whose entire job it is to stay on the
    phone, trying to get the care approved for their patients.
        Senator Crapo. Well, thank you.
        And this question will be for you, Ms. Matthews. For many
    Idahoans, especially in rural communities, small physician
    practices provide a crucial lifeline for health-care services,
    from medical imaging to chronic disease treatment.
    Unfortunately, these providers often lack an accessible avenue
    to participate in Medicare's value-based care programs. MIPS in
    particular demands dozens of hours of administrative tasks for
    every participating clinician. Low Medicare patient volumes
    also make MIPS unworkable for many rural clinicians. According
    to MedPAC, roughly 460,000 remain ineligible. How could CMS or
    Congress help to promote participation by small rural practices
    in MIPS or AAPMs?
        Ms. Matthews. Thank you for the question, Senator. Our ACO
    certainly provides support and resources to critical access in
    rural communities. We appreciate the opportunity that we think
    highly coordinated care is very likely in rural communities
    because everyone knows each other, and they have a little bit
    more opportunity to communicate among the health-care
    providers.
        I think that stability in the program is critical to ensure
    that we are sending the message that this is a long-term
    commitment to the investments that it takes. It is complex,
    change is hard, and having a financial payment model that
    supports the financial methodologies in rural communities, many
    of which are based on cost-based reimbursement versus the
    typical fee-for-service payment, is essential.
        So, it requires a little special attention for the rural
    communities. But in our several years of engaging with Critical
    Access Hospitals in smaller communities, we have felt that they
    have done an incredible job and are very committed to highly
    coordinated care.
        I think I would just leave you with this, Senator Crapo. I
    think that value-based care is a dimmer switch and not a light
    switch, and I think as we get going, we need to continue to
    turn up the light volume on these models, and really crack the
    code on how to best support critical access in rural
    communities.
        Senator Crapo. Thank you.
        The Chairman. Senator Stabenow?
        Senator Stabenow. Well, thank you so much, Mr. Chairman,
    and to you and our ranking member for all of your efforts.
        We have been talking about these issues for a long time,
    and the importance of coordination, the importance of getting
    the right incentives in place, and value-based care. I remember
    all the discussions in the Affordable Care Act, talking about
    ACOs and everything. We are making steps, but we certainly have
    a lot more to do, as all of you are showing us, and thank you
    for your testimony today. I really appreciate the Bipartisan
    Working Group on Physician Payment Reform that we put together:
    Senator Thune and I, Senators Cortez Masto, Blackburn, Warner,
    and Barrasso. And so hopefully, working with all of you, we can
    make some further steps here--obviously in the right direction.
        I do want to also stress though--because we talk about
    Medicare Advantage when we talk about traditional Medicare--
    Medicare Advantage plans do get paid more, and so one of the
    issues is, I mean, why is that happening versus traditional
    Medicare? I understand the flexibilities, but we built this in
    when we were doing--it has been there a long time--the
    Affordable Care Act and so on. So that is really a question. If
    they can do more but they are paid more, what does that say
    about what we should be doing here overall?
        I also just wanted to mention one bill that Senator
    Marshall and I have. There are so many pieces of how we
    coordinate care and comprehensive care and deal with all the
    factors, all the social determinants, all the factors for
    people, one being food, right? Food is medicine, and Senator
    Marshall and I have a bill to authorize medically tailored
    meals under Medicare, which is important if we are talking
    about the health of people. Eating healthy and having access to
    the capacity to do that is also very, very important.
        So, we have a lot to do in this area, and, Dr. Turner, I
    wanted to ask you a question about the Physician Fee Schedule.
    I mean, obviously there are a lot of challenges here that we
    are talking about. But when we talk about it from a specialist
    standpoint, it is very important that we are looking at the
    front end. But from a specialist standpoint, you have spoken
    about the fact that support to some specialists has caused cuts
    to other specialists due to the conversion factor.
        You have talked about this already. But could you talk more
    about changes to the current payment system that would support
    all physicians? Obviously, primary care physicians are
    incredibly important; so are specialists. And so, what would
    you recommend?
        Dr. Turner. Thank you for that question, Senator. Clearly,
    we are all trying to provide great care for our patients. Our
    primary care colleagues, surgeons, all specialists are trying
    to provide the best care for patients. So it is incredibly
    unhelpful to have the budget-neutrality trigger set so low that
    when an appropriate enhancement to one area comes about, it
    requires that some other area that may have nothing to do with
    the evidence base is cut.
        And as we focus on value, on improvement, on evidence-based
    care, it really does not enhance patient care when we think
    about it that way. So we would favor raising the trigger for
    budget neutrality to the point that modest improvements and
    modest enhancements do not necessarily trigger that sort of
    intervention that requires some other specialty in an unrelated
    fashion to lose.
        We would like to think of it as a win-win, and when we
    focus again on the value-based, on the evidence-based, we know
    for example, with our geriatric surgery verification program,
    that the care of the older patient is more complex, and it does
    require integration and a holistic approach that meets the
    patient with all of their comorbid factors, and allows us to
    provide better-quality surgical care in the continuum of care
    that enhances across the board.
        And so, we would favor all of us benefiting by the rising
    tide that raises all boats, so that we can enhance the care
    that we are providing for the complex older patient who does
    have more of the comorbidities and requires a more complex
    approach.
        Senator Stabenow. Thank you.
        And, Mr. Chairman and Ranking Member, it seems to me the
    budget-neutrality requirement--I understand what happened, why
    that happened. But it does not make sense to me when we are in
    the context of services for people, that in order to
    incentivize certain services, we have to cut other services.
    That does not make sense to me, and so I hope we are going to
    really, really focus on that.
        And then just very quickly, Dr. Furr, could you talk more
    about the alternative payment models as a way to expand quality
    for Medicare beneficiaries? You have talked about this, but
    could you speak a little bit more about that?
        Dr. Furr. I think for family physicians, and particularly
    for rural family physicians in an underserved area, I think
    there are a couple of things. One, we found out in the ones we
    did before, that we need more time for those models to truly
    work. Often, those are set up for 3 to 5 years, and that is not
    enough time to at least show the cost savings and the
    difference they can make.
        Two, because so many of our practices are financially in
    such a tough situation, there have got to be some up-front
    payments. You cannot, if you are just barely making a living,
    afford to invest in quality that you might get later on. So,
    there's got to be some prospective payments that go along with
    it. But the time and the up-front payment are the two biggest
    things, and then of course the training that would go along
    with that.
        Senator Stabenow. Thank you very much, Mr. Chairman.
        The Chairman. Thank you, Senator Stabenow. And I know that
    you and Senator Thune are going to do good work with our
    colleagues working on this effort to look at the payment issue.
        Senator Grassley?
        Senator Grassley. My first discussion will be with Dr. Furr
    and Ms. Matthews. I frequently hear from Iowans about poor
    access to health-care services, especially in rural areas. In
    many States, pharmacists, audiologists, and more are licensed
    and trained to perform certain medical services that Medicare
    does not pay for.
        Example: right now pharmacists cannot get paid under
    Medicare Part B rules for providing wellness screenings,
    immunization, or diabetes management. I support modernizing
    Federal rules. Should modernizing Federal rules to match
    licensing and training laws in the various States be a part of
    strengthening and improving health-care outcomes for patients
    with chronic conditions?
        Dr. Furr. Thank you, Senator. And I know you are concerned
    about rural areas and the importance of the geographic index
    also, and that we are protected there. I think that the problem
    in the rural areas is also, everybody is overworked, and my
    pharmacists are doing everything they can to fill their
    prescriptions. I do not know how they could even possibly
    consider doing wellness visits if they had that time to do
    that. But at this time, I mean, they are trying to do that and
    do immunizations. So we are all overworked, and I do not know
    how they could actually do that, personally.
        Ms. Matthews. Thank you for the question, Senator. I would
    just share that in the Advanced Alternative Payment Models,
    that we have made investments, including in the rural
    communities, to help support pharmacists' engagement with the
    patients and the providers to help support that kind of work.
        Those are the kinds of things that ACOs do without a
    billing code, because they are responsible for the total cost
    of care. So, wrapping their services around, the ACOs are
    making investments to help bring additional access to these
    communities. That is inherently baked into the models.
        Senator Grassley. Dr. Furr and Dr. Navathe, I have
    championed efforts to ensure Iowa physicians, and other rural
    States as well, get paid fairly for health-care services.
    Iowans pay the same amount of money in Medicare as everyone
    else. So the physicians labor market is not local but national,
    especially with the expansion of telehealth.
        Through the end of this year, Congress has established the
    Geographic Practice Cost Index--GPCI for short--that floor, to
    ensure that rural State physicians receive a fair
    reimbursement.
        So to you two, is CMS using the more current and complete
    input data for GPCI to determine physicians' payments?
        Dr. Furr. The AFP has strongly endorsed that and keeping
    that floor. The one thing we have learned from COVID is,
    suddenly all of my nurses decided they could be travel nurses
    and make two or three times what they could in rural Alabama.
    So now we are having to compete with New York and California
    and Georgia and everywhere else. So, if they are going to come
    back and practice with us, they want to get the same rates. So
    the labor costs do not reflect, I think, what actually is going
    on, and inflation is the same everywhere. Our costs are just as
    great in our State as they are anywhere else--and in rural
    Iowa.
        Dr. Navathe. Thank you, Senator, for that question. I think
    it is correct that the way the labor markets are functioning
    now is different, as Dr. Furr has highlighted, and there are
    needs to update the data to reflect that. There is granular
    data that is collected by other agencies across the U.S.
    Federal Government that could be used to update the input data,
    for example, for the GPCI, which I agree is so important.
        Senator Grassley. A follow-up for you, Dr. Furr. Currently,
    36 States have statewide areas for GPCI and do not distinguish
    more urban areas within the rural States. Should there be more
    geographic areas to account for this?
        Dr. Navathe. I certainly think it is important that we have
    the right geographic designations for us to be able to
    categorize the way that labor markets work and the way that
    individuals actually do, for example, commute from rural areas
    into urban areas or vice versa. And so, I think as you are
    highlighting, reexamining, so we are constantly up to date on
    how the markets function, is absolutely correct.
        Senator Grassley. To you too, I am going to shorten up my
    introduction by just asking this question. Is Medicare
    Advantage an effective model to expand and improve chronic care
    management services for seniors, while also lowering Medicare
    spending?
        Dr. Navathe. So, I believe there are two sides to this. I
    think on one hand Medicare Advantage, which is more generously
    paid--you know, MedPAC for example has put out estimates that
    Medicare Advantage payment is up to 20 percent, maybe even more
    than that, more generous than the traditional Medicare program.
        Those dollars are at least in part being deployed to
    support things like transportation, which the traditional
    Medicare program does not have any support for, which I can say
    from my own personal experience has been critical at times.
    Very, very important to get beneficiaries who have
    disabilities, for example, to their appointments. Otherwise, it
    can be very hard.
        On the flip side, because there is such generous
    overpayment, if you will, to the Medicare Advantage side, it is
    hard to know whether we are really getting true value from all
    of those dollars. Certainly, there is some value in the
    supplemental benefits that are helping chronic disease care.
    But are we really getting value from it? And I would say we do
    not know the answer to that, and that is a very challenging
    question for us to wrestle with. One thing is for sure: there
    is no symmetry across traditional Medicare and Medicare
    Advantage. It is very hard for us to deliver the same kind of
    tailored care in traditional Medicare unless we do alternative
    payment models like ACO, as Ms. Matthews has highlighted.
        The Chairman. The time of the gentleman has expired.
        Senator Johnson?
        Senator Johnson. Thank you, Mr. Chairman. First of all,
    thank you for this hearing. This is another one that I think is
    highlighting the fact that we have a horribly broken medical
    financing system, and I would argue that Medicare has not
    helped that. And I think the testimony today pretty well proves
    that, because we are talking about the payment schedule, how it
    has distorted medicine.
        Now, I do not even want to call it a market, because I do
    not think we have a market in medicine anymore. And you know, I
    listened to Senator Stabenow--so we have been talking about
    this for a long time. Dr. Turner talked about innovation. I
    think somebody else talked about being flexible. Well,
    government does not really drive innovation very well.
    Government is not particularly flexible, and that is the
    problem we are all dealing with here.
        So I really want to focus--I am sure you probably do not
    want to be practicing for 80 years, but I will take 40. I wish
    I could talk to a physician who was practicing 80 years ago.
        But what I want to focus on, Dr. Furr, is, forget the
    medical innovations, which have been unbelievable, what we have
    been able to do in the last number of decades. I mean, what we
    can do in medicine is truly remarkable. But just the practice
    of medicine--is it better today or worse? I mean, would you
    like the medical innovations while being able to practice in
    the 1980 model? Do you know what I am trying to get at here?
        Dr. Furr. It is better. I mean, years ago, we had people
    die out of just benign infections. We did not have penicillin--
    --
        Senator Johnson. But again, set aside the medical advances.
    Just about the practice. I mean, you are a primary care
    physician. We aren't able to track them very well. I mean, it
    seems like the solution here is a more primary-care-physician
    model, which we were closer to in the 1980s, probably more so
    in the 1950s and 1960s.
        Dr. Furr. Yes. I think, we have gotten better, like you
    say, in advances and all, but as far as the stress of
    practicing, it is much more difficult now than it has ever
    been. Physicians used to work hard, but they spent their time
    taking care of patients. They do not feel like they are
    spending time taking care of patients now. They are doing prior
    authorizations and other things to get those innovations there.
    But there is not as much enjoyment of it.
        Senator Johnson. And again, you are doing those
    authorizations because you have to do it for Medicare and
    Medicaid. You have to do it for insurance. You have to do it
    for a third-party payer system; correct?
        You did not have to do that when you were actually billing
    the patient directly, when you had consumerism in health care,
    when you had patients making the decision, do I want to go to
    10 different specialists, or do I really want to rely on a
    primary care physician, kind of let him work with me to make
    those decisions?
        Dr. Furr. That is correct.
        Senator Johnson. Again, the point I am making is--and I
    have said this, whether we are talking about our overly complex
    tax system or our completely broken health-care financing
    system--we are talking in this committee about putting a band-
    aid on a dying patient, and I am trying to figure out, how do
    we revive the patient? How do we bring back consumerism?
        I often say that two areas of our economy that we are very,
    just habitually dissatisfied with, are education and health
    care. What they have in common is, we have largely driven the
    benefits of free market competition out of both areas, and in
    particular in medicine. How do we get it back?
        Again, we are not going to do it through changing the fee
    schedule--and, Ms. Matthews, I know you have your own little
    solution here. It is not a solution. It is really not fixing
    things. It is maybe improving things marginally.
        But we are paying what, double what world health-care costs
    are, and we are getting, in many cases, worse outcomes. I mean,
    this is not working. We need a paradigm shift here. We need to
    think outside the box. Again, I just do not think putting a
    band-aid on the Medicare payment system is going to do it.
        I mean, does anybody have any ideas or just want to comment
    on that? Dr. Turner, you look like you want to say something.
        Dr. Turner. Well, thank you for that question and for that
    comment, Senator. I do think that the opportunity for those
    closest--the subject matter experts--to propose innovative ways
    to provide better care and bend the cost curve, as was the
    plan, we think, under MIPS, is probably a good idea.
        Bringing some of those good ideas that came forward through
    the PTAC and allowing them to actually be tested and
    implemented, I think, will get at part of what you are
    describing. One size does not fit all. Making sure that we are
    centering the patient and that we have the subject matter
    experts propose what could really be the innovation that could
    help to change the conversation, that is part of the solution.
        And so, thinking about some of those great ideas--you know,
    we had one other specialty that brought forth smart,
    innovative, thoughtful solution-oriented ideas to the PTAC, and
    then they were not able to really be tested and then ultimately
    implemented.
        So that would be one possible of the many solutions that
    might address what you are describing. But I agree with you
    entirely, that when we talk about access, and in a rural
    community, we have surgeons who are out there trying to keep
    their practice doors open who want to provide care, but the
    administrative burden is so onerous that in those Critical
    Access Hospitals, where they are the only game in town, so to
    speak, we want them to be able to provide the care that they
    want, but the administrative burden is overwhelming them.
        Senator Johnson. And it is the administrative burden that
    is just a self-inflicted wound, and that is why we need to stop
    doing it. I would love to talk about the prospects of using AI
    and more expert systems in medicine. I have seen that debate
    over the decades, but we do not have time for that as well.
        But thank you, Mr. Chairman.
        The Chairman. I thank my colleague. We will be doing a lot
    of discussion about AI in the days ahead.
        Senator Warner--we don't really do ``gangs'' here in the
    Senate Finance Committee, but to the extent we do task forces
    and coalitions, Senator Warner was my partner back when we got
    this off the ground with the late Johnny Isakson and Orrin
    Hatch. That was a good crowd to run with, and we welcome you.
        Go ahead, please, with your questions.
        Senator Warner. Well, thank you, Mr. Chairman. You took the
    words right out of my mouth. I was going to actually start with
    a compliment to both you and the ranking member for holding
    this hearing, and the fact is, I do not fundamentally disagree
    with my friend from Wisconsin. But I do not know how, with the
    complexity of medicine, we reinstall this back into consumer
    choices, when a consumer is going to have to figure out which
    advertisement to believe about which promised drug or which
    promised therapy might work.
        I do think one of the things that, again with our dear
    friends Johnny Isakson and Orrin Hatch--the whole notion of the
    CHRONIC Care Act was recognizing that some of these diseases
    are not going to be solved with a pill, but are going to have
    to be managed over a long period of time. And getting that
    right--I would agree with Senator Johnson that what we have
    done generally here--gosh, this is hard, so let's just bump up
    reimbursement rates across the board--is not going to be the
    answer as well.
        I do think some of the work a lot of us on this committee
    have done beyond chronic care on things like telehealth, on
    things like getting folks to be able to get more services in
    the home, some of the prevention activities--we still do not
    have a scorecard system that scores prevention. And you know, I
    think about diabetes and the good work some of us have tried to
    do on diabetes, but that does not get recognized in any way, at
    least in terms of the scorecard.
        But I am going to start with Dr. Furr. You know, I have
    spent a long, long time on advanced care planning. I have done
    it on Alzheimer's, and I think we are the only industrial
    nation in the world that has not had an adult conversation
    about end of life, and has not been able to sort that out in
    any meaningful way.
        Let me be clear: I think everyone should have all the
    medical options available to them, but we just do not have that
    kind of conversation. So for years, we have been trying to get
    a Medicare reimbursement on advanced care planning. You know,
    this is a conversation we have all got to have. It is a hard
    conversation.
        We got it in, and yet it appears to me that the take-up
    rate, particularly for family physicians, outside that annual
    wellness visit, has not really worked that well. Do you have
    any idea on how we--when Congress tries to set, or CMS tries to
    set a reimbursement schedule, that we do not so overburden it
    that the physicians and providers themselves just find this is
    too much hassle to use?
        Dr. Furr. You know, I think that was a great advancement,
    and we do use it in our office. It means a lot to have that
    time to spend with the patient and look at that, and make sure
    they do have a plan going forward. I think the problem is,
    because of all the other hassles in medicine right now with the
    prior authorization and the other things, there are just so
    many hours in the day, and there are just not enough hours to
    do that. That does take time----
        Senator Warner. But I've got to--I want to just interrupt.
    I mean, if we are talking about end-of-life kind of issues or
    last stage--I know we are not supposed to use the politically
    incorrect ``end of life'' anymore. But who do you have to get
    prior authorization from, God? [Laughter.]
        Dr. Furr. No, no. We do that, but----
        Senator Warner. That was just too easy. I couldn't let you
    get by on that one.
        Dr. Furr. Yes. I mean, we do that, and we utilize that code
    very much. But again, there are only so many hours in the day,
    and your staff is doing prior authorizations. They cannot get
    CT scans covered. You are now forced to do all these other
    things that you should not have to do----
        Senator Warner. Right.
        Dr. Furr [continuing]. So you cannot get to the really
    important things, and I think this is the problem with medicine
    right now. We do not have time to do the important things like
    you are mentioning because we have all these other hassles that
    really should not be there, and we cannot do them. So our time
    is spent doing unnecessary things, rather than doing the
    necessary things that you are mentioning.
        Senator Warner. Well, while I am on it--and maybe this
    would be for the panel because, I mentioned my mom had
    Alzheimer's for 11 years, 9 years of which she did not speak.
    My father and sister took care of her in a remarkable way.
    Hardest thing; I could never have done that.
        But for Alzheimer's, how do we even think about
    reimbursement? We just, I think--FDA just recently approved
    another drug, $3.5 billion, and I think drug therapy makes
    enormous sense. But there is a whole portion of caring.
        How do we get it right in terms of chronic illness like
    Alzheimer's, to give the providers the right incentives to do
    the appropriate care, whether in-home or elsewhere, without all
    the hassles? Let me just go quickly down, recognizing I only
    have 25 seconds, and Senator Whitehouse has been very, very
    patient.
        Dr. Navathe. So, I think that the short answer is, in the
    fee-for-service program we have to pursue alternative payment
    models that force the provider entity and the clinicians to
    internalize, balancing the health benefit with the cost. If we
    cannot get there, it is going to be very hard to actually steer
    that forward.
        Senator Warner. And that is hard to do. Very quickly,
    because my time has expired. But, Dr. Furr, and the balance of
    the panel.
        Dr. Furr. And the key is, I think, for all those patients
    to have a family physician who coordinates their care and knows
    their patient, and spends time with them and their family and
    knows their needs. I think that makes all the difference in the
    world.
        Senator Warner. Dr. Turner?
        Dr. Turner. I think this is an opportunity to highlight the
    expansion of facility-based scoring in MIPS, to think about the
    type of collaborative shared accountability measures that would
    work for Alzheimer's and work for other chronic conditions. So,
    thinking about the holistic approach would address that
    concern.
        Senator Warner. Ms. Matthews?
        Ms. Matthews. I might just add that there is a new dementia
    care model that goes into effect July 1st of this year called
    the GUIDE model, and that is one of the models in which to
    provide additional support for Alzheimer's intervention-related
    care, and I applaud the work for this very vulnerable
    population.
        Senator Warner. And how we make sure that providers
    understand this and do not get intimidated by this new process
    is important. I know we have another--again, I will not use the
    disparaging ``gang,'' although my first gang was with Mike
    Crapo on the Simpson-Bowles effort. But I do think the working
    group we put together on this, I look forward to trying to
    participate on.
        The Chairman. Well, thank you, Senator Warner. Good job as
    always. And before you got here, I went through the history of
    the fact that in our original chronic care bill, as you will
    recall, we had major telemedicine provisions. I remember the
    day--I will never forget it--when Donald Trump's head of CMS
    called me and asked me would it be okay if they used the
    bipartisan product of the Finance Committee.
        I should have called you up and said, ``Mark, hold a party
    for us,'' because this was a product of the Finance Committee
    that really laid the foundation for expanding telemedicine
    during COVID. What I would like to work with you on, as you go
    through this task force, is expanding telemedicine, and one of
    the areas we ought to start with is interstate coverage.
    Because this idea, in this age when we talk so much about tech
    and AI and the like, that you cannot have patients treated when
    they are, you know, 10 minutes away from another place----
        Senator Warner. I do wonder who that CMS director got prior
    authorization from. [Laughter.]
        The Chairman. That director--when the chair of the
    committee recovered from his shock and forgot to ask you to
    hold a party, it was amazing, because it was talked about again
    and again. Out of all the horrors of COVID--of which there are
    so many--one of the things that made a difference was
    telemedicine. I appreciate all the good work.
        Okay. In the order of appearance it would be Senator
    Blackburn, but I know Senator Whitehouse has been waiting.
    Senator Lankford has been waiting.
        Next in order of appearance will be Senator Blackburn.
        Senator Blackburn. Thank you so much, Mr. Chairman. And I
    am glad we are talking about telehealth, because I had the
    legislation in the House. And I think we were all pleased when
    it was picked up during COVID, and we really felt its worth and
    its impact.
        I have to tell you, in February I had the opportunity to
    sit down with members of the HIMSS chapter in Nashville, and as
    you all know, they are so focused on this bucket of issues that
    we are discussing today. They are innovators; they are forward
    thinkers.
        In Nashville, our health-care industry generates, every
    year, $100 billion in revenue, and it is responsible for over
    500,000 jobs. So it is important, and any of my committee
    members or the witnesses who want to come to Nashville, we will
    be more than happy to set up meetings and show it off. We think
    it is pretty important.
        But one of the things that came up in this meeting with
    health-care innovators and physicians was the issue of
    consistent reimbursement policies, and the need for that
    transparency for physicians and for patients and providers, and
    also for investors, to give them confidence. Because many of
    them are investing in this new innovation and new technologies,
    which are going to end up yielding better outcomes.
        And one of the things I have witnessed in my years in the
    House and here in the Senate is, before we passed MACRA in
    2015, we voted 17 times--17 times--to delay the pay cuts, and
    this was under the Sustainable Growth Rate formula. So that
    inconsistency, that amount of nerve-wracking, that uncertainty
    around compliance and being able to meet your compliance--you
    know, this is why I think it is so important that we look at
    stable physician payments as we look at MACRA. And it has been
    mentioned by others on the committee, we do have a working
    group that some of us are going to be a part of to try to find
    some answers to this.
        I know it would make your life easier, and physicians are
    always talking to me about trying to cope with operational
    cost, and the pressure that is there. What we have seen in
    rural Tennessee is the closure of some practices, some early
    retirements, consolidations in these independent practices. And
    what I have noticed is, it has detrimental delays in care
    delivery, in wait times, and in access to affordable health
    care.
        So, a ``yes'' or ``no'' from you all, and we will just go
    right down the list. I would like to know if you agree that the
    cost of providing care in practices has increased over the
    years, and if you agree that payment has kept pace with that
    rising cost. So ``yes'' or ``no,'' has cost increased and has
    payment kept pace?
        Dr. Navathe. So, I do believe that costs have increased,
    particularly when you factor in inflation, and so I think that
    is absolutely correct.
        Senator Blackburn. Okay.
        Dr. Furr. Yes, to the first question, no to the second.
        Senator Blackburn. Okay.
        Dr. Turner. Costs have absolutely increased, and the
    payment has not kept up with that. The inflation has been
    problematic and the reason.
        Senator Blackburn. Okay.
        Ms. Matthews. I have the same answer. Costs increased.
        Senator Blackburn. Then you all are right in line with
    Tennessee physicians.
        I want to talk about MIPS. I know several others have
    talked about this. Dr. Navathe, talk to me about your
    experience with MIPS and the administrative burden that is
    there with that, and then what you see should be the changes.
    What lessons should we learn? What should we keep, and what
    should we toss?
        Dr. Navathe. So I think the experience that my colleagues
    have had under MIPS has been one that, frankly, has not been
    that effective. So you have rightfully pointed out the
    operational administrative burden that comes along with that
    type of reporting. And it is unclear that reporting the
    measures that we are reporting on are actually in keeping with
    what beneficiaries really care about. I think that is a
    fundamental disconnect. I think approaches like MIPS, in
    general, have been shown not to be very effective in improving
    care.
        One of the challenges getting toward what we can do is--
    MIPS kind of presents this choose-your-own-adventure type of
    approach, and that is kind of weird actually, right, in terms
    of trying to get a standardized set of data. I think it is very
    challenging to improve MIPS, to make marginal changes to it and
    actually get to where we need to go.
        I think most likely we need to reimagine it completely, and
    potentially replace it.
        Senator Blackburn. So you would say toss it and start over?
        Dr. Navathe. I would say replace it; that is correct.
        Senator Blackburn. Okay; that is great.
        Dr. Turner, I have a question for you I will submit, and it
    has to do with overestimating spending and the payment policies
    of the Physician Fee Schedule. So let me do that, because we
    need to talk about the forecast error adjustments.
        But, Mr. Chairman, thank you.
        The Chairman. I thank my colleague, and I am glad she is on
    the working group that is going to tackle these issues.
        Next is Senator Whitehouse.
        Senator Whitehouse. Thanks very much.
        I would like to talk about two pieces of legislation. One
    is a primary care bill that Senator Cassidy and I are working
    on, whose discussion draft is out and which provides for hybrid
    payments for primary care, and creates a physician payment
    expert panel to try to better organize the payment model.
        Dr. Navathe, I believe you are familiar with that
    discussion draft?
        Dr. Navathe. Yes, Senator, I am.
        Senator Whitehouse. And it seems to align quite well with
    your testimony before the committee today.
        Dr. Navathe. Yes, sir. I think I would highlight two
    points. One, the hybrid payment model that is in the discussion
    draft is part of the Physician Fee Schedule. So it is not a
    single-model alternative payment model. I think that is very
    important to scalability.
        The second point I would highlight is, there is a provision
    for establishment of an advisory committee that will not
    reduplicate the important work that the RUC does, but really
    add to it so CMS has appropriate tools to manage the fee
    schedule.
        Senator Whitehouse. And the resulting benefit if those were
    to become law would be----
        Dr. Navathe. So really, two things. One, as we have talked
    about--Senator Wyden very nicely characterized how chronic care
    is such an important challenge. I think for primary care
    physicians, a hybrid payment could catalyze a completely new
    payment model at scale across the Nation.
        We have talked a lot about stability here. You know, one of
    the challenges around alternative payment models has been that
    they have tended to change maybe every 5 years. It is very hard
    for practices to invest in something if the rules of the game
    are going to change 5 years later.
        So the stability of what you have proposed in that
    discussion draft, I think, is fundamentally critical to
    actually getting better chronic disease care in the long run.
    That will necessitate adaptations to the fee schedule, and so
    the advisory committee really then comes in to fill in the
    additional needs there.
        Senator Whitehouse. Thank you. And let me just take a
    moment to thank Senator Cassidy for his work with me on that
    legislation.
        The other bill is the Value in Health Care Act that I am
    doing with Senator Barrasso. Other members on this committee
    who are cosponsors include Senators Tillis, Cassidy, Thune, and
    Blackburn.
        Among other things it, would extend the 5-percent incentive
    payment. It will help address the cost issues that ACOs face
    when they are trying to pay their way through a very expensive
    and difficult transition to treatment that is consistent with
    the new payment model. And I would like to ask Ms. Matthews how
    those incentives relate to the ability of ACOs to improve and
    invest in patient care?
        Ms. Matthews. Thank you, Senator, for the question. First,
    I want to thank the committee for supporting the advanced
    alternative payment bonuses. They are really critical at
    engaging the physician in ACOs, and encouraging stability and
    engagement.
        Second, I would say that those bonuses go directly to the
    providers, and that allows them to make investments in care
    coordination and technology.
        I am reminded there was a previous question around MIPS and
    reporting. We support independent physicians, and those
    incentives were paramount for engaging in AAPMs and really
    promoting the continuation of independent practice by helping
    support the investments that are critical for this
    transformation from fee-for-service to value.
        And then also--just to make a quick comment for you,
    Senator Whitehouse, on the work under the hybrid--under some of
    these ACO models, we are testing and paying capitation to
    primary care. I used to say that one of the reasons I knew that
    we were being successful in value-based care was listening to
    and watching my physicians take their phone calls to manage
    their patients.
        They were so engaged in their total care, and they were
    aligned around all things for their patients. So at 5, if they
    got a call, they said, ``Come on down, let me see you,'' and
    they were not going to the ER, as an example. They were
    completely accountable, and the hybrid capitation helps with
    that.
        Senator Whitehouse. It is the outcome we want.
        Ms. Matthews. Yes.
        Senator Whitehouse. My time is about to expire, so let me
    ask a last question for any of you who choose to comment on it
    for the record. So an answer in writing, so we are not
    burdening the time of the committee further.
        We are working on a bill to, in a nutshell, require prior
    authorization by CMS before any prior authorizations can be
    applied by insurance companies to providers. They would have to
    really show that there is a medical justification for the prior
    authorization, and we would be focusing on applying that to
    providers that were under an alternative payment model,
    incentivized value-based model, and had shown that they
    succeeded.
        So presumably, they have no interest in running up bills
    that would raise their costs and diminish their payment at the
    end of the day. It does not make sense to apply a prior
    authorization to a provider who is successfully engaged in an
    at-risk, value-based practice. And so, we are looking at trying
    to get rid of that, just get rid of it, and/or make them at
    least come in first to CMS and say, ``You have to authorize me
    requiring prior authorization, otherwise, I cannot do it at
    all,'' and put that kind of a check on the misuse of prior
    authorization.
        If you have any thoughts about that, I would be grateful to
    hear. I do think that it probably needs to focus on those who
    are participating in advanced payment models and have skin in
    the game, and have shown themselves to be successful. But I
    would be interested in your thoughts, and I thank the chairman.
        The Chairman. I thank my colleague. And for those who are
    guests of the Finance Committee, Senator Whitehouse has spent
    an enormous amount of time over the years on these primary care
    issues. I have enjoyed working with him, and we look forward to
    doing a lot more in the days ahead.
        Senator Lankford is next.
        Senator Lankford. Mr. Chairman, thank you. Thank you all
    for spending your time here. A lot of things you could be doing
    today. Thanks for being here and being a part of it.
        We have all talked about the Physician Fee Schedule and the
    struggle with that. That is frustrating for all of us, but
    especially for physicians on it. I am one of the folks who
    thinks we need to incentivize more doctors coming into the
    process, rather than the next generation of folks thinking, ``I
    do not want to do that, to be able to deal with the hassle of
    that all the time.''
        I would like for more folks to be able to come into the
    process with several things we have kind of highlighted, and I
    am not going to go through them as well. But the Critical
    Access Hospital piece has been a challenge in my State, a State
    that is split evenly rural and urban, and trying to be able to
    manage that.
        We have a bill, the Rural Hospital Closure Relief Act,
    which gives some States some flexibilities. We have not talked
    about
    physician-owned hospitals, but that continues to be an issue
    long-term: allowing physician-owned hospitals to continue to be
    able to grow and to be able to take care of their patients.
        I do want to talk a little bit about this prior
    authorization. Dr. Furr, you have mentioned this a couple of
    times as well. We have hospitals in my State that are just no
    longer taking Medicare Advantage because of the prior
    authorization issue on that. How does that get resolved? What
    do you see as the solution to that?
        Dr. Furr. And you are seeing physicians refusing to take
    them, along with that, and it is a huge hassle. It takes a huge
    amount of time. I think physicians need to be able to practice.
    And again, when it is for big-budget items, I do not have a
    problem with prior authorization, but when it comes to basic
    drugs and basic things we need to do----
        Just to give you a perfect example, if I have a patient
    with an acute abdomen, it is easier to send them to the
    emergency room--because they do not have to get a prior
    authorization to do their CT scan--than for me to do it in my
    office because it could take me a day or 2 to get that done.
        So the prior authorizations, which are meant to control
    costs, in many ways are actually increasing cost. And sometimes
    the best drug might be a more expensive drug, but it is better
    for the patient because it might lower their cardiovascular
    risk, along with taking care of their diabetes or their
    hypertension.
        So those are all issues with prior authorization that keep
    us from providing the best care that we can, and actually drive
    up cost.
        Senator Lankford. Okay. That is helpful to be able to get
    context.
        Ms. Matthews, you have talked a lot about the value-based
    care, and some of the issues and the innovations that are
    there. With 34 ACOs that are operating in Oklahoma, they have
    saved $50 million, the best we can guess, the last couple of
    years on it.
        But I do want to give an example of this. We have one ACO
    in Oklahoma that saved almost $9 million just in 2022. But they
    missed the minimum savings rate by .17 percent. So here is the
    challenge. What recommendations would you make on making
    changes to the Shared Savings Plan to make sure that we have
    more ACOs and that we do not actually frustrate entities that
    are trying to get into this?
        Ms. Matthews. I think building in the stability for the
    long-term commitment to the AAPM, and engaging with CMS and
    Congress on the importance of accuracy around benchmarking. You
    know we had, through COVID, very, very different utilization
    patterns, and those were realized very differently depending on
    the State that you lived in as well.
        And so, when we look at creating national and regional
    benchmarks, there is some implication in the benchmarks from
    COVID, just because of the utilization and historical
    expenditures. So that certainly created some of those
    methodologies.
        The other thing is, we are learning so much, and so I
    applaud the work that we are doing to take a look at what we
    called the lessons learned in the models, and how do we
    continue to iterate on those to be more successful for the
    models in the future.
        Senator Lankford. Okay.
        I want to ask about something that we have not talked a lot
    about today, and that is hospice care and how it interacts with
    Medicare, just for the care of patients and individuals. I know
    that it is set up typically for the last 6 months of life; not
    always. We have a rather famous example of that in President
    Carter, who I think has been in hospice care 14 months at this
    point or approaching that. The design of it is to be able to
    help with end of life, to be able to help through not only
    families, to increase some benefits in some areas and decrease
    them in others.
        I walked through this recently. I will not go through all
    the story on this with my own mom, who was a Parkinson's
    patient for years. She passed away a year and a half ago. But
    some physicians toward the end would talk to me about hospice
    care and were walking through that as a son and a mom and a
    physician.
        I was advised, well, you know what? If hospice care is not
    working out and you want to come see a specialist or whatever
    it may be, you can just drop it, go back into Medicare, be in
    Medicare for a while, then drop that, go back into hospice
    care. I suddenly understood there is loophole in the system
    that is literally being built in, and it is being exploited. I
    personally watched firsthand in that, other issues that are
    like that.
        What would you recommend on changes in hospice care and
    ways that we can help families in those moments, whether that
    be in the value of it or what needs to be done do be able to
    improve hospice? I am open to anyone who wants to contribute.
        Dr. Navathe. I am happy to contribute. Thank you so much
    for the question.
        So I think a couple of things to highlight here. I think
    first, one thing that is actually quite interesting is another
    Federal program. The Veterans Health Administration provides a
    benefit to veterans where, when they opt into hospice, they
    actually do not have to forego regular life-extending care.
        And I believe the latest estimate from the VA is that that
    is a cost-saving program for them still, because it allows
    palliative care clinicians to come and educate patients and
    align care with their preferences, without what might seem to a
    family or a patient as a somewhat draconian thing, which is, I
    have to walk away from opportunities for other care. So that is
    one thing to contemplate.
        The other thing is, our hospice payment system also has
    opportunities for improvement. There are some peculiar
    incentives, in that we have caps on sort of duration of care
    that hospices can give. Those create distortions. So it is
    unclear that those caps are actually doing well for our
    beneficiaries, and that is something else that could be
    contemplated.
        Senator Lankford. Thank you for that.
        The Chairman. And the time of my colleague has expired.
        Senator Warren?
        Senator Warren. Thank you, Mr. Chairman.
        Physicians' practices are increasingly being gobbled up by
    corporations and Wall Street. Today, nearly three out of four
    physicians work for a hospital or a corporate owner rather than
    for themselves. In between 2012 and 2021, private-equity
    buyouts of physician groups increased over 500 percent. And
    it's not just private equity. Insurance companies like
    UnitedHealth, giant retailers like Amazon, and investor-backed
    groups have all dramatically expanded their control over
    physician practices.
        Here is one to look at. The total capital raised for
    private investment in primary care alone increased by over
    1,000-fold in just a decade. It went from $15 million--with an
    ``m''--in 2010 to $16 billion--with a ``b''--in 2021. This is
    an alarming trend, and corporate consolidation of health care
    can increase costs, it can lower the quality of care, and it
    can accelerate physician burnout. But to reverse the trend, we
    need first to understand what is motivating physicians to sell
    their practices.
        So, Dr. Furr, you are the president of the American Academy
    of Family Physicians. Why do you think independent private
    physicians are increasingly willing to sell their practices and
    work for a big corporation?
        Dr. Furr. Thank you, Senator, and I do not think it is
    their first choice. Physicians tend to be independent-minded,
    and when I first had a practice 40 years ago, most of us did go
    into practice for ourselves.
        The cost of practice has just become overwhelming. It
    started with the emergence of the EHRs and the amount of cost
    that went into that, and even though there was some
    reimbursement for that, it was still a cost expense. Now the
    cost of running your practice--what you have to pay for your
    staff to have good staff, what you have to pay to do all the
    prior authorizations and all the other hassles that go along
    with that--the cost has just become enormous. And then, you
    have something like the Change Healthcare attack, where you
    suddenly do not get payments for 6 weeks and you are having to
    take money out of your bank account to fund your practice. And
    of course, if you are an independent physician, what happens
    is, you pay everybody else, and the way you make up the
    difference is, you do not take any pay.
        Senator Warren. So you are telling me it is about the
    economics of this?
        Dr. Furr. Yes.
        Senator Warren. And----
        Dr. Furr. And the complexity of the system.
        Senator Warren. And the complexity of the system. But that
    is a part of the economics too, right?
        Dr. Furr. Yes, it is.
        Senator Warren. So let's take a look at the Medicare part
    of this. Seniors, people with disabilities, rely on Medicare
    Part B to cover their doctor's office visits and other
    physician services. But Medicare payment rates, for primary
    care physicians in particular, are basically too low to cover
    their costs.
        Medicare payment rates are set through what is known as the
    Physician Fee Schedule, which determines how much Medicare will
    reimburse a doctor for, say providing a routine check-up or
    performing knee surgery. The payment rate is determined in
    large part by the ``relative value assigned to it.''
        A secretive committee run by the American Medical
    Association has played an out-sized role in recommending the
    relative values of physician services, and it has
    overwhelmingly recommended that specialty services are worth a
    whole lot more than primary care.
        So, Dr. Navathe, can you explain why this committee over-
    values specialty services?
        Dr. Navathe. The methodology the committee uses very much
    heavily values inputs like time, differentiated skill,
    intensity--and these are easier to estimate for concrete things
    like doing a surgical procedure, more so than they are for a
    cognitive activity like diagnosing a patient effectively.
        Senator Warren. So that is interesting. So let me ask: the
    committee itself for the AMA, is it dominated by specialists?
        Dr. Navathe. I believe there is an overrepresentation of
    specialists relative to primary care, yes.
        Senator Warren. Well, the reason I ask about this is, many
    organizations, including the National Academy of Medicine and
    the GAO, have called for changes in structure, so that primary
    care is adequately paid. I strongly agree with them, and so I
    think this is a part of what we have to understand about why
    physicians feel forced to sell their practices.
        There is another reason, though, why primary care
    physicians have been motivated to sell their practices, and it
    is the growing administrative burdens that you talked about
    earlier, Dr. Furr, where doctors are spending more time doing
    paperwork and less time with patients, which has widened the
    gap between primary care physicians and their Medicare patients
    even more.
        Now, we know that the number of independent physicians who
    have chosen to sell their practices appears to have
    significantly grown over the last 10 to 15 years. Dr. Furr,
    what changed during that time period to make the administrative
    burden so much worse?
        Dr. Furr. As I mentioned earlier, one of the things is,
    more of them are covered by Medicare Advantage plans, which
    have a lot of prior authorization, even on drugs now, that we
    used to not have to deal with----
        Senator Warren. Okay. So prior authorization is part of it.
    Anything more?
        Dr. Furr. The prior authorizations, and then just even
    admissions to the hospital, things like that. All of those have
    to be prior authorized procedures--all of those things. And
    then the complexity of coding continues to get more and more
    complex, and so then you have to do additional codes, and if
    you do not do one little thing, and you code it wrong, that
    code gets kicked out.
        Then your claim gets rejected, and you have to resubmit
    again, and there is just all that continual cost of doing that.
        Senator Warren. So, I had a doctor tell me last week, after
    we had done a hearing, that it is now the case that you cannot
    just do an animal bite as your code, that there is a different
    code for a turtle bite, as opposed to a fish bite. And so, we
    want to watch out for this going forward, right?
        Look, my view is, we should reward high-quality care rather
    than high-volume care. But to do this requires significant up-
    front investments that existing payment rates for primary care
    just do not cover. And I think this has created the perfect
    environment for corporate investors to swoop in.
        There are things we can do to make physicians less
    vulnerable to corporate vultures. As this committee continues
    to work on physician payment reform, it is critical that we
    root out the conflicts of interest that assign more value to
    specialist services than to primary care. But we must also
    ensure that the transition to value-based care does not lead to
    further consolidation and further corporatization.
        Thank you, Mr. Chairman.
        The Chairman. I thank my colleague for her remarks. Those
    were very important issues. I am not going to get into all of
    the animal species, but my colleague is making the key point,
    which is, we have to stop the financial vultures. And one of
    the things that I am going to do--and I look forward to working
    with my colleague on the whole suite of issues she just went
    into--is, we touched on it earlier, the $6 billion that goes
    for marketing.
        I think that money can be spent in a better place, and we
    are going to be talking to these nice four witnesses, and our
    working group, and the like, about whether we can find some
    common ground on putting that money, as Senator Warren is
    talking about, into patient care. Because right now, as she
    just described, patients and taxpayers--because it is two sides
    of one coin--are getting fleeced. So let me just offer a quick
    comment, and we will be out the door.
        At one point, I think one of our colleagues talked about,
    well, is this going to be another band-aid on Medicare? No.
    What we want to do is fundamental change. When we recognize
    that Medicare has changed, that it is not just about a broken
    ankle, it is about chronic care--and, Senator Warren, I think
    you might not have been able to be here because it has been
    such a busy day.
        Dr. Navathe talked about 50 interactions for a particular
    patient with all of these different kinds of people. And what
    you are talking about is primary care and particularly focusing
    on these chronic illnesses and patients rather than just
    propping up the vultures. And what we began in 2018, when
    Chairman Hatch was in charge of this committee, was CHRONIC
    Care 1.0.
        We have gotten good advice today about how to start closing
    the gap between Medicare Advantage and traditional Medicare.
    That is urgent business. And we certainly heard a lot about
    reducing administrative hassles and letting doctors put their
    time into patients rather than filling out forms and going
    through all these bureaucratic hoops.
        So this has been a good hearing of the Finance Committee.
    This is about the future of Medicare. We started it in this
    committee, and this is now moving to CHRONIC Care 2.0, and
    getting more to patients and protecting taxpayers and not all
    these rip-offs that Senator Warren just appropriately
    described.
        With that, the committee is adjourned.
        [Whereupon, at 11:52 a.m., the hearing was concluded.]

                                A P P E N D I X

                  Additional Material Submitted for the Record

                                  ----------

                    Prepared Statement of Hon. Mike Crapo,
                           a U.S. Senator From Idaho
        Across the country, more than 60 million Americans rely on Medicare
    to meet their health-care needs. Over the next decade, this population
    will grow by more than 20 percent. Medicare's coverage and payment
    policies play a dominant role in setting benchmarks and baseline rules
    of the road not just for the program itself, but also for countless
    other payers, affecting hundreds of millions of working families.

        In short, ensuring a resilient and robust Medicare program has
    become more vital than ever. Unfortunately, our current policies seem
    poised to fall short of that goal.

        Today's hearing highlights the urgency of advancing durable
    clinician payment reforms--both for front-line medical providers and,
    more importantly, for patients. In the absence of proactive policy
    changes, tens of millions of seniors will suffer the consequences. The
    risks of inaction range from surges in wait times and delays--including
    for critical care--to clinician office closures and cutbacks in
    provider participation. Our committee has an obligation to strengthen
    the Medicare program and avert these unacceptable outcomes.

        A successful legislative initiative must reckon with a range of
    challenges under the current paradigm, which has served to devalue and
    distort payments for vital services, as well as to exacerbate
    administrative burdens. In inflation-adjusted terms, Medicare Physician
    Fee Schedule payments have declined by more than 25 percent over the
    past 2 decades, even as clinicians continue to face skyrocketing costs
    for overhead, equipment, supplies, and staffing needs.

        As the Medicare trustees cautioned last year, the colossal gap
    between stagnant fees and steep inflation poses a dire threat to long-
    term patient access. The current conversion factor update schedule
    cannot sustain an effective--or even adequate--clinical workforce
    moving forward.

        For many specialists, recent regulatory changes have further
    intensified these issues, as new billing codes and valuation shifts
    have triggered drastic cuts under the program's budget-neutrality
    rules. Based on inflexible cost-containment measures, a payment bump
    for primary care prompts payment reductions for entirely unrelated
    procedures and services, from brain surgery to advanced cancer care.

        From 2014 to 2023, for instance, even before adjusting for
    inflation, the fees for chemotherapy administration and IV infusions
    declined. Under these conditions, it should come as no surprise that
    many physicians have opted to sell their practices, join health
    systems, or limit new Medicare patients. Structural fee schedule
    reforms should shift away from the status quo, which forces clinicians
    to vie for ever-
    dwindling resources, and move toward models that promote and reward
    team-based, patient-centered approaches.

        Nine years ago, Congress took concerted action to repeal the
    draconian Sustainable Growth Rate (SGR) system, which had threatened
    cascades of dramatic cuts. In enacting the Medicare Access and CHIP
    Reauthorization Act (MACRA), policymakers sought to stabilize the fee
    schedule and incentivize value-based care.

        In practice, these reforms have largely failed. The Merit-based
    Incentive Payment System aimed to establish an accessible on-ramp to
    participation in quality-driven alternative payment models, or APMs.
    Instead, this system has buried clinicians in dozens of hours of
    paperwork each year, all in exchange for potential, marginal payment
    bumps, based on ambiguous metrics that lack meaningful value for
    patients.

        A number of primary-care-focused APMs have shown promise, but
    countless specialties lack access to any clinically relevant models at
    all. While the MACRA-
    established committee to translate clinician-developed APM concepts
    into concrete policy options has worked through dozens of viable
    proposals, the Centers for Medicare and Medicaid Services (CMS) has
    largely rejected these opportunities.

        Reforms to advance value-based care thus demand a focus not just on
    financial incentives, but also on structural improvements that ensure
    meaningful options, informed by clinical experience and aligned with
    patient needs. I look forward to building on this committee's
    bipartisan work to bolster and modernize our clinician payment systems.
    The program's current and future enrollees depend on it.

        Thank you to our witnesses for being here today, and thank you, Mr.
    Chairman.

                                     ______

              Prepared Statement of Steven P. Furr, M.D., FAAFP,
                President, American Academy of Family Physicians
        Chairman Wyden, Ranking Member Crapo, and distinguished members of
    the committee, thank you for the opportunity to testify today. My name
    is Steven Furr, M.D., FAAFP, and I am a practicing family physician
    from Jackson, AL. I am a cofounder of Family Medical Clinic of Jackson,
    a rural health clinic, a member of the medical staff of a small rural
    hospital, and medical director of the local nursing home. As the
    President of the American Academy of Family Physicians (AAFP), I am
    honored to be here today representing the more than 130,000 physician
    and student members of the AAFP.

        As a family medicine specialist who has cared for patients for more
    than 35 years, I can speak firsthand about how fee-for-service payment
    in traditional Medicare, including its underinvestment in primary care
    and associated administrative burden, are impeding the delivery of
    high-quality, patient-centered, comprehensive primary care, which
    encompasses chronic care management (CCM).

        Family physicians provide continuing and comprehensive medical
    care, health maintenance and preventive services to patients across the
    lifespan regardless of age, gender, or type of problem. Through
    enduring partnerships, family physicians help patients prevent,
    understand, and manage illness; navigate the health system; and set
    health goals. The defining features of primary care, including
    continuity, coordination, and comprehensiveness, mean family physicians
    are particularly well-suited to serve as the focal point of care for
    patients with chronic conditions.

        Nearly 95 percent of adults 60 years and older have at least one
    chronic condition, and nearly 80 percent have two or more.\1\ This is
    only projected to get worse in the coming years as the number of adults
    50 years and older with at least one chronic disease is estimated to
    increase by almost 100 percent from 71.522 million in 2020 to 142.66
    million by 2050.\2\ Effectively meeting the current and future needs of
    our patients with chronic conditions requires our Nation to better
    leverage primary care as the foundation of our health-care system.
    However, our current fee-for-
    service payment structure favors and incentivizes work that is done to
    a patient, rather than done with and for them. We need doctors who care
    for people, not doctors to deliver services.
    ---------------------------------------------------------------------------
        \1\ National Council on Aging. Chronic Inequities: Measuring
    Disease Cost Burden Among Older Adults in the U.S. A Health and
    Retirement Study Analysis. Page 5, Figure 2. April 2022. Accessed
    online at: https://ncoa.org/article/the-inequities-in-the-cost-of-
    chronic-disease-why-it-matters-for-older-adults.
        \2\ Ansah JP, Chiu CT. Projecting the chronic disease burden among
    the adult population in the United States using a multi-state
    population model. Front Public Health. 2023 January 13;10:1082183. doi:
    10.3389/fpubh.2022.1082183. PMID: 36711415; PMCID: PMC9881650.

        I'm seeing how our failure to invest in and uplift the true value
    of primary care is impacting my patients every day. Our physician
    workforce skews heavily toward non-primary care specialists, and we
    have fewer primary care physicians relative to the population than in
    other countries. This is having severe impacts on patient access. In a
    recent comparison of primary care access across 10 peer countries, U.S.
    adults were the least likely (43 percent) to have a longstanding
    relationship with a primary care provider and a growing number of
    adults have reported not having any usual source of care over the past
    decade.\3\ At the same time, three-quarters of U.S. adults (73 percent)
    say the health-care system is not meeting their needs.\4\ This data is
    telling. People are losing their trusted relationship with a primary
    care physician and, in turn, their trust in the health-care system.
    ---------------------------------------------------------------------------
        \3\ Gumas ED, et al. ``Finger on the Pulse: The State of Primary
    Care in the U.S. and Nine Other Countries,'' March 28, 2024. The
    Commonwealth Fund. Accessed online at: https://
    www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-
    pulse-primary-care-us-nine-countries.
        \4\ The Harris Poll, ``The Patient Experience: Perspectives on
    Today's Healthcare.'' 2023. Accessed online at: https://www.aapa.org/
    download/113513/'tmstv=1684243672.

        Evidence continues to suggest this type of longitudinal
    relationship that I and other primary care physicians foster with our
    patients leads to better control of chronic conditions, fewer emergency
    department visits and hospital stays, and improved health
    outcomes.\5\, \6\ Unfortunately, traditional Medicare
    underinvests in these trusted relationships with patients. Low primary
    care payment rates in a system that rewards volume over value means
    physicians are pressured to see as many patients as possible.
    Meanwhile, overwhelming administrative burden takes time away from
    delivering patient care and often requires physicians to spend hours
    outside of the office doing documentation.
    ---------------------------------------------------------------------------
        \5\ Jennifer Arnold, ``Fostering Long-Term Doctor-Patient
    Relationships to Improve Outcomes,'' Duke Health, January 17, 2017.
        \6\ Cabana MD, Jee SH. Does continuity of care improve patient
    outcomes? J Fam Pract. 2004 December;53(12):974-80. PMID: 15581440.

        These factors are leading current primary care physicians to leave
    the field and, when combined with the burden of student loan debt,
    dissuading medical students from pursuing primary care specialties like
    family medicine. At a time when Americans have more chronic conditions
    than ever, we should be making strides to embed primary care physicians
    in every community. Instead, we've created a policy framework that is
    actively driving prospective physicians away from primary care and
    ---------------------------------------------------------------------------
    perpetuating nationwide workforce shortages.

        Decades of systemic underinvestment in primary care and prevention
    have led to poorer population health and a greater emphasis on rescue
    medical care, rather than health care. We as a Nation have worried
    about increased up-front spending and implemented policies that have
    wrongly steered people away from high-value, low-cost services like
    preventive screenings and primary care office visits. By failing to
    invest more up-front dollars in primary care, we're paying an even
    higher price. We're spending more than ever on health-care costs, both
    as a Nation and as consumers, because we have sicker patients receiving
    later diagnoses and utilizing expensive settings like the emergency
    room and hospital as their ``usual source of care.''

        Establishing a health-care system that prioritizes primary care
    will, among many other things, require a meaningful overhaul of
    physician payment that will take time. However, as a starting point, I
    urge Congress to consider policies that work toward the following
    objectives:

              More appropriately valuing the work of primary care within
            the Medicare Physician Fee Schedule, which is the framework for
            many value-based payment arrangements;

              Reforming budget neutrality requirements that unnecessarily
            pit physician specialties against one another while undermining
            CMS's ability to invest in all the services a patient may need;

              Addressing existing financial barriers that dissuade
            patients' utilization of chronic care management and other
            primary care services by waiving cost sharing responsibilities;
            and

              Providing primary care physicians and practices with more
            prospective, sustainable revenue streams that allow them to
            tailor the care they deliver to their patient's needs.

    Reforming Fee-for-Service to Better Value Primary Care

        As noted in my introduction, access to longitudinal, coordinated
    primary care--which family physicians like me provide every day--has
    been shown to increase utilization of preventive care, improve outcomes
    for patients with chronic conditions, and reduce costly emergency
    visits, hospitalizations, and unnecessary specialty outpatient visits.
    Yet the United States has continuously underinvested in primary care
    with only 5 to 7 percent of total health-care spending going to primary
    care.\7\
    ---------------------------------------------------------------------------
        \7\ Jabbarpour Y, Greiner A, Jetty A, et al. Investing in Primary
    Care: A State-Level Analysis. Patient-Centered Primary Care
    Collaborative and the Robert Graham Center; July 2019.

        Last month, the AAFP's Robert Graham Center, in collaboration with
    the Milbank Memorial Fund and the Physicians Foundation, released the
    Nation's second primary care scorecard, which reported that national
    spending on primary care decreased from 6.2 percent in 2013 to 4.7
    percent in 2021. Primary care spending decreased for all payers between
    2019 and 2021 with Medicare being the most pronounced with a 15 percent
    drop.\8\ While some of this decrease could be due to a drop in office
    visits during the pandemic, it is a trend worth noting.
    ---------------------------------------------------------------------------
        \8\ Jabbarpour Y, Jetty A, Byun H, Siddiqi A, Petterson S, Park J.
    The Health of U.S. Primary Care: 2024 Scorecard Report--No One Can See
    You Now. The Milbank Memorial Fund and The Physicians Foundation.
    February 28, 2024.

        The impact of this long-term underinvestment is evidenced in our
    Nation's health. When we look at health outcomes across the world,
    we're not doing well by almost any measure. Compared to other high-
    income, peer nations, the U.S. has higher rates of obesity, diabetes,
    and heart disease, and a larger share of the population with multiple
    chronic conditions.\9\ A common theme across countries with better
    health outcomes and lower health-care costs is that they invest more in
    their primary care system with estimates placing primary care spending
    between 12 and 17 percent of total health-care spending for these high-
    performing nations.\10\
    ---------------------------------------------------------------------------
        \9\ Turner A, Miller G, and Lowry E. ``High U.S. Health Care
    Spending: Where Is It All Going?'', The Commonwealth Fund. Published
    October 4, 2023. Available online at: https://www.
    commonwealthfund.org/publications/issue-briefs/2023/oct/high-us-health-
    care-spending-where-is-it-all-going.
        \10\ Baillieu R, Kidd M, Phillips R, et al. The Primary Care Spend
    Model: A systems approach to measuring investment in primary care. BMJ
    Global Health 2019;4:e001601.

        One of the major factors contributing to this underinvestment is
    the relative undervaluation of primary care in fee-for-service (FFS),
    the predominant payment model. In general, the Medicare Physician Fee
    Schedule (MPFS) values procedural services delivered by other
    specialists higher than it does office visits and other cognitive
    services, which are most delivered by primary care physicians. Primary
    care and other cognitive services have been passively devalued over
    time as many new procedural codes with higher values have been
    added.\11\
    ---------------------------------------------------------------------------
        \11\ Linzer M, Bitton A, Tu SP, et al. The End of the 15-20 Minute
    Primary Care Visit. J Gen Intern Med. 2015;30(11):1584-1586.
    doi:10.1007/s11606-015-3341-3.

        This devaluation has led to lower compensation for primary care
    physicians who specialize in treating the whole person compared to our
    specialist peers, despite the vital role we play in managing chronic
    conditions and coordinating patient care across a large team and
    despite the fact evidence has shown that primary care
    office/outpatient evaluation and management (E/M) visits are more
    complex and comprehensive than those delivered by other
    specialties.\12\ This devaluation is not limited to Medicare. Many
    other private and public payers peg their payment rates to the MPFS
    rates or use the relative values in the MPFS to set their rates.
    ---------------------------------------------------------------------------
        \12\ Katerndahl D, Wood R, Jaen CR. Complexity of ambulatory care
    across disciplines. Healthcare. 2015, Available at: https://doi.org/
    10.1016/j.hjdsi.2015.02.002.

        FFS doesn't just underinvest in primary care--it also makes it
    extremely complex to get paid. We must submit unique codes for each and
    every service we provide--documenting both what we did and why we did
    it. This is incompatible with the continuous, comprehensive nature of
    primary care which spans everything from basic preventive services to
    more complex services involving chronic care management, integrated
    behavioral health, and care coordination. For patients with chronic
    conditions, these discrete services may include patient education, care
    planning, and managing medications, all of which are ongoing and
    continuous processes. Each of these services must be individually
    documented to justify payment for typical, comprehensive primary care,
    even though these services are all foundational aspects. Billing for
    primary care under FFS is like trying to cut a roll of paper with a
    ---------------------------------------------------------------------------
    hole punch rather than a pair of scissors.

        The retrospective, volume-based nature of FFS also fails to account
    for the costs of longitudinally managing patients' overall health. It
    does not provide practices with the time and flexibility to invest in
    the care management staff and population health tools that enable
    practices to efficiently and effectively meet patients' individual
    evolving health needs. For example, FFS structures have not
    historically paid for wraparound patient activities, such as community
    health workers or care coordination, but these interventions enable
    family physicians to better address a patient's identified health-
    related social needs (HRSNs) within a patient's community context. This
    disadvantages patients who require more support and the physicians who
    care for them. While Medicare has implemented new codes for some of
    these services in 2024, such as community health integration and social
    drivers of health risk assessments, their utilization and effectiveness
    is not yet known.

        For these reasons, the AAFP has long advocated to accelerate the
    transition to value-based care using alternative payment models (APMs)
    that provide prospective, population-based payments to support the
    provision of comprehensive, longitudinal primary care. We strongly
    believe well-designed APMs provide primary care a path out of the
    undervalued and overly burdensome FFS payment system that exists today,
    and in turn will better enable the Medicare program to meet the needs
    of its growing and aging beneficiary population in new and innovative
    ways. Unfortunately, a dearth of primary care APMs and the inadequacy
    of FFS payment rates that often underlie APMs are undermining the
    transition to value-based care. Because most APMs are designed based on
    FFS payment rates, modernizing FFS payment for primary care is one
    essential strategy to support physicians' transition into value-based
    care.

        Therefore, while FFS is not the future the AAFP envisions for
    primary care, it is the present. Federal policymakers must ensure the
    current FFS system appropriately and sustainably compensates primary
    care physicians to make more meaningful progress toward the future--one
    that rewards value over volume of services.

        We have been encouraged by recent regulatory policy changes aimed
    at more appropriately valuing and paying for primary care and other
    types of cognitive care in Medicare. The AAFP greatly appreciates that
    CMS finalized and Congress supported implementation of the G2211 add-on
    code in 2024, which can be billed alongside offices visits that are
    part of an ongoing, longitudinal care relationship. G2211 is an
    incremental but meaningful step in appropriately valuing primary care
    and supporting longitudinal, holistic patient-physician relationships,
    relative to other services in the fee schedule.

        However, the zero-sum, budget-neutral nature of the MPFS is
    undermining investments like G2211. Existing budget neutrality
    requirements force CMS to offset increases or additions anywhere in the
    MPFS with across-the-board cuts to all services in the MPFS, including
    those most delivered by primary care physicians. In short, this means
    Medicare cannot appropriately pay for all the services a patient might
    need, and it perpetuates inequities in the fee schedule, which bleed
    into and impact the success of primary care practices in VBP
    arrangements and outside of Medicare.

        For these reasons, the Academy has long called for reforms to
    budget-neutrality requirements, which are unnecessarily pitting
    physician specialties against one another. We strongly urge the
    committee to consider proposals such as increasing the current budget
    neutrality threshold, which has not been updated since the fee schedule
    was created in 1992, correcting the impact of over- or under-
    utilization assumptions by CMS on the availability of funds, and more
    regularly updating the direct costs used to calculate practice expense
    Relative Value Units (RVUs). I'd also like to raise the suggestion that
    Federal policymakers should think of budget neutrality in broader terms
    than it currently is. As I've discussed, proper investment in primary
    care yields the potential to increase long-term cost savings through
    outcomes such as reduced emergency department visits, hospitalizations,
    and better management of chronic conditions. I would make the case that
    those savings should be considered as part of the direct budgetary
    impacts of increasing primary care investments in Medicare.

        In terms of other opportunities to improve CCM in traditional
    Medicare, I'd like to discuss the experience of family physicians and
    their patients in utilizing some of the CCM codes. In 2015, Medicare
    began paying physicians for delivering non-face-to-face CCM through
    separate codes. Being able to bill for CCM has been an overall positive
    experience for our practice. However, there remain some operational
    challenges such as patient cost-sharing requirements that are limiting
    uptake by patients who would truly benefit from this type of additional
    support. A 2022 study found that MPFS billing codes for preventive
    medicine and care management services are being underutilized even
    though primary care physicians were providing code-appropriate services
    to many patients. The median use of the preventive and care
    coordination billing codes was 2.3 percent among eligible patients.\13\
    ---------------------------------------------------------------------------
        \13\ Sumit D. Agarwal, Sanjay Basu, Bruce E. Landon The Underuse of
    Medicare's Prevention and Coordination Codes in Primary Care: A Cross-
    Sectional and Modeling Study. Ann Intern Med.2022;175:1100-1108. [Epub
    28 June 2022]. doi:10.7326/M21-4770.

        I've had patients in my practice opt out of receiving these
    services simply because the $15 or so a month they faced in cost-
    sharing was not financially feasible. In almost every case these were
    the very patients that would most benefit from CCM. This rings true for
    many of the other new codes Medicare has implemented, including G2211,
    SDOH risk assessments, and community health integration services.
    Patients are not used to paying for these services and, understandably,
    are likely to be resistant to doing so. If we want to incentivize usage
    ---------------------------------------------------------------------------
    of these high-value services, we must waive patient cost-sharing.

        In many ways, CCM is a preventive service in that it reduces
    emergency department and other outpatient visits. Removing cost sharing
    for CCM and other primary care services increases access to these
    services without increasing overall health care spending.\14\ The
    available evidence indicates that reducing or removing cost barriers to
    primary care increases utilization of preventive and other recommended
    primary care services, which improves both individual beneficiary and
    population health. For example, while cost sharing for most preventive
    services is waived across payers, many patients don't access all the
    preventive care recommended for them because they don't know what is or
    isn't covered or they are concerned they might be charged for raising
    other health issues in the same visit.
    ---------------------------------------------------------------------------
        \14\ Ma Q, Sywestrzak G, Oza M, Garneau L, DeVries A. ``Evaluation
    of Value-Based Insurance Design for Primary Care.'' (2019). The
    American Journal of Managed Care. 25: 5. https://www.ajmc.com/view/
    evaluation-of-valuebased-insurance-design-for-primary-care.

        Therefore, the AAFP supports the Chronic Care Management
    Improvement Act (H.R. 2829), which would waive patient cost sharing for
    the CCM codes under traditional Medicare. We urge Congress to pass this
    and other legislation to remove cost-sharing barriers to other primary
    care services.

    Supporting the Transition to Primary Care Value-Based Payment

        Alternative payment models (APMs), when well-designed and
    implemented to meaningfully support primary care, provide practices
    with predictable, stable revenue streams that afford them the funding
    and flexibility needed to build teams and implement technology and
    infrastructure to deliver high-quality, patient-centered care--without
    the administrative complexity of FFS.

        Value-based payment (VBP) arrangements, such as population-based
    payments or Accountable Care Organizations (ACOs), better support and
    encourage physicians to deliver a more comprehensive set of services,
    such as care coordination and addressing HRSN, through prospective
    payment and flexibility. These types of arrangements invest in the
    longitudinal, continuous relationships primary care physicians have
    with their patients in ways that FFS has not historically and enable
    practices to tailor their care to better support patients with chronic
    conditions while improving related health outcomes. For example,
    practices might host monthly diabetes group visits to improve A1C. The
    frequent touches and support from these group visits can lead to better
    health outcomes for patients with type 2 diabetes and help the practice
    meet quality measure requirements.

        In the Comprehensive Primary Care Plus (CPC+) model tested by the
    Center for Medicare and Medicaid Innovation, participating practices
    reported they used the model's prospective payments to invest in care
    delivery transformation that would not have been possible if FFS was
    their only source of revenue. Some of these transformations included
    key CCM activities, such as: providing patients with after-hours access
    to a physician or other clinical staff member who has real-time access
    to the practice's EHR; using designated care managers, typically onsite
    staff who are nurses or medical assistants, to deliver longitudinal
    care management services; and co-location of a pharmacist at the
    practice site to support comprehensive medication management. To be
    clear, the primary difference that afforded practices the opportunity
    to make these investments is that the payment was prospective; while
    they are possible to make in FFS, the retrospective payment makes it
    much more challenging for practices to do so.

        Given these and other benefits, there is mounting multistakeholder,
    cross-
    industry support for a primary care payment system that rewards value
    and holds promise for improving health, addressing disparities, and
    slowing the overall growth of health-care costs. Federal policymakers
    should increase participation opportunities in primary care models that
    align with the AAFP's guiding principles for VBP and meet practices
    where they are, allowing them to gain a foothold in and stay in VBP.

        Congress tried to provide an on-ramp for more practices to
    participate in APMs with the passage of the Medicare Access and CHIP
    Reauthorization Act (MACRA) and implementation of the Merit-based
    Incentive Payment System (MIPS), which was intended to provide
    clinicians with experience being measured on their performance. The
    AAFP supported the intent of fostering continuous performance
    improvements that lead to better outcomes for patients. Unfortunately,
    continuous cuts to Medicare FFS payments have inhibited most practices
    from making the necessary investments that would allow them to
    successfully move into APMs. Further, the current design of MIPS, which
    focuses on individual clinician performance using largely process
    rather than outcomes measures, does not appear to be driving care
    improvements as much as it is adding administrative complexities that
    detract from patient care while unfairly penalizing small and rural
    practices.

        MACRA requires CMS to apply payment adjustments to Medicare Part B
    FFS payments based on an eligible clinician's (EC) performance in MIPS.
    Clinicians with a MIPS final score above the performance threshold
    receive a positive adjustment while those below the threshold receive a
    negative adjustment. The adjustments must be budget neutral--meaning
    the total value of annual positive adjustments are equal to the total
    value of negative adjustments. As such, both the positive and negative
    adjustments are made on a sliding scale with the exception that those
    in the bottom quartile automatically receive the maximum penalty for
    the year.

        While most physicians have met or exceeded the MIPS performance
    threshold in past performance years, physicians in small and rural
    practices consistently have lower than average MIPS scores. As the
    performance threshold increases, it will become more difficult for
    small and rural practices to avoid a negative payment adjustment, which
    can be up to 9 percent to their Medicare Part B services. Given these
    challenges, I urge Congress to consider reforms to the MIPS program to
    alleviate the administrative costs of reporting to the program, ensure
    it drives meaningful quality improvement, and assist physician
    practices in building the necessary competencies to transition into
    alternative payment models.

        Congressional action is also needed to ensure Federal policies
    provide appropriate support and incentives to physician practices
    moving into APMs. I appreciate that Congress passed legislation last
    month to extend the advanced APM (AAPM) incentive payment through
    performance year 2024, albeit at a lower amount.

        These payments have served as an important tool for attracting
    physicians to participate in AAPMs, which require significant up-front
    (and often ongoing) investments in new staff, technology, and other
    practice improvements. Primary care practices have also used the AAPM
    bonus payments to offset the cost of investing in care delivery
    transformation that drives success in these models by improving patient
    outcomes and lowering spending. Expiration of the AAPM incentive
    payment could institute an additional barrier to continued AAPM
    participation for physician practices and further impede family
    physicians' ability to transition value-based payment models.

        Congress should also consider legislation to provide CMS with
    authority to modify AAPM qualifying participant thresholds to ensure
    independent practices are not left behind. The Value in Health Care Act
    (S. 3503), which the AAFP has endorsed, is one piece of legislation
    that would do so.

        However, primary care physicians still face significant barriers to
    entering and sustaining participation in VBP arrangements, even when
    they align with AAFP's principles. Practices must comply with an ever-
    increasing number of Federal and State regulations, negotiate contracts
    with multiple payers, acquire and effectively aggregate and analyze
    data to track patient utilization, treatment adherence, and identify
    outstanding needs--all while doing our primary job of taking care of
    patients. This creates an immediate and high barrier to entry,
    particularly for independent practices that don't have the up-front
    capital or resources.

        To address this problem, Federal policymakers should increase
    options for primary care practices to benefit from APMs that provide
    up-front or advance payments and other supports to enable the
    investments required to be successful. For example, practices
    participating in CPC+ not only received population-based, per-member
    per-month (PMPM) payments, but CMMI provided them with a robust data
    dashboard and other technical assistance that enabled new practices to
    join the model and successfully reduce emergency visits and
    hospitalizations. CMMI also partnered with State Medicaid agencies and
    commercial payers to drive alignment across payers in CPC+ regions,
    which in turn provided practices with greater financial support across
    their contracts and accelerated care delivery innovations.

        We are encouraged by CMS's recent announcement of a new model, ACO
    Primary Care Flex, which will heed our recommendations and provide low
    revenue ACOs participating in the Medicare Shared Savings Program
    (MSSP) with a one-time up-front shared savings payment and a
    prospective PMPM payment. CMMI's forthcoming Making Care Primary (MCP)
    model, which is set to launch in July, also builds upon lessons learned
    from CPC+ and Primary Care First (PCF) and provides participants who
    are new to value-based care with up-front payments to develop
    infrastructure and build advanced care delivery capabilities. CMMI is
    also working with State Medicaid agencies and other payers in the
    selected States to align MCP and State programs, helping facilitate the
    multi-payer alignment that has contributed to successful aspects of
    earlier models.

        Congress should also consider providing CMMI with additional
    flexibility in how it evaluates the success of primary care models.
    Currently, Federal statute only allows CMMI to expand models that
    reduce health-care spending and maintain quality, or improve
    performance on quality metrics without increasing spending.
    Demonstrating savings in primary care often takes several years as
    physicians build relationships with their patients, use data to better
    manage their care, and increase utilization of preventive and other
    high-value services, like care management.

        The current statutory framework has prevented CMMI from making
    important model improvements or continuing to test models that do not
    show significant savings within a short model test period, ultimately
    causing more complexity and financial instability for participating
    physician practices. Further, all CMMI primary care model evaluations
    have been done at the national level, which may be masking regional
    successes. Congress should consider enabling and encouraging CMMI to
    evaluate several other markers of success for primary care APMs, such
    as whether they successfully bring new physicians into value-based
    payment, improve patient experience measures, markedly improve care
    delivery transformation, enable more beneficiaries to access the
    behavioral health services they need, and when applicable, evaluate
    models both nationally and regionally. These additional criteria would
    allow CMMI to continue testing models that show early markers of
    success and iterate upon them to meet current patient, clinician, and
    market needs.

        While value-based payment can and should be used to buoy primary
    care practices, health systems, hospitals, payers, and other large
    companies will continue to enter these models. Federal policymakers
    should take steps to ensure value-based payment is being used as a tool
    to significantly increase our Nation's investment in primary care, not
    as a leverage point to increase profits in other business areas. In
    other words, payments and financial rewards from APMs should be
    reinvested into the primary care practice, not redirected to other
    service lines or books of business.

        In closing, thank you again for the opportunity to provide this
    testimony. On behalf of the AAFP and as a family physician, I look
    forward to working with the committee to advance policies that invest
    in high-quality primary care, improve patients' outcomes and
    experiences, and better support family physicians by more appropriately
    paying for the work we do. We all have the same goal: to improve the
    lives of the people we serve.

        Founded in 1947, the AAFP represents 130,000 physicians and medical
    students nationwide. It is the largest medical society devoted solely
    to primary care. Family physicians conduct approximately one in five
    office visits--that's 192 million visits annually or 48 percent more
    than the next most visited medical specialty. Today, family physicians
    provide more care for America's underserved and rural populations than
    any other medical specialty. Family medicine's cornerstone is an
    ongoing, personal patient-physician relationship focused on integrated
    care. To learn more about the specialty of family medicine and the
    AAFP's positions on issues and clinical care, visit www.aafp.org. For
    information about health care, health conditions and wellness, please
    visit the AAFP's consumer website, www.familydoctor.org.

                                     ______

       Questions Submitted for the Record to Steven P. Furr, M.D., FAAFP
                     Questions Submitted by Hon. Mike Crapo
        Question. As you noted in your testimony and responses during the
    hearing, numerous features of the Physician Fee Schedule (PFS), as
    currently structured, have resulted in volatility and uncertainty for
    clinicians. Broad utilization overestimates for certain new billing
    codes, for instance, have triggered draconian conversion factor (CF)
    reductions across all specialties and subspecialties, and policy
    changes aimed at ensuring appropriate reimbursement for certain
    subgroups of clinicians necessitate, under budget neutrality rules,
    sizable payment cuts for others, with no countervailing enhancements
    for the latter groups.

        What specific legislative steps should Congress consider taking in
    order to provide long-term stability and sustainability for the PFS,
    beyond modifying the current CF update schedule?

        Answer. In addition to updating the conversion factor by applying
    an annual inflationary update based upon the Medicare Economic Index,
    the AAFP strongly urges Congress to make immediate reforms to existing
    budget-neutrality requirements. As noted in my written testimony, the
    zero-sum, budget-neutral nature of the MPFS is undermining investments
    Medicare tries to make in primary care. Existing
    budget-neutrality requirements force CMS to offset increases or
    additions anywhere in the MPFS with across-the-board cuts to all
    services in the MPFS, including those most delivered by primary care
    physicians. In short, this means Medicare cannot appropriately pay for
    all the services a patient might need, and it perpetuates inequities in
    the fee schedule, which bleed into and impact the success of primary
    care practices in VBP arrangements and outside of Medicare.

        Budget neutrality is unnecessarily pitting physician specialties
    against one another. We strongly urge the committee to consider
    proposals such as increasing the current budget neutrality threshold,
    which has not been updated since the fee schedule was created in 1992,
    correcting the impact of over or underutilization assumptions by CMS on
    the availability of funds, and more regularly updating the direct costs
    used to calculate practice expense Relative Value Units (RVUs).

        I'd also like to raise the suggestion that Federal policymakers
    should think of and interpret budget neutrality in broader terms than
    it currently is. As I've discussed, proper investment in primary care
    yields the potential to increase long-term cost savings through
    outcomes such as reduced emergency department visits, hospitalizations,
    and better management of chronic conditions. I would make the case that
    those savings should be considered as part of the direct budgetary
    impacts of increasing primary care investments in Medicare.

        Question. In the absence of these types of steps, what concrete
    impacts will current and future beneficiaries most likely experience?

        Answer. While I cannot predict the future, I can point to the past.
    Over the last decade or so, we have seen more and more primary care
    practices closing their doors or being bought up by a health system,
    hospital, insurer, or private equity. This trend accelerated during
    COVID, when primary care practices that were already operating on
    razor-thin margins were hit with an unprecedented financial reckoning.
    While we're on the other side of the pandemic now, insufficient
    Medicare physician payment rates continue to exacerbate the difficult
    financial environment for many practices. Costs for administrative and
    clinical staff, medical supplies, and overhead all continue to rise
    while payment rates go down through a combination of statutorily
    required cuts and failure to keep pace with inflation. Absent any
    meaningful reforms from Congress, more primary care physicians will
    leave the field, practices will close, and most importantly, patients
    will struggle to access all of the care that they need--particularly
    preventive and primary care that keeps them from having to pursue more
    expensive care in costlier settings.

        Question. Regulations finalized earlier this year aim to streamline
    and standardize prior authorization standards and requirements in
    certain contexts, but the final rule expressly excludes outpatient
    medications, whether administered by clinicians or dispensed to
    beneficiaries via pharmacy. Both the American College of Surgeons (ACS)
    and the American Academy of Family Physicians (AAFP) made note of this
    omission in comments submitted in response to the proposed rule.

        Specifically, ACS ``urge[d] CMS to apply its proposed policies to
    all drugs covered by any of the impacted payers to align PA processes
    and related implementation efforts with those for all other covered
    items and services.'' Similarly, AAFP expressed concern and
    disappointment that ``these proposals do not apply to prior
    authorizations for prescription and outpatient drugs,'' and went on to
    ``strongly urge CMS to expand the proposals in this rule to Medicare
    Part D plans and prescription drug coverage across other impacted
    payers.''

        Virtually all clinician organizations concurred with these
    recommendations, including those focused on treating some of the most
    onerous chronic conditions, such as cancer. The Community Oncology
    Alliance, for instance, asserted, ``Addressing the drug treatment for a
    person's cancer should clearly be part of any effective, comprehensive
    regulatory initiative to streamline the current onerous prior
    authorization processes.'' Patient advocates uniformly agreed with
    these concerns, which a number of groups have cited as a key source of
    delays and denials of potentially life-saving therapeutics, across both
    the provider-administered setting and the retail pharmacy context.

        Studies have found that physician-administered drugs and biologics
    account for a large and growing share of all forms of prior
    authorization and utilization management (UM) under Medicare Advantage
    (MA) plans' medical benefits, and the application of various UM tools,
    such as prior authorization, step therapy, and formulary exclusion, has
    risen dramatically in recent years under Medicare Part D plans.
    Analysts broadly project that these trends will accelerate, rather than
    reverse, in the midst of Part D's benefit redesign.

        What specific components should Congress, or CMS, consider
    including in any effort to streamline and otherwise reform requirements
    and standards for UM tool application to outpatient drugs (both
    physician-administered and pharmacy-
    dispensed)?

        Answer. In a 2023 rule, CMS proposed requirements to adopt the
    updated National Council for Prescription Drug Programs (NCPDP) SCRIPT
    (standards used to exchange information for e-prescriptions) version
    2023011 (and to retire version 2017071) for Part D e-prescribing
    starting January 1, 2027. CMS also proposed to update other e-
    prescribing related standards including the adoption of NCPDP Real-Time
    Prescription Benefit (RTPB) standard version 13 for real-time benefit
    transactions (RTBT) and the adoption of NCPDP Formulary and Benefit
    (F&B) standard version 60. The AAFP supported these proposals.\1\ CMS
    did not announce a final decision in the published rule and we assume
    these proposals are still under consideration.
    ---------------------------------------------------------------------------
        \1\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
    administrative/LT-CMS-MedicareAdvantageCY25-122123.pdf.

        The AAFP also supported earlier proposals to adopt NCPDP RTPB
    standards, which enable the real-time exchange of patient-specific
    coverage (including restrictions and alternatives) and estimate cost-
    sharing at the point of prescribing.\2\ We supported CMS's proposal,
    which they finalized in the 2024 Part D rule, to adopt RTPB standard
    version 13 because it would offer enhancements that would enable payers
    to provide additional product-level details about coverage and
    formulary status.
    ---------------------------------------------------------------------------
        \2\ https://www.aafp.org/dam/AAFP/documents/advocacy/coverage/
    medicare/LT-HHS-CMS-MedicareAdvantagePriorAuthorization-021323.pdf.

        NCPDP F&B standards enable plans to share formulary and benefit
    information at the plan level, as opposed to the patient-level
    eligibility information offered by RTPB standards. These standards
    allow payers to transmit information about formulary status, preferred
    alternatives, and coverage restrictions consistent with each plan's
    benefit design. F&B standards are the foundation of electronic prior
    authorization (ePA) functionality and real-time benefit checks for
    individual patients in Part D. We have previously urged CMS to require
    plans (including Part D plans) to implement ePA standards, and we
    support the adoption of the proposed F&B standards which will
    facilitate the use of ePA in Part D plans.\3\ Currently, family
    physicians spend a significant amount of time determining whether a
    prior authorization is required, and if so, the documentation
    requirements for approval. We believe this proposal is a foundational
    step to require Part D plans to implement ePA and make prior
    authorization requirements more transparent to physicians and their
    staffs. CMS did not announce a final decision in the published rule and
    we assume these proposals are still under consideration.
    ---------------------------------------------------------------------------
        \3\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
    administrative/LT-CMS-PriorAuthorizationEHR-031023.pdf.

        CMS requires Medicare Advantage plans to use coverage criteria that
    is no more restrictive than Traditional Medicare coverage policies.
    When there are no applicable Medicare statute, regulation, National
    Coverage Determination (NCD) or Local Coverage Determination (LCD) that
    establish coverage criteria, plans may only create internal coverage
    criteria based on publicly available clinical literature or widely used
    treatment guidelines. We urge CMS to apply this proposal to
    ---------------------------------------------------------------------------
    prescription drugs and Part D plan sponsors.

        Question. What benefits would these components offer to patients
    and clinicians?

        Answer. The NCPDP RTPB standards discussed above would allow family
    physicians to understand formulary and prior authorization requirements
    for patients when writing a prescription, which aligns with AAFP policy
    stating physicians must have real-time information available about drug
    formularies at the point of care.\4\ These more recent standards would
    increase transparency of prior authorization requirements, formulary
    design, and patient financial responsibility at the point of
    prescribing. Having this data at the point of prescribing would allow
    physicians to have a more robust discussion with patients about
    treatment options. We continue to support the use of ePA standards in
    Medicare Part D plans and urge Congress and CMS to apply these
    standards to all other non-Part D prescription plans.
    ---------------------------------------------------------------------------
        \4\ https://www.aafp.org/about/policies/all/patient-centered-
    formularies.html.

        Question. In the absence of reform efforts along these lines for
    medications, what prior authorization and UM burdens and other effects
    will clinicians and beneficiaries continue to experience, even after
    ---------------------------------------------------------------------------
    CMS's final rule takes effect?

        Answer. I experience--and frequently hear from other family
    physicians who do as well--significant administrative burden associated
    with PA requirements for prescription drugs. PA processes force
    physicians to take time away from patient care to understand arbitrary
    formulary changes and/or new PA requirements. Without access to plan
    coverage details at the point of prescribing, physicians spend a
    significant amount of time going back and forth with the pharmacy to
    identify alternative medicines that meet coverage requirements. In
    addition to the burden on physicians, these PA processes increase
    burden on pharmacists and beneficiaries.

        Question. On a number of fronts, CMS has leveraged subregulatory
    guidance as a means of clarifying current-law and regulatory
    requirements for plans, providers, and beneficiaries. In the context of
    Part D, 42 CFR 423.272(b)(2) establishes regulatory requirements for
    plan designs, noting that the agency will not approve a bid if ``the
    design of the plan and its benefits (including any formulary and tiered
    formulary structure) or its utilization management program are likely
    to substantially discourage enrollment by certain Part D eligible
    individuals under the plan.'' Notably, clause (iii) specifies that even
    if a plan adheres to proper category/class inclusion requirements, such
    a plan may still fall short of this standard by virtue of its exclusion
    of certain drugs.

        Patients, providers, and plans, however, have flagged uncertainty
    as to the scope and practical implications of this language. Updates to
    the regulations themselves, or else to the relevant sections of the
    Medicare Prescription Drug Manual, could present a potential avenue for
    clarifications, along with exemplary examples of compliant and
    noncompliant formulary design and UM tool applications.

        What types of clarifications or examples, in this context, could
    CMS provide, either through guidance or regulations, to ensure adequate
    and efficient medication access for Part D enrollees, many of whom take
    multiple prescriptions for chronic diseases?

        Answer. Part D, 42 CFR 423.272(b)(2) establishes regulatory
    requirements for plan design including a prohibition on excluding
    certain drugs that, if not included, might discourage sicker patients
    from enrolling. Chapter 6 of the Medicare Prescription Drug Benefit
    Manual,\5\ Part 30.2.5--Protected Classes requires plans to include
    ``substantially all'' drugs in certain classes, and CMS notes this
    policy was established to ``ensure that Medicare beneficiaries reliant
    upon these drugs would not be substantially discouraged from enrolling
    in certain Part D plans, as well as to mitigate the risks and
    complications associated with an interruption of therapy for these
    vulnerable populations.'' Guidance in the same section further states,
    ``Part D sponsors may not implement PA or ST requirements that are
    intended to steer beneficiaries to preferred alternatives within these
    classes for enrollees who are currently taking a drug.'' The policy
    includes ``all drugs in the immunosuppressant (for prophylaxis of organ
    transplant rejection), antidepressant, antipsychotic, anticonvulsant,
    antiretroviral, and antineoplastic classes.)
    ---------------------------------------------------------------------------
        \5\ https://www.cms.gov/medicare/prescription-drug-coverage/
    prescriptiondrugcovcontra/
    downloads/part-d-benefits-manual-chapter-6.pdf.

        We encourage CMS to consider whether this policy or list of
    conditions should be expanded. There may be more categories of
    conditions or drugs that support their intent of reducing harms and
    complications associated with an interruption of therapy. For example,
    the CMS Innovation Center is developing a model that establishes a list
    of 150 commonly filled generics and sets their copay at two dollars.\6\
    Many chronic diseases can be managed with low-cost prescription drugs,
    and establishing a formulary standard for commonly prescribed, low-cost
    generics used to treat chronic disease would help patients with
    multiple chronic diseases by reducing their total copays, and by
    preventing patients from being forced to change prescriptions due
    formulary changes, despite the fact that their disease is currently
    well controlled.
    ---------------------------------------------------------------------------
        \6\ https://www.cms.gov/blog/cms-innovation-centers-one-year-
    update-executive-order-lower-prescription-drug-costs-americans.

        Question. In some cases, formularies exclude or disadvantage lower-
    cost alternatives to branded medications with higher list prices while
    charging beneficiaries coinsurance tied to said inflated sticker-price
    figures. The Part D statute directs pharmacy and therapeutic (P&T)
    committees to ``base clinical decisions on the strength of scientific
    evidence and standards of practice,'' but it remains unclear to what
    extent these committees or the Part D plans themselves factor cost
    sharing, UM hurdles, or lower-priced alternatives (and the role of
    ---------------------------------------------------------------------------
    rebates) in making these types of determinations.

        How does cost-sharing burden affect medication adherence and
    clinical outcomes for patients, and how should plans (and their P&T
    committees) incorporate these types of considerations into their
    recommendation and review processes?

        Answer. Cost sharing has very tangible, and often negative, impacts
    on patients' medication adherence and clinical outcomes. In my
    practice, I have experienced patients requesting a certain medication
    for the sole reason that it had a lower cost-sharing amount, regardless
    of whether it was the best treatment or what I would recommend. I have
    had patients stop taking medication or ration doses because of the
    costs. Research has backed up my anecdotal experiences, as well.
    Studies have consistently shown that, regardless of disease area,
    increased cost sharing was associated with worse adherence,
    persistence, or discontinuation, with data suggesting that the more
    significant the cost sharing, the worse the treatment or medication
    adherence.\7\ For example, one study found that a low copayment for
    generic statins is the strongest factor influencing their utilization
    and eliminating the copay altogether has an even larger effect.\8\
    ---------------------------------------------------------------------------
        \7\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10394195/
    #::text=The%20majority%20
    of%20publications%20found,sharing%2C%20the%20worse%20the%20adherence.
        \8\ https://www.healthaffairs.org/doi/10.1377/
    hlthaff.2012.0019?url_ver=Z39.88-2003&rfr
    _id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed.

        The AAFP's policy on patient-centered formularies provides several
    recommendations to inform these recommendation and review processes,
    including:\9\
    ---------------------------------------------------------------------------
        \9\ https://www.aafp.org/about/policies/all/patient-centered-
    formularies.html.

              Formulary design should be patient-centered, fiscally
            responsible, and
            evidence-based. Drug selection should be based on clinical
            outcomes, clinical comparability, safety, patient ease of use,
            and bioequivalancy with drug unit cost being a secondary
            consideration.
              Formularies should be designed to offer patients multiple
            levels of drug choice (from more to less restrictive) with
            accompanying patient cost-sharing levels to account for
            variables including patient preferences (e.g., ``direct
            marketing-induced'' demand).
              Formularies should be designed to reduce or eliminate out-
            of-pocket costs for patients with chronic conditions to
            increase medication adherence and improve patient well-being.
              Health plans and PBMs should provide drug utilization and
            cost information to physicians in clear and understandable
            reports that are useful for physicians in affecting positive
            change in their prescribing behavior.
              Sufficient information concerning PBM design should be
            provided by health plans to physicians and patients in a clear
            and useful format. (Note: this includes information concerning
            generic drug and therapeutic substitution policies, deductibles
            and copays, appeal process for adverse decisions, formulary
            choices, product information, contractual arrangements with a
            PBM, et cetera).

        Question. What formulary review mechanisms or reporting
    requirements could CMS implement in order to ensure effective and
    meaningful oversight of formulary design, UM tool application, and the
    clinical basis for these decisions?

        Answer. A 2019 analysis found that 72 percent of the formularies
    reviewed placed at least one branded drug in a more favorable (lower-
    cost) tier than its generic, and the price of the branded drug was
    nearly four times the cost of the generic.\10\ We believe CMS should
    consider the impact of this type of cost sharing when evaluating the
    adequacy of a formulary. A 2023 GAO report, ``CMS Should Monitor
    Effects of Rebates on Plan Formularies and Beneficiary Spending''\11\
    noted similar findings: ``rebate practices may influence formulary
    design in ways that could affect beneficiary access for certain Part D
    drugs and may not be identified by a clinical formulary review.''
    Reviewing plan rebate structures during the clinical plan design and
    benefits review could enable CMS staff to assess whether a drug may be
    at risk for lower adherence rates due to patient cost sharing, and help
    to identify when copays might discourage certain beneficiaries from
    enrollment.
    ---------------------------------------------------------------------------
        \10\ https://jamanetwork.com/journals/jamainternalmedicine/
    fullarticle/2728446.
        \11\ https://www.gao.gov/assets/gao-23-105270.pdf.

        Question. Artificial intelligence (AI) has the potential to
    mitigate administrative burden and enhance health-care quality,
    including in the context of Medicare. That said, some clinicians have
    raised concerns around the program's inability to keep pace with AI-
    enabled tool development through its coverage and payment policies,
    ---------------------------------------------------------------------------
    undercutting access, especially for smaller practices.

        What use cases for AI-enabled tools and technologies seem most
    promising in the context of clinician care?

        Answer. AI-enabled tools that focus on administrative burden
    reduction have the most promise today for supporting clinicians. Five
    key areas of administrative burden are documentation, prior
    authorization, EHR inbox management, quality measurements, and chart
    review. We have seen how AI assistants can dramatically reduce
    documentation time and cognitive burden of chart review, while
    supporting more timely and empathetic responses to inbox messages. We
    have also seen how AI assistants can reduce the burden of coding for
    billing and risk-based adjustments under value-based care. The AAFP is
    hopeful for additional AI-powered solutions to help with prior
    authorization and quality measurement.

        In the near future, there is promise for AI to power technologies
    that help primary care be more comprehensive, provide better continuity
    and coordination of care, and improve patient access. Work is still
    needed to address the issues of trustworthiness and safety as AI moves
    more into the clinical realm.

        Question. What steps should CMS and Congress take to ensure
    adequate coverage and reimbursement for appropriate AI-enabled tools in
    this context?

        Response: For the administrative burden reduction use cases,
    coverage and reimbursement are not the key barriers; rather, issues of
    interoperabilty with EHRs and willingness for health-care systems to
    invest are key to further adoption. There is clear evidence that
    investments in primary care result in lower total costs and improved
    patient outcomes. So, as the investment in primary care more generally
    happens to align payments with the value generated, this could also
    incentivize health-care systems to invest in primary care
    infrastructure, including AI solutions.

        On the near future clinical applications, it is important for
    coverage to allow for primary care physicians to practice to the top of
    their training and not have coverage tied to a particular specialty.
    This is due to the opportunity AI has to empower primary care
    physicians to be more comprehensive.

        The biggest potential driver of responsible AI-powered solutions
    for clinical care is the alignment of payment to high-quality primary
    care and to pay prospectively. This alignment incentivizes the adoption
    and use of AI that improves outcomes and lowers total cost.
    Furthermore, additional fee-for-service payments can be used to
    accelerate adoption of newer solutions.

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. In 2005, this committee held a hearing that I chaired
    titled, ``Improving Quality in Medicare: The Role of Value-Based
    Purchasing.'' I said at the time that we do not want to overburden
    providers with reporting requirements. I went on to say that it is
    important to develop these health care quality measures by consensus.

        Do you feel reporting requirements are developed by consensus and
    do not overburden providers? If not, what actions should we take to
    reduce the burden?

        Answer. We support the goal to implement health care quality/
    performance measures that do not overburden physicians. We appreciate
    HHS's and CMS's efforts to improve the measurement landscape by
    recommending a ``Universal Foundation,''\12\ which is one step toward
    measure alignment across programs. We also appreciate the ability to
    participate in annual, multistakeholder, measure review processes to
    make recommendations for measures that should be implemented in Federal
    programs like Medicare, as well as measures that should be removed from
    use in Federal program. That said, there's still a tremendous amount of
    work that must be done to decrease the significant burden created by
    the current measurement landscape. While quality measurement is
    essential to moving toward a value-based health-care system, our
    current approach fails to measure what matters to patients and
    clinicians or drive meaningful improvement. The eagerness to measure
    has burdened family physicians with the onerous task of capturing
    structured electronic data to feed an excessive number of measures,
    taken time away from patients, and led to loss of joy in practice.
    ---------------------------------------------------------------------------
        \12\ https://www.cms.gov/medicare/quality/cms-national-quality-
    strategy/aligning-quality-measures-across-cms-universal-foundation.

    ---------------------------------------------------------------------------
        To further reduce burden, we recommend the following actions:

              Use fewer measures overall and implement only those measures
            focused on improving outcomes that matter to patients and/or
            improve health equity.
              Align performance measures and other aspects of value-based
            payment models across all payers and programs.
              Continue to involve physicians and patients in selection of
            measures to be used in Federal programs and allow their
            feedback to help determine which measures are used.
              Ensure physicians are measured according to patients who
            truly are under their care, and provide physicians and clinics
            with rosters of patients for whom they are accountable on a
            timely basis and in an easy-to-use format.
              Optimize health information exchanges and allow primary care
            physicians easy access to real-time health information showing
            care provided to their patients outside their clinic.
              Ensure all electronic health record (EHR) systems are
            equipped to discretely capture and electronically report
            performance measures before implementation without any added
            administrative burden or cost.
              Ensure Federal payment programs provide coverage for care
            where physicians are held accountable via performance measures
            (e.g., physicians should be able to administer the shingles
            vaccine in their offices if they are being measured on it).

        Question. According to the Medicare Payment Advisory Commission
    (MedPAC), Medicare's Physician Fee Schedule updates have grown more
    slowly than input cost growth in recent years. Yet Medicare spending on
    an annual basis is up 30 percent over 5 years and the Congressional
    Budget Office (CBO) just revised Medicare spending for benefits--for
    this year and last year--up another $272 billion. MedPAC explains this
    is due to an increase in the volume and intensity of Medicare services.

        Can you explain the root cause for higher Medicare spending while
    at the same time, physicians are receiving less in reimbursement?

        Answer. By law and with some exceptions, Medicare generally covers
    only the diagnosis and treatment of illness or injury rather than
    prevention. Thus, part of the root cause for higher Medicare spending
    is the program's inclination to pay for a pound of cure rather than an
    ounce of prevention.

        Beyond that, Medicare spends less than 5 percent of its total
    spending on primary care. Between 2019 and 2021, there was a 15 percent
    drop in Medicare spending on primary care.\13\ When we look at health
    outcomes across the world, we're not doing well by almost any measure.
    Compared to other high-income peer nations, the U.S. has higher rates
    of obesity, diabetes, and heart disease, and a larger share of the
    population with multiple chronic conditions.\14\ We know from extensive
    evidence that other countries and even U.S. States that invest a
    greater percentage of spending in primary care reap the benefits in
    reduced overall spending. Thus, the biggest root cause for higher
    Medicare spending is the program's failure to invest in primary care
    and over-investment in other facets of the health-care system.
    ---------------------------------------------------------------------------
        \13\ https://www.milbank.org/publications/the-health-of-us-primary-
    care-2024-scorecard-report-no-one-can-see-you-now/.
        \14\ https://www.commonwealthfund.org/publications/issue-briefs/
    2023/oct/high-us-health-care-spending-where-is-it-all-going.

        Question. There are an estimated 8,000 medical services codes that
    ---------------------------------------------------------------------------
    physicians bill for a range of health-care services.

        How many are typically used in a primary care setting? Are the
    suite of primary care codes overly burdensome or complicated? If so,
    how? How does this compare to billing under Medicare Advantage or other
    commercial insurance?

        Answer. The number of codes by themselves is not overly burdensome
    or complicated. What is burdensome and complicated are the myriad rules
    (some associated with the code set(s) and others created by Medicare
    and other payers) that govern when codes may be reported either
    independently or in conjunction with other codes. This is true in
    almost any fee-for-service payment system, whether traditional
    Medicare, Medicare Advantage, or commercial insurance. Research has
    concluded that creating additional billing codes for distinct
    activities in the MPFS may not be an effective strategy for supporting
    primary care,\15\ due to the burden associated with billing each one.
    This is part of the reason the AAFP advocates for prospective, risk-
    adjusted per-patient per-month payments for the continuous,
    comprehensive care delivered by primary care physicians.
    ---------------------------------------------------------------------------
        \15\ https://www.acpjournals.org/doi/10.7326/M21-4770.

                                     ______

                   Questions Submitted by Hon. Maria Cantwell
        Question. Health plans are legally required to offer to pay medical
    practices through standardized electronic payments, similar to the
    direct deposit system through which many Americans receive their
    paychecks. These payments are known as electronic fund transfers, or
    EFTs. Receiving payments electronically is convenient, but there's a
    catch. Health plans use vendors to process EFTs that charge physicians
    processing fees of 2 percent to 5 percent of the claims payment. Under
    this egregious system, physicians are essentially ``paying to get
    paid'' and receiving less than the fully contracted payment amount for
    care that they already provided.

        In a survey conducted by the Medical Group Management Association,
    nearly 60 percent of physician practice respondents said they are
    forced to pay these
    percentage-based fees without ever having agreed to them. These fees
    are particularly burdensome for small practices, which may not have the
    margins or administrative support to cope with them.

        To address this problem, Senator Cassidy and I introduced the No
    Fees for EFTs Act earlier this year. Our bill would prohibit health
    plans from imposing these unnecessary fees for electronic transfers on
    providers. Doctors should be focused on providing care, not dealing
    with burdensome EFTs.

        Are your members or you personally subjected to these fees? Could
    you comment on how they affect the financial outlook for practices who
    treat a high portion of patients with complex chronic care needs?

        Answer. Yes, I hear from family physicians who are subjected to
    these fees. The AAFP has previously expressed concerns to CMS about
    physicians incurring fees for electronic payments from health
    plans.\16\ Family medicine practices report that they are increasingly
    forced to pay mandatory, percentage-based fees for the receipt of
    electronic payments made from health plans via the electronic funds
    transfer (EFT) transaction standard. These fees are adding to
    practices' already overwhelming administrative burden and ongoing
    financial strain. Practices cannot afford to lose a percentage of each
    claim payment due to EFT fees. Disenrolling in EFT payments is often
    not permitted by payers, but when allowed it leads to additional
    administrative tasks that take time away from patient care.
    ---------------------------------------------------------------------------
        \16\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
    administrative/LT-CMS-EFTFees-102221.pdf.

        Question. Do you agree that the No Fees for EFTs Act would help
    ---------------------------------------------------------------------------
    protect providers from unfair processing fees?

        Answer. Yes. The AAFP is proud to have endorsed your
    legislation,\17\ the No Fees for EFTs Act, to help protect family
    physicians and other clinicians from these fees, as you note.
    ---------------------------------------------------------------------------
        \17\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
    administrative/LT-Senate-NoFeesEFTsAct-032524.pdf.

                                     ______

                    Questions Submitted by Hon. John Cornyn
        Question. In 2015, Medicare began reimbursing providers for chronic
    care management under a separate code in the Medicare Physician Fee
    Schedule. This code was supposed to compensate providers for the
    additional time needed outside of a typical visit to coordinate care
    for patients with chronic diseases, but only a fraction of eligible
    Medicare beneficiaries have received these services.

        Under current CMS guidelines, eligible chronic care management
    beneficiaries must have two or more chronic conditions. This can
    include mental health conditions like depression or a substance use
    disorder.

        What is preventing better utilization of these services?

        Answer. Although CCM helps prevent hospitalizations and emergency
    department visits, it is subject to beneficiary cost sharing, unlike
    most preventive services. For monthly services, such as CCM, this means
    patients must pay cost sharing each month. This cost sharing prevents
    better utilization, especially among beneficiaries who are financially
    disadvantaged and those without a supplemental policy (e.g., Medigap).

        Another barrier to better utilization is the way CCM codes are
    structured and paid under fee-for-service. The code descriptors and
    payers require a certain number of minutes of clinical staff or
    physician (or qualified health professional) time to be documented
    before the codes may be submitted and claimed. This necessitates
    tracking individual interactions with the patient or on the patient's
    behalf over the course of a calendar month before a claim can be
    submitted. Tracking and documenting that information over the course of
    a month to claim payment in a fee-for-service environment is cumbersome
    and sometimes deters use of services, especially as compared to a
    payment model where such services are paid on a prospective, per-
    patient per month basis for attributed beneficiaries.

        Question. For the estimated 1.7 million Medicare beneficiaries with
    a substance use disorder, can using this code improve outcomes for this
    more vulnerable patient population? For example, how might this reduce
    patient emergency room visits?

        Answer. I don't know of any research that specifically looks at use
    of the CCM code for Medicare beneficiaries with SUD, but some research
    has indicated that CCM more broadly has the potential to be a
    successful model for treating patients with SUD.\18\ However, I do
    believe that one of the remaining and significant barriers that may
    prevent the full benefits of CCM being realized for this population is
    the insufficient number of behavioral health clinicians, particularly
    those that are trained in CCM.
    ---------------------------------------------------------------------------
        \18\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902022/
    #::text=CCM%20is%20
    multidisciplinary%20patient%2Dcentered,(a%20substance%20use%20disorder).

        Question. Do CCM services reduce overall health-care costs for
    ---------------------------------------------------------------------------
    chronic care patients when used?

        Answer. Data has indicated that the answer to your question is yes.
    CMMI released a report showing that CCM was associated with lower
    growth in Medicare costs,\19\ reduced hospital admissions and increased
    connections with community-based resources for patients. Over an 18-
    month period, it reduced costs by $74 per beneficiary per month. CMS
    claims data has shown that if a patient is in the program for at least
    a year,\20\ Medicare achieves $888 per patient, per year in gross
    savings. Additionally, patients in CCM had lower hospital, ED, and
    nursing home costs and CCM was linked with a reduced likelihood of
    hospital admission for people with diabetes, chronic obstructive
    pulmonary disease, congestive heart failure, urinary tract infection,
    dehydration, and pneumonia.
    ---------------------------------------------------------------------------
        \19\ https://www.cms.gov/priorities/innovation/files/reports/
    chronic-care-mngmt-finalevalrpt.pdf.
        \20\ https://www.chartspan.com/blog/effectivity-of-chronic-care-
    management-programs/.

                                     ______

                     Questions Submitted by Hon. John Thune
        Question. As part of the Merit-based Incentive Payment System
    (MIPS), physicians must be compliant in promoting interoperability as
    part of their reimbursement, which helps to facilitate the sharing of
    data between various providers.

        I have long been an advocate for health IT initiatives that can
    improve efficiencies and reduce costs in the health-care system, and I
    believe that sharing information between providers through an
    interoperable network has immense upside, so long as there are
    safeguards to protect patient privacy and ensure taxpayer funds are
    spent appropriately.

        However, there continue to be challenges to physicians meeting
    interoperability metrics, like information blocking for example in
    which an individual or entity impedes the delivery or utilization of an
    electronic health record, making interoperability impossible.

        In your view, how have practices been impacted by information
    blocking?

        Answer. Practices have been impacted both by information blocking
    itself, as well as by information blocking regulations. The AAFP has
    long supported efforts to advance the interoperability of health IT,
    including through the Office of the National Coordinator (ONC) for
    Health IT's development of information blocking regulations. Despite
    ONC's longstanding efforts to reach and educate the health-care
    community about information blocking, significant knowledge gaps still
    exist regarding the implementation and enforcement of information
    blocking regulations. Several independent, small, rural, and solo
    medical practices are still unaware or underinformed about information
    blocking requirements. The AAFP has urged HHS,\21\ ONC, CMS, and other
    agencies to develop an intraagency communications plan and educational
    outreach program specifically designed to reach physicians in
    underserved communities and small practices. Family physicians want to
    follow regulations and appropriately share information with their
    patients and other members of their patients' care team, and
    significantly more education is needed for practices to be able to
    achieve those goals.
    ---------------------------------------------------------------------------
        \21\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
    ehr/LT-HHS-ONC-InformationBlocking-122223.pdf.

        Question. Are you aware of instances in which the timeliness or
    quality of the care physicians are able to provide patients has been
    impacted by a limited ability or complete inability to access
    ---------------------------------------------------------------------------
    electronic health records?

        Answer. Yes. My family physician peers have shared several
    examples.

              A clinical example is medication reconciliation. One family
            physician shared that they use a different EHR than their local
            hospital system, and the ER and inpatient services cannot see
            the physician practice's updated medication list despite both
            organizations being connected through Epic's Care Everywhere.
            When patients are discharged from the hospital, they are
            routinely discharged on a medication list that has no
            reflection of their home medications because the medication
            list in the hospital system was wrong in the ER, stayed wrong
            upon admission, was never corrected during the hospitalization,
            and was of course all wrong upon discharge.
              Another physician stated that consulting subspecialists in
            their two main systems assume that ``everyone'' can see their
            notes and no longer send chart notes in response to referrals.
            The practice's referral coordinator spends time every day
            trying to track down consult notes from subspecialists who
            think their notes are visible throughout the system due to
            their ``connected'' systems. When notes do come in as an
            electronic ``Record of Care,'' they are not tied back to the
            referral order to close the loop automatically. Instead, they
            must be manual labeled as a consult note and attached to the
            order that generated the initial referral by a staff person or
            the physician.
              A physician stated that they are unable to get the data from
            outside laboratories to know if the patient got the test. They
            must resort to having the patient follow up with another
            appointment to ensure the labs were completed and where, so
            they can request the results.
              Finally, a physician stated that they are unable to get data
            from an urgent care center and are forced to call the center
            and request the information be faxed to them. These are not
            isolated events, but rather we hear these types of stories all
            the time. The lack of interoperability increases costs, delays
            care, and adds burden to primary care to find and get the
            needed data.

        Question. Furthermore, beyond information blocking, what other
    challenges persist in physicians accessing patients' health information
    electronically despite the billions of dollars spent to implement
    electronic health IT and interoperability?

        Answer. See above for examples that also respond to this question.

                                     ______

                Question Submitted by Hon. Robert P. Casey, Jr.
        Question. Your testimonies and discussions at the hearing noted
    that the Merit-based Incentive Payment System (MIPS) is cumbersome for
    clinicians. The intention of MIPS is to foster performance
    improvements, leading to better outcomes for patients. You all
    mentioned that MIPS is burdensome and may not accurately capture the
    quality of care physicians provide.

        Are there policy proposals that could be implemented to make MIPS
    more accurate and less burdensome?

        Answer. MIPS uses four siloed performance categories--all with
    different measures and reporting requirements. Despite multiple calls
    for consolidation and cross-category credit, CMS argues that they do
    not have the statutory authority to alter the program in that regard.
    One significant step toward reducing burden would be to give CMS the
    flexibility to provide cross-category credit. For example, a physician
    who reports a quality measure related to depression screening should
    automatically receive credit for the corresponding improvement
    activity.

        The AAFP has also repeatedly advocated that CMS allow practices to
    attest to using CEHRT rather than requiring multiple burdensome
    measures for the promoting interoperability category. Again, CMS does
    not have the authority to offer such an option. As we noted in our
    comments on the 2024 MPFS NPRM, years of policy changes to the legacy
    Meaningful Use program and now the promoting interoperability category
    have failed to move the needle on health information exchange. It is
    beyond time to move away from such burdensome requirements--doing so
    would be an important step toward reducing the burden of the MIPS
    program.

                                     ______

                 Question Submitted by Hon. Sheldon Whitehouse
        Question. I am working on a bill to relieve providers excelling in
    the Medicare Shared Savings Program (MSSP), from prior authorization
    (PA) requirements in MA. The bill rewards providers in Accountable Care
    Organizations (ACOs) that generate savings for Medicare by granting an
    exemption from PA requirements for their MA beneficiaries. If an
    insurer believes there is a rationale for maintaining PA in such
    instances, this bill would require them to seek prior approval from the
    Centers for Medicare and Medicaid Services (CMS). I would welcome your
    thoughts and comments on this idea.

        Answer. AAFP policy supports the concept that family physicians
    that contract with health plans to participate in a financial risk-
    sharing agreement should be exempt from prior authorizations.\22\
    ---------------------------------------------------------------------------
        \22\ https://www.aafp.org/about/policies/all/prior-
    authorizations.html.

                                     ______

                    Question Submitted by Hon. Maggie Hassan
        Question. I am working with my colleagues on the Finance Committee
    to address discrepancies in Medicare reimbursement that disadvantage
    independent doctors. Older adults, and the Medicare program, often pay
    a huge markup for basic services if their provider's office is owned by
    a hospital.

        If a patient on Medicare with arthritis received a routine steroid
    injection from an independent doctor, Medicare would pay $50 and the
    patient would pay about $15. For the same injection at an office owned
    by a hospital, Medicare would pay $250, and the patient would pay $60.

        What impact does this huge price differential have for patients in
    rural areas, and how can we level the playing field so that we are not
    disadvantaging physician-led care?

        Answer. The AAFP has been strongly calling for Congress to advance
    policies that will meaningfully address site-of-service payment
    differentials for the reasons you identified in your question:\23\ they
    are creating an uneven playing field for independent practices across
    the country and patients are quite literally paying the price for it,
    without getting anything in return.
    ---------------------------------------------------------------------------
        \23\ https://www.aafp.org/dam/AAFP/documents/advocacy/payment/
    medicare/LT-HouseEC-HealthCareSpending-013124.pdf.

        There is little evidence that these additional payments hospitals
    are able to charge are reinvested in the acquired physician practice,
    many of which are primary care practices. Thus, the hospital increases
    its revenue by acquiring physician practices and beneficiaries are
    ---------------------------------------------------------------------------
    forced to pay higher coinsurance.

        Medicare's increased payments for services performed in HOPDs does
    not just impact the Medicare program and beneficiaries, however.
    Private health plans generally use Medicare's payment system as a basis
    for how much they pay physicians and hospitals, meaning that this
    influences and directs spending and resources among commercial plans
    and patients. Therefore, adopting comprehensive site-
    neutral payment policies in Medicare would have significant impacts in
    saving money across the health-care sector, with one study estimating
    that it would lead to $471 billion in savings over the next 10
    years.\24\
    ---------------------------------------------------------------------------
        \24\ https://www.bcbs.com/sites/default/files/file-attachments/
    affordability/Phil_Ellis_
    Site_Neutral_Payment_Cost_Savings_Report_BCBSA_Feb_2023.pdf.

        In terms of direct patient costs, Medicare patients collectively
    would save about $67 billion on Part B premiums and $67 billion on cost
    sharing. Premiums for private health insurance plans would be about
    $107 billion lower over that period, which would amount to a reduction
    in aggregate premiums of 0.75 percent. Privately insured patients would
    ---------------------------------------------------------------------------
    also save about $18 billion on cost sharing due to lower payment rates.

        Therefore, the AAFP continues to encourage Congress to extend
    payment parity for all clinically appropriate services to off-campus
    HOPDs established before 2015. We have also supported more incremental
    policies such as requiring that payment for physician drug
    administration services be the same in an off-campus HOPD as in a
    physician's office.

                                     ______

                  Questions Submitted by Hon. Marsha Blackburn
        Question. Medicare physician pay and its impact on patient access
    to care remains a significant issue for my constituents. Adjusted for
    inflation in practice costs, Medicare physician pay plummeted 29
    percent from 2001 to 2024. Although Congress did act in the March 8th
    government funding package to reduce the 3.37-percent cut that went
    into effect on January 1, 2024, by an additional 1.68 percent, the 29-
    percent reduction in Medicare payments over the last 2 decades is
    reflective of this most recent congressional action. Plus, physicians
    are now set up for another steep payment cut at the end of this year.
    Nonpartisan government stakeholders recognize the damaging impact these
    cumulative payment cuts have on patient access to care. Multiple
    Medicare trustee reports stated that ``absent a change in the delivery
    system or level of update by subsequent legislation, the trustees
    expect access to Medicare-participating physicians to become a
    significant issue in the long term.''

        Can you discuss some of the impacts of this pressing financial
    instability on physician practices, including consolidation, difficulty
    retaining staff, and trouble keeping their doors open amid rising
    costs?

        Answer. Your question includes much of the answer. Insufficient
    payment rates, particularly for small, independent primary care
    practices that are already operating on thin margins, make it extremely
    difficult for them to compete with hospitals, health systems, plans,
    and other corporate entities who are recruiting for the same staff with
    more attractive salaries and more significant resources (such as access
    to advanced tools and technology, additional administrative support,
    and other experts). For the physician, increasingly high rates of
    student loan debt have a clear impact on the decision for many to
    choose employment with a well-resourced system or plan. All of these
    factors together, in addition to having to comply with an extremely
    burdensome regulatory environment, are accelerating consolidation
    within primary care.

        Question. What available mechanisms do Congress and HHS have within
    current statutory authority to help provide adequate Medicare payments
    to physicians and ensure continued patient access to care? For example,
    alleviating the administrative burden on practices through reforms to
    the Merit-based Incentive Payment System?

        Answer. As noted in a response above, we have made several
    recommendations on ways to improve MIPS and alleviate associated
    administrative burden on practices--however, CMS has indicated their
    statutory authority to do so is limited. Absent congressional action,
    CMS and HHS do not have much existing authority that allows them to
    provide adequate Medicare payments to all physicians. For example,
    efforts made by CMS to try and better value primary care within their
    existing authority have required them to also offset these investments
    by cutting payment for all Medicare fee schedule services (including
    all of the other primary care services). Congress must lead the charge
    on providing adequate Medicare payments to physicians by first
    reforming budget-neutrality requirements and implementing an annual
    inflationary update for physician payment based upon the MEI, as two
    important starting points.

        Question. Do these cuts disproportionately impact access to care in
    underserved areas?

        Answer. As a rural family physician, I can attest that the answer
    is ``yes.''

        Question. As a value-based purchasing program, MIPS was supposed to
    reward physicians who achieved quality and cost-efficient care.
    However, for years physicians have raised concerns about the program,
    including that it increases administrative burden and does not
    accurately capture quality.

        What has been your experience with MIPS and the administrative
    burden that it entails?

        Answer. I have heard from many family physicians that MIPS has not
    supported them in the transition to alternative payment models but
    rather it has only contributed to significantly more time spent on
    administrative tasks. A 2021 study in JAMA \25\ of the time and
    financial costs to practices to participate in MIPS found that small
    and medium primary care practices had mean per-physician costs of
    $18,466 and $13,631. It also found that physicians, clinical staff
    members, and administrators spent 201.7 hours annually per physician to
    participate in the MIPS program. Physicians alone spent more than 53
    hours per year on MIPS activities. These statistics are even more
    significant when you consider that they only apply to MIPS, and family
    physicians often participate with 7-10 different payers.
    ---------------------------------------------------------------------------
        \25\ https://jamanetwork.com/journals/jama-health-forum/
    fullarticle/2779947.

        Question. Is it time to consider replacing the program with a more
    valuable alternative? If so, what are some of the program's benefits
    ---------------------------------------------------------------------------
    that should be considered when designing its replacement?

        Answer. Whether it's complete replacement or a significant
    overhaul, it is clear that the current program is not working as
    intended.

        The MACRA statute included funding for technical assistance.
    However, this funding expired, and the Small, Underserved, and Rural
    Support (SURS) program ended in 2022. The SURS Extension Act (H.R.
    6576) would have authorized additional funding, but it has yet to move.
    The SURS program provided valuable and direct assistance to practices
    through tools and resources to help them navigate the complex MIPS
    reporting requirements. Under the current structure, the performance
    threshold will continue to increase. We've already seen that these
    practices are more likely to face difficulties in meeting the
    performance threshold, which will lead to significant payment
    adjustments.

        Without continued technical support as well as other program
    reforms, the disproportionate financial impact may accelerate
    consolidation and exacerbate access issues. We believe technical
    support for practices is just as important as program design and
    critical to ensuring practices can succeed under value-based payment
    arrangements. We urge Congress to provide additional funding for such
    support.

        While the statute requires the Secretary to provide performance
    feedback data to physicians, CMS has not been able to develop a
    mechanism that provides timely and actionable information to
    physicians. Feedback reports often include data that is 2 years old--
    making it outdated and significantly limiting its utility.

        Question. How have your practices been impacted by information
    blocking?

        Answer. See above responses to the questions posed by Senator
    Thune.

        Question. Have you had experiences where your ability (or
    inability) to access health records has impacted the timeliness or
    quality of the care you are able to provide your patients?

        Answer. See above responses to the questions posed by Senator
    Thune.

        Question. Do existing Federal quality and payment incentive
    programs under Medicare, like ``Promoting Interoperability'' under the
    Merit-based Incentive Payment System, enable up-to-date, consolidated
    longitudinal health records accessible without special effort?

        Answer. No.

        Question. With over $40 billion spent and nearly 2 decades of
    effort put into implementing electronic health information technology,
    fax machines remain widely used for sharing health data in our health-
    care system.

        Why is this the case, and what challenges persist in accessing
    patients' health information electronically?

        Answer. Fax machines are reliable, easy to use, and HIPAA-
    compliant. They also have a single, standard way to send information to
    many entities. For small and underresourced practices in particular,
    fax machines can be a straightforward way to securely exchange health
    information. Additionally, lack of technological literacy and lack of
    access to reliable broadband Internet are two significant obstacles to
    patients' health information being electronically accessible.

        AAFP members have shared stories of their EHR vendor blocking
    access to records during billing negotiations or disputes, examples of
    previous EHR vendors refusing to share records that should have been
    transferred during EHR transitions, and instances of hospitals refusing
    to send an admission, discharge, and transfer (ADT) or to provide
    access to summary of care documents for physicians without staff
    privileges. These are just a few of many challenges that persist today
    when attempting to access patients' health information electronically.

                                     ______

     Prepared Statement of Melanie Matthews, MSN, Chief Executive Officer,
    Physicians of Southwest Washington; and President, MultiCare Connected
                                      Care
        Thank you, Chairman Wyden, Ranking Member Crapo, and members of the
    committee, for the opportunity to testify today about how to improve
    care for people with chronic conditions. My name is Melanie Mathews,
    and I serve as the chief executive officer of PSW and president of
    MultiCare Care Connected. I have over 20 years of health-care
    experience with a focus on the delivery of value-based care.

        Founded by independent physicians, PSW has led health-care
    innovation with the guiding principle of supporting the physician-
    patient relationship to improve the quality of care since its inception
    in 1995. Committed to the value of innovation, PSW's approach is to
    meet our partners ``where they are.'' We seek to find the complementary
    balance of organizational experience and operational strength to
    support our partner's success. PSW's diversified business portfolio
    includes payer network operations, accountable care models, and
    advisory and management solutions; this collective work accounts for
    more than 400,000 member lives with a clientele of hospital systems,
    payers, vendors, and provider practices.

        In 2017, PSW created its first Accountable Care Organization (ACO):
    NW Momentum Health Partners (NWMHP). NWMHP was created to give our
    partner providers the ability to join a single network and engage in
    new innovative Federal payment models. Since then, NWMHP has
    participated in several CMS Innovation Center models: the Next
    Generation ACO Model, the Bundled Payments for Care Improvement
    Advanced (BPCI) Model, Global and Professional Direct Contracting
    (GPDC) Model, and the ACO Realizing Equity, Access, and Community
    Health (REACH) Model.

        In 2018, PSW began its partnership with MultiCare Health System and
    MultiCare Connected Care (MCC). MCC was developed to be the Clinically
    Integrated Network (CIN) for MultiCare Health System and participate as
    an ACO in the Medicare Shared Savings Program (MSSP). MCC's ACO
    includes all MultiCare Health System hospitals and several other
    provider organizations throughout Washington State.
         accountable care is improving care delivery and lowering costs
        Through our vast experience, we have seen how accountable care
    (also called alternative payment models) delivers coordinated care that
    best meet the needs of people, particularly those with chronic
    conditions. Accountable care delivery holds providers responsible for
    the cost of care and health outcomes. As opposed to a fee-for-service
    system where the incentives are aligned toward greater volume,
    accountable care focuses on healthier populations and people.

        Accountable care efforts have shown that holding clinicians
    responsible for total cost of care and patient outcomes improves care,
    expands access, and saves money for Federal programs:

              Accountable care improves care experiences by holding
            providers responsible for patient outcomes and creating cash
            flow through up-front or population-based payments that
            providers can use to invest in tailored care management
            programs, including for the chronically ill. Accountable care
            strategies including care coordination, care transitions
            programs (smoothing the transition from hospital to home for
            example) and care management for medically complex patients
            improve people's care experiences.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347295/.

              Accountable care expands access to care, for example,
            increasing weekend and evening hours appointments, using data
            to identify gaps in care, and developing relationships with
            community providers and social needs organizations to improve
            health outcomes and address social determinants of health.\2\
    ---------------------------------------------------------------------------
        \2\ https://accountableforhealth.org/wp-content/uploads/2024/02/
    BRG_ImprovingAccess
    ThroughValueBasedCare2024.pdf.

              By incentivizing preventative care and reducing wasteful
            spending, accountable care saves money. Advanced APM
            Accountable Care Organization (ACO) portfolio (ACOs that take
            on two-sided risk, including two-sided risk Medicare Shared
            Savings Program and CMS Innovation Center ACOs) saved $4.2
            billion in traditional Medicare in 2022,\3\ and a total of $8.4
            billion in gross savings after taking into account spillover
            effects in Medicare Advantage.
    ---------------------------------------------------------------------------
        \3\ https://www.naacos.com/assets/docs/pdf/2023/
    NAACOS2022ACOSavingsResource.pdf.
    ---------------------------------------------------------------------------
         chronic care management successes in accountable care delivery
        PSW's Chronic Care Management (CCM) program, overseen by the chief
    medical officer (CMO) and chief nursing officer (CNO), is specifically
    designed to enhance the quality of life for patients dealing with
    chronic health conditions. Its primary objectives are to reduce health
    disparities, minimize unnecessary health-care costs, and align with
    value-based reimbursement systems. This initiative places a strong
    emphasis on empowering patients to take charge of their health through
    active engagement with primary care services.

        The CCM program is particularly geared towards individuals with
    chronic diseases who require support for self-management to improve
    health outcomes. It operates within home settings, where patients or
    their designated representatives assume responsibility for self-care
    under professional guidance. Notably, the program takes a proactive
    approach by identifying patients with poorly controlled chronic
    conditions or significant negative impact of social determinants of
    health, with the overarching goal of enhancing patient well-being and
    health outcomes.

        One of the program's core strategies is to foster long-term
    positive outcomes by ensuring patients and their caregivers possess the
    necessary knowledge and skills to identify and address health concerns
    promptly. A registered nurse plays a pivotal role in this process by
    developing and executing personalized care plans. This nurse
    collaborates closely with a multidisciplinary team comprising
    physicians, licensed practitioners, social workers, discharge planners,
    pharmacists, and other health-care professionals as needed.

        Services provided through the CCM program are highly
    individualized, tailored to support patients with chronic conditions in
    improving their overall health and well-being. The program places a
    strong emphasis on patient education and empowerment for effective
    chronic disease management and self-care. Through a collaborative team
    approach involving the patient, nurse care manager (NCM), and primary
    care provider (PCP), the program strives to achieve the patient's
    specific health goals.

        Additionally, comprehensive documentation of services follows
    stringent National Committee for Quality Assurance (NCQA) requirements.
    Participation in the Complex Care Management Program is voluntary, with
    patients having the option to opt out at any time, provided they meet
    the established enrollment criteria. This comprehensive approach
    ensures that patients with complex health issues receive holistic care
    tailored to their individual needs, ultimately aiming for improved
    health outcomes and quality of life.
    Patient Example
        A patient with multiple health issues, including congestive heart
    failure, experienced setbacks due to hospitalizations for sepsis and
    pneumonia. Despite adhering to prescribed medications, their symptoms
    worsened at home. After enrolling into a PSW ACO care management
    program, a PSW nurse care manager began engaging with the patient and
    recognized critical signs. The nurse care manager immediately took
    action by contacting the primary care physician and recommending daily
    monitoring of weight and blood pressure. With the remote monitoring and
    PCP's adjusted medication regimen, the patient rapidly improved within
    2 days, avoiding further complications. This success highlights the
    vital role of ACO care management programs in providing timely support
    and interventions for patients dealing with complex health issues,
    enabling them to recover at home.
    ACO Successes
        NWMHP and MCC have played a pivotal role in transforming health-
    care delivery and improving patient outcomes in Washington State,
    resulting in significant cost savings for Medicare. Through their
    innovative and patient-centered approaches, these ACOs have
    collectively saved $120 million for Medicare while maintaining an
    impressive average quality score of 96 percent and an average savings
    rate of 4.5 percent from 2017 to 2022.

        NWMHP's emphasis on accountable care has led to notable
    advancements in patient outcomes across the State. By prioritizing
    coordinated care initiatives, they have streamlined care transitions,
    reduced hospital readmissions, and bolstered preventive care services.
    NWMHP has partnered with independent providers and Critical Access
    Hospitals alike to expand access to care and benefits to Medicare
    beneficiaries. Moreover, NWMHP's proactive approach to preventive care
    has resulted in increased utilization of wellness visits and
    recommended screenings, fostering early detection and management of
    health conditions.

        Similarly, MCC's commitment to accountable care has yielded
    positive outcomes for patients throughout Washington State. Through
    targeted programs focusing on chronic disease management, MCC has
    empowered patients to better manage their conditions, leading to
    improved health outcomes and reduced health-care expenditures. The
    emphasis on preventive screenings, including mammograms and flu
    vaccines, has promoted proactive health management and wellness among
    beneficiaries. Additionally, MCC's efforts in care coordination have
    facilitated smooth transitions for patients navigating different care
    settings, ensuring continuity of care and optimal patient experiences.

        The combined achievements of NWMHP and MCC underscore their
    dedication to delivering high-quality care while driving cost savings
    for Medicare. Their success stories exemplify the transformative impact
    of accountable care models in enhancing care coordination, promoting
    preventive services, optimizing chronic disease management, and
    ultimately, improving patient outcomes and health-care affordability in
    Washington State.
        federal policy can drive better care for chronically ill people
        The Medicare Access and CHIP Reauthorization Act (MACRA) has been
    instrumental in driving participation in accountable care that improves
    care for people. MACRA included incentives for participation in two-
    sided risk models, where providers can share in savings if they beat
    spending targets while improving quality or repay losses if they exceed
    those targets. Participants also received an incentive payment for
    participating in a two-sided risk arrangement, known as the advanced
    APM bonus. Those incentives served as a powerful motivator to grow
    accountable care and allowed participants to reinvest into the health
    care delivery system to expand access, improve care, and support our
    clinical network. As a result, substantially more clinicians today,
    including specialists, are participating in accountable care as
    compared to before MACRA was enacted. ACO participation in the Medicare
    Shared Savings Program has more than doubled, from 220 ACOs providing
    care to fewer than 5 million Medicare beneficiaries in 2012,\4\ to 480
    ACOs providing care to nearly 11 million aligned beneficiaries in
    2024.\5\
    ---------------------------------------------------------------------------
        \4\ https://www.federalregister.gov/documents/2014/12/08/2014-
    28388/medicare-program-medicare-shared-savings-program-accountable-
    care-organizations.
        \5\ https://www.cms.gov/newsroom/press-releases/participation-
    continues-grow-cms-accountable-care-organization-initiatives-2024.

        While accountable care has shown progress toward the goals of
    better outcomes and lower costs, additional work is necessary to drive
    change to the way care is delivered in Medicare and for other payers.
    Now, nearly 10 years after MACRA's passage and over a decade into our
    ACO and APM experience, we know more about what incentives work to
    ---------------------------------------------------------------------------
    drive participation in APMs. Specifically, we would recommend:

              Extend the advanced APM bonus in the short term to
            demonstrate Congress's bipartisan continued commitment to
            ensuring better care for patients in traditional Medicare.
              Restructure the bonus in the longer term to strengthen that
            commitment, delinking advanced APM bonuses from volume of
            services provided and shortening the time between payment and
            performance (which is currently a 2-year delay).
              Focus on advanced APM policies that simplify and support
            provider participation and create clear advantages for
            participating in an advanced APM.
              Strengthen the data infrastructure to support accountable
            care and population health.
                     incentives for beneficiaries to engage
        Creating incentives for beneficiaries to engage with ACOs is
    crucial to ensuring that the intended programs developed by ACOs have a
    true impact on the population. Cost sharing incentives, for example,
    can increase access services that otherwise might be avoided or
    forgone. In Washington State, Columbia County Health System saw this as
    they embarked on a journey to provide greater support to their patients
    at risk of or diagnosed with chronic obstructive pulmonary disease
    (COPD). Recognizing the challenges faced by these individuals, Columbia
    County Health System developed a comprehensive program in collaboration
    with their chronic care management efforts.

        This program was designed to offer additional support and
    resources, including regular nurse consultations, enhanced care
    coordination, increased primary care visits, and facilitated access to
    community-based and State-funded services to address social
    determinants of health. However, despite the immense potential of this
    program to improve patient outcomes and quality of life, Columbia
    County Health System encountered a significant obstacle: low enrollment
    among Medicare beneficiaries.

        The primary deterrent to enrollment was the financial burden
    imposed by coinsurance payments, rendering many beneficiaries unable to
    afford these health-care services. It was evident that without
    addressing this barrier, the program's impact would be severely
    limited, denying vulnerable populations access to the care they
    desperately needed.

        In response to this challenge, Columbia County Health System, with
    the support of our ACO, implemented the ACO REACH cost-sharing waiver.
    This strategic decision to waive coinsurance payments proved to be a
    game-changer. By alleviating the financial burden on beneficiaries, we
    witnessed a remarkable surge in program enrollment.

        The waiver not only facilitated greater participation but also
    translated into tangible improvements in patient outcomes. Patients
    with COPD who previously struggled to access care now had the means to
    engage proactively in managing their health. This translated into
    increased use of primary care, improved disease management, and
    ultimately, enhanced quality of life for these individuals.

        The success story of Columbia County Health System's COPD program
    underscores a fundamental principle: when we remove financial barriers
    and create incentives for engagement, we unlock the full potential of
    ACO initiatives to deliver transformative health-care solutions. It is
    imperative that we continue to explore and implement innovative
    strategies, such as cost-sharing waivers, to ensure equitable access to
    quality care for all beneficiaries.
     support provider participation in sustainable, effective accountable
                                      care
        ACOs have supported and improved care for chronically ill
    individuals for over a decade. Through two main avenues, the Medicare
    Shared Savings Program and the ACO portfolio at the CMS Innovation
    Center, participants in these total cost of care models, where
    providers are accountable for population health and cost, have
    consistently demonstrated savings and care improvements.

        More can be done to support these models as well. In the Medicare
    Shared Savings Program, CMS can continue to develop options with
    greater levels of financial risk and reward, such as a full risk ACO
    that was included in the Value in Health Care Act, introduced earlier
    this year. In addition, Congress and CMS should work to ensure that
    there are clear advantages under MACRA to participating in MSSP,
    disentangling MSSP participants from burdensome MIPS requirements.

        The ACO portfolio at the CMS Innovation Center has been a mainstay
    of that portfolio since the Innovation Center's creation and continuing
    across administrations with bipartisan support. Congress should support
    continued operation of ACO models at the CMS Innovation Center that
    support the transition to population-based payments, experiment with
    new waiver flexibilities, and allow greater pursuit of coordinated care
    strategies that support patent care.
                                   conclusion
        I thank the Committee for the opportunity to testify today. On
    behalf of PSW and MultiCare Care Connected, we look forward to
    continuing to work with you to advance the United States health care
    delivery system to get better outcomes for patients.

    Melanie's Affiliations

    Accountable for Health (A4H)--board member
    National Association of ACOs (NAACOS)--board member and chair-elect
    America's Physician Groups (APG)--board member
    Health Care Transformation Task Force (HCTTF)--board member

                                     ______

          Questions Submitted for the Record to Melanie Matthews, MSN
                     Questions Submitted by Hon. Mike Crapo
        Question. Advanced Alternative Payment Models (AAPMs) hold
    significant promise as a means of driving improved value while ensuring
    appropriate and targeted stewardship of Federal Medicare dollars for
    both beneficiaries and taxpayers.

        What specific steps should Congress or CMS take in order to improve
    uptake of these models, including for specialties with low
    participation rates?

        Answer. To improve uptake of these models, Congress should pass
    legislation that provides clear, strong incentives for the move to
    accountable care. For example, Congress should extend the alternative
    payment model (APM) incentive payment which helps providers address the
    start up costs and ongoing costs associated with participating in these
    models, including hiring staff, investing in health IT and standing up
    care management programs. Congress should also make clear that the
    Merit-based Incentive Payment System (MIPS) is less attractive than APM
    participation. Today, the maximum MIPS potential bonus is 9 percent
    while the advanced alternative payment model bonus is 1.88 percent.
    These programs are reversed if the goal is to increase uptake in
    alternative payment models.

        Congress should also review the qualifying thresholds to obtain APM
    status. MACRA established revenue/performance thresholds--known as
    Qualifying APM Participant (QP) thresholds--that APM participants must
    meet to qualify for incentives. These statutory levels, which increase
    over time, have proven unrealistic relative to the real-life
    experiences of clinicians. Congress has previously adjusted the QP
    thresholds in 2020, 2022, and 2024.

        The Value in Health Care Act ensures that qualifying thresholds
    remain attainable to promote program growth by freezing them at 50
    percent for 2 years and giving the Centers for Medicare and Medicaid
    Services (CMS) authority to adjust thresholds through rulemaking and
    set varying thresholds for more targeted models where participants
    (e.g., specialists) cannot meet the existing one-size-fits-all
    thresholds.

        Last year, CMS also proposed making QP determinations at the
    individual NPI level instead of the APM entity. This policy was not
    finalized due to broad stakeholder concerns, but CMS has expressed
    interest in revisiting this change.

        While the current QP thresholds can make it difficult for some ACOs
    to include specialists, there is concern that only making QP
    determinations at the individual level would further discourage
    specialist participation in ACOs.

        As uptake of APMs continues to underperform original projections
    the agency should use a determination process that will maximize the
    number of QPs and promote growth in APMs.

        Question. What specific flexibilities would help Accountable Care
    Organizations to improve patient care quality and reduce costs, and
    what steps could Congress take to advance these types of flexibilities?

        Answer. MIPS--Reduce program complexity by ensuring that clinicians
    in APMs are not required to engage in duplicative quality reporting
    efforts. Emphasize that MIPS should prepare clinicians for and
    encourage adoption of APMs.

        Interoperability and use of CEHRT--CMS should repeal policies
    changing the CEHRT requirements for MSSP ACOs and other APM
    participants in 2025. In April, over 100 ACOs and dozens of health-care
    associations wrote to CMS outlining how PI changes finalized in the
    2024 Medicare Physician Fee Schedule will result in significant
    increases in burden, especially for small practices.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.naacos.com/assets/docs/pdf/2024/
    AMASignonLetter_PICEHRTChangesAPMs
    041024.pdf.

        Digital Quality--Direct CMS to pilot test new digital quality
    measurement to identify key challenges and unintended consequences.
    Congress should provide incentives to participate in pilot tests, such
    ---------------------------------------------------------------------------
    as exemptions from existing reporting requirements.

        MSSP--(1) Remove the high or low revenue-based designation in MSSP
    that penalizes certain ACOs, especially those including rural and
    safety net providers, (2) establish guard rails for CMS to ensure that
    the process to set financial benchmarks is transparent and
    appropriately accounts for regional variations in spending, to prevent
    arbitrary winners and losers, (3) direct CMS to establish a voluntary,
    full-risk track MSSP, and (4) expand the ACO Primary Care Flex model to
    all ACOs to ensure that more clinicians can take advantage of
    prospective population-based payments for primary care.

        Waivers--Direct CMS to establish a common set of waivers for APMs,
    incorporating successful waivers from the Next Generation ACO Model and
    the ACO REACH Model into MSSP.

        Chronic Care Management (CCM)--While APMs offer opportunity to
    allow providers to reduce beneficiary cost sharing to ensure patients
    receive enhanced care management, we encourage the committee to look at
    legislative options to waive the beneficiary coinsurance related to
    CCM.

        GAO Report on Parity--Evaluate the potential of parity between APMs
    and Medicare Advantage (MA) so policymakers can seek greater alignment
    between the programs to ensure that both models provide attractive,
    sustainable options for innovating care delivery, and to ensure that
    APMs do not face a competitive disadvantage.

        CMMI--Ensure that promising aspects of innovative models have a
    more predictable pathway for becoming permanent.

        Question. Artificial intelligence (AI) has the potential to
    mitigate administrative burden and enhance health-care quality,
    including in the context of Medicare. That said, some clinicians have
    raised concerns around the program's inability to keep pace with AI-
    enabled tool development through its coverage and payment policies,
    undercutting access, especially for smaller practices.

        What use cases for AI-enabled tools and technologies seem most
    promising in the context of clinician care?

        Answer. AI-enabled tools and technologies offer numerous promising
    use cases in the context of clinician care. One area is quality gap
    closure, where AI systems can efficiently communicate with patients and
    schedule appointments on their behalf, ensuring timely and seamless
    health-care delivery. This not only improves patient experience but
    also optimizes clinic workflows.

        Another valuable application is in annual wellness visits, where AI
    tools can streamline the process, making it more comprehensive and
    personalized. This ensures that preventive care measures are
    effectively implemented, leading to better health outcomes.

        Chronic disease monitoring is another promising area where AI
    shines. By continuously monitoring patients and sending reminders about
    necessary tests and visits, AI tools empower patients to manage their
    conditions more effectively while providing clinicians with real-time
    data for proactive intervention.

        Additionally, AI can support clinicians in providing accurate and
    timely differential diagnoses through clinical decision support and
    chart review functionalities. This not only enhances diagnostic
    accuracy but also aids in treatment planning.

        One of the notable benefits of AI-enabled tools is the potential
    for reducing administrative expenses significantly. The automation of
    administrative tasks frees up resources that can be redirected towards
    patient care, ultimately improving the overall quality of health-care
    delivery.

        Lastly, AI has the potential to enhance documentation practices by
    providing more robust and accurate documentation of patient encounters.
    This not only improves the quality of medical records but aids in
    research and analysis for improvement in health-care practices.

        Question. What steps should CMS and Congress take to ensure
    adequate coverage and reimbursement for appropriate AI-enabled tools in
    this context?

        Answer. To ensure adequate coverage and reimbursement for
    appropriate AI-
    enabled tools in the context of clinician care, both CMS and Congress
    can take several proactive steps.

        Establish programs and incentives: Implement programs and
    incentives that encourage the use of AI-enabled tools in health-care
    settings. These programs can be tracked through auditing processes to
    ensure proper utilization and effectiveness. Incentives could include
    financial rewards, performance-based bonuses, or accreditation benefits
    for clinics and providers adopting AI tools effectively.

        Develop specific billing codes: Work collaboratively to develop
    specific billing codes that reflect services leveraging AI
    technologies. For example, for tools used in completing assessments
    like the PHQ-9 (Patient Health Questionnaire-9) with patients, there
    could be dedicated billing codes that allow for appropriate
    reimbursement. These codes should be designed to accurately capture the
    value and complexity of AI-enabled services provided.

        Collaborate with industry stakeholders: Engage with industry
    stakeholders, including AI developers, healthcare organizations, and
    professional associations, to gather insights and best practices for
    integrating AI tools into clinical care. This collaboration can help
    identify opportunities for coverage and reimbursement improvements and
    address any regulatory or policy barriers hindering the adoption of AI
    technologies.

        Regular review and updates: Establish a framework for regular
    review and updates of coverage and reimbursement policies related to
    AI-enabled tools. This ensures that policies remain current with
    advancements in technology and health-care practices, allowing for
    agile adjustments to support appropriate reimbursement for innovative
    AI solutions.

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. The Center for Medicare and Medicaid Innovation (CMMI)
    receives $10 billion in mandatory funding every decade. The nonpartisan
    Congressional Budget Office (CBO) has found that CMMI has not lowered
    Medicare spending. Separately, CBO has found the Medicare Shared
    Savings Program (MSSP) was not a factor in the slower growth of Federal
    health-care spending.

        Are the spending impacts on Medicare from CMMI and MSSP each
    validated by an independent, third-party organization? If not, why
    would that be important?

        Answer. There have been limited independent, third-party
    organizations who have assessed the impact of MSSP. Studies conducted
    by MedPAC,\2\ the National Association of ACOs,\3\ and researchers at
    Harvard University,\4\ have all concluded net savings to Medicare. In
    fact, in MedPAC's 2020 report to Congress the Commissioners estimated
    that ACO models accounted for a 1- or 2-percent slower growth rate in
    spending. The report from the commission goes on to say, ``Although the
    estimated savings from these models are modest, they surpass those
    achieved by a wide variety of care coordination models Medicare has
    tried.''
    ---------------------------------------------------------------------------
        \2\ https://www.medpac.gov/wp-content/uploads/import_data/
    scrape_files/docs/default-source
    /reports/jun20_ch2_reporttocongress_sec.pdf.
        \3\ https://www.naacos.com/assets/docs/pdf/
    ExecutiveSummaryStudyMSSPSavings2012-2015.
    pdf.
        \4\ https://www.nejm.org/doi/full/10.1056/NEJMsa1803388.

        It is important to bolster the ability for independent third-party
    organizations to evaluate the impact of CMMI and MSSP. The current
    approaches that CBO and CMMI uses to assess programs may not capture
    the full impact of the model. For example, current approaches are
    ineffective in quantifying the impact of health-care delivery changes.
    Providers in APMs deliver care management improvements for their
    patient populations, not just the patients aligned to the APM. This
    ``spillover effect'' creates savings accrued to non-model patients.
    Similarly, it is increasingly challenging to evaluate models against a
    population that is not in any value model. This counterfactual is
    difficult with Medicare alternative payment models because so many
    traditional Medicare patients are in at least one, if not multiple,
    models. It's hard to find a population on which to make a true
    ---------------------------------------------------------------------------
    comparison of no value-based care interventions.

        The proliferation of value, while a testament to its success, will
    create challenges in assessing its impact. Providers in Medicare APMs
    have been engaging in value-based arrangements with Medicaid, Medicare
    Advantage, and commercial payers. This ultimately drives system-wide
    changes that are not captured by single model evaluations.

        In this vein, CBO has previously testified that ACOs may not have
    been the primary driver of lower health-care spending. However, a
    recent CBO report cited reductions in the growth of health-care
    spending is due to reductions in spending on patients with
    cardiovascular diseases due to better care management and increased use
    of technology.\5\ To those of us working to improve patient care, these
    findings are a direct result of value-based care. Care management and
    leveraging technology to support population health management are two
    core components of all APMs, yet these aspects are not measured as part
    of CBO reports or CMMI evaluations.
    ---------------------------------------------------------------------------
        \5\ https://www.cbo.gov/system/files/2023-10/59660-testimony.pdf.

        To support more independent, third-party organization research and
    ---------------------------------------------------------------------------
    to better demonstrate the impact of value, we recommend the following:

              CMMI should release more granular data on providers
            participating in these models. Even CBO has had to rely on the
            formal, published evaluations for its conclusions about CMMI
            models.

              CMMI and CBO should include a broader set of model aspects
            in its evaluation reports--such as provider satisfaction,
            beneficiary satisfaction, overlap with other models, potential
            spillover to practice change, and additional benefits or
            services provided to beneficiaries because of inclusion in the
            model.

              CMMI and CBO should consider how to assess quality
            improvements. As outlined by Congress, CMMI models should lower
            costs without sacrificing quality, improve quality without
            raising spending, or both lowering costs and improving quality.
            CMMI models should be deemed successful if they improve quality
            of care, even if they don't lower Medicare spending.

        Question. In 2005, this committee held a hearing that I chaired
    titled, ``Improving Quality in Medicare: The Role of Value-Based
    Purchasing.'' I said at the time that we do not want to overburden
    providers with reporting requirements. I went on to say that it is
    important to develop these health-care quality measures by consensus.

        Do you feel reporting requirements are developed by consensus and
    do not overburden providers? If not, what actions should we take to
    reduce the burden?

        Answer. MACRA created pathways for reducing provider burden by
    excluding all clinicians in advanced APMs from MIPS. This has been a
    strong nonfinancial incentive for providers to join APMs; however, we
    are concerned that CMS has removed some of this burden reduction. In an
    effort to align ACOs and APMs reporting approaches with MIPS, CMS is
    now requiring:

              Advanced APMs to report the Promoting Interoperability (PI)
            category of MIPS instead of attesting to CEHRT use by
            clinicians in the APMs. This adds burden as it will require
            reporting of metrics that are not indicative of improved care.
            ACOs must be committed to information sharing to be successful
            in the model, so these requirements are duplicative and
            unnecessary.

              ACO reporting requirements to align with MIPS. The MIPS
            reporting requirements and scoring rules were created with a
            focus on individuals and small groups and have therefore caused
            a number of problems when applying to ACOs who are a collection
            of clinicians, hospitals, and other providers. This has
            resulted in expensive data aggregation and de-duplication work
            to report quality measures at the ACO level using MIPS
            measures, specifications and reporting types.

              ACOs to report electronic clinical quality measures (eCQMs)
            ahead of industry readiness, with a lack of full adoption of
            standards and interoperability impeding this effort.

        Additionally, quality measures have not been designed to measure
    the care delivered in value arrangements. The quality measures that
    have been developed since the passage of MACRA have been focused on
    implementation in a fee-for-service system. Measures for APMs are then
    selected from the available FFS measures. For value-based care
    entities, the measure sets vary across programs and models, there are
    multiple reporting methods, and a misalignment with the measures sets
    used in MA and commercial value arrangements.

        Fundamentally, we believe that this approach is flawed. Reporting
    for ACOs and other APMs should be the gold standard with MIPS
    structured to prepare clinicians for adopting APMs. To accomplish this,
    Congress should:

              Exclude all APMs from all MIPS, this will reduce program
            complexity by removing duplicative efforts.

              Direct CMS structure MIPS to prepare clinicians for
            transitioning to APMs.

              Direct CMS to exclude advanced APMs from all MIPS reporting
            categories, repealing the recently finalized rule requiring
            advanced APMs to report PI. Instead, CMS could require advanced
            APMs to attest to additional needed elements such as
            information blocking. Over 100 ACOs and dozens of stakeholders
            recently sent a letter to CMS requesting this change.\6\
    ---------------------------------------------------------------------------
        \6\ https://www.naacos.com/assets/docs/pdf/2024/
    AMASignonLetter_PICEHRTChangesAPMs
    041024.pdf.

    ---------------------------------------------------------------------------
              Direct CMS to develop measures specifically for APMs.

              Direct CMS to pilot test eCQMs and other digital quality
            measure approaches ahead of required implementation.

        Question. In CBO's report on pilot programs supported through CMMI,
    only six of the 49 pilot program models saved money.

        Are CMMI models effective at lowering total Medicare spending? Did
    the Comprehensive Primary Care Plus model save money?

        Answer. The Innovation Center has been successful in testing
    innovative payment arrangements and increasing adoption of APMs. The
    successes of the Innovation Center are not always captured within
    current evaluation approaches. For example, CBO estimates that CMMI's
    activities increased direct spending by $5.4 billion in the first 10
    years and another $1.3 billion by 2030.\7\ However, CBO's report
    focuses only on savings achieved and does not account for many aspects
    of value-based payment models such as provider burden relief, patient
    experience, clinical transformation, and the spill-over effect that
    occurs when providers apply value principles across all patient
    populations. The Innovation Center's evaluation criteria and criteria
    for model expansion have similar challenges. Congress should work with
    CMS to ensure that promising models have a more predictable pathway for
    being implemented and becoming permanent and are not cut short due to
    overly stringent criteria. Specifically, Congress should:
    ---------------------------------------------------------------------------
        \7\ https://www.cbo.gov/system/files/2023-09/59274-CMMI.pdf.

              Broaden the criteria by which CMMI models qualify for Phase
            2 expansion. The criteria should consider if the model reduces
            provider burden, increases patient satisfaction, offers
            additional benefits and services to patients that are not
            billed to Medicare, expands participation to more provider
            types, results in clinical care transformation, or is adopted
    ---------------------------------------------------------------------------
            in private sector value arrangements.

              Direct CMMI to engage stakeholder perspectives during APM
            development. The Innovation Center could leverage the
            Physician-Focused Payment Model Technical Advisory Committee
            (PTAC) to provide input on models in development.

        The Comprehensive Primary Care Plus (CPC+) model evaluation \8\
    demonstrated that practices simultaneously participating in MSSP did
    achieve reductions in total expenditures even though the model did not
    reduce total Medicare expenditures after accounting for enhanced
    payments. CPC+ practices in the MSSP cohort were also found to have
    reduced acute inpatient expenditures by over 2 percent during the
    course of the model.
    ---------------------------------------------------------------------------
        \8\ PY4 evaluation: https://www.cms.gov/priorities/innovation/data-
    and-reports/2022/cpc-plus
    -fourth-annual-eval-report.
        Summary: https://www.cms.gov/priorities/innovation/data-and-
    reports/2022/cpc-plus-fourth
    -annual-report-findings.
        PY5 (final) evaluation: https://www.cms.gov/priorities/innovation/
    data-and-reports/2023/cpc-plus-fifth-annual-eval-report.
        Summary: https://www.cms.gov/priorities/innovation/data-and-
    reports/2023/cpc-plus-fg-fifth-annual-eval-report.

        Given the positive interaction of CPC+ and MSSP, it is important to
    replicate this approach for all ACOs. Currently, ACOs in the REACH
    model can offer primary care capitation. The new ACO Primary Care Flex
    (PC Flex) Model, which will provide monthly, prospective, population-
    based payments for primary care practices in participating MSSP ACOs
    will replicate the success of CPC+ and MSSP together. However, it is
    disappointing that the model is limited to ACOs that are designated as
    ``low revenue,'' have selected prospective assignment, and begin a new
    agreement period beginning in 2025. This will significantly limit
    participation in the model since the majority of primary care providers
    currently participating in MSSP are in ``high revenue'' ACOs, including
    67 percent of primary care physicians, 68 percent of NPs, 72 percent of
    PAs, 87 percent of RHCs, and 25 percent of FQHCs. To build on known
    ---------------------------------------------------------------------------
    successes, CMS should open the PC Flex model to all ACOs in MSSP.

        Question. You stated in your written testimony that the ``advanced
    APM Accountable Care Organization portfolio (ACOs that take on two-
    sided risk, including two-sided risk Medicare Shared Savings Program
    and CMS Innovation Centers ACOs) saved $4.2 billion in traditional
    Medicare in 2022, and a total of $8.4 billion in gross savings after
    taking into account spillover effects in Medicare Advantage.''

        Are these figures validated by an independent, third-party
    organization? If so, by whom?

        Answer. These savings numbers are derived from public use files CMS
    makes available and reflect the difference between CMS-generated
    benchmarks for a given year and an ACOs' collective spending compared
    to those benchmarks.\9\
    ---------------------------------------------------------------------------
        \9\ https://www.cms.gov/medicare/payment/fee-for-service-providers/
    shared-savings-program-ssp-acos/data.

        Recently, CBO released an updated report highlighting how several
    counterfactual studies have shown ACOs in the MSSP program are
    associated with net budgetary savings for the Medicare program.\10\
    Many of CBO's recommendations to increase ACO savings--increasing and
    extending current provider incentives, ensuring accurate financial
    benchmarks, improving patient engagement, and offering tools like
    primary care hybrid payments--are options that PSW and other
    stakeholders have previously discussed with Congress. We hope this
    report spurs additional interest in these topics from Capitol Hill.
    ---------------------------------------------------------------------------
        \10\ https://www.cbo.gov/publication/60213#footnote-038-backlink.

        Question. A common concern from Iowa providers is the lack of
    preparation and notice for final payment rules from CMS. When final
    payment rules are set a couple of months or less from the start of the
    payment rule's implementation date, providers do not have time to
    prepare or adjust to new payment policies and administrative
    ---------------------------------------------------------------------------
    requirements. This includes changes to value-based care efforts.

        Should there be a longer preparation period (e.g., 6 months, 1
    year) for providers to adjust to new payment policies and
    administrative requirements under Medicare? What effect would that
    have? Alternatively, should payment policies and administrative
    requirements remain consistent for more than 1 year except for newer
    input data (e.g., inflationary or economic factors)?

        Answer. There should be longer preparation periods for some new
    policies. Certain small changes or changes in response to ACO
    participant challenges could be implemented more rapidly, while other
    significant changes or payment cuts have at least a year-long
    preparation period before they are put in place. This would allow
    provider organizations a reasonable amount of time to implement
    necessary operational changes or carefully consider strategic decisions
    that would impact their participation in Advanced Alternative Payment
    Models (AAPM).

        One example of this is the impact of participation in the Medicare
    Shared Savings Program (MSSP) based on the timing of the Medicare
    Physician Fee Schedule rule. Currently, MSSP ACOs must submit to CMS
    their list of participating providers who have signed an agreement to
    participate in MSSP by the beginning of August. This submission
    ultimately determines the decision for the AAPM that a provider
    organization will participate in for the upcoming year. However, the
    final Medicare Physician Fee Schedule rule is typically not released
    until November with policy changes that often affect MSSP for the
    upcoming year.

        This can be a challenge for provider organizations looking to
    participate in AAPMs as these late policy changes make projections for
    potential performance highly unpredictable. Creating a sufficient
    preparation period before new policies are finalized will ensure that
    provider organizations are given a proper amount of time to evaluate
    the effects of those policies on their operations and financial
    stability.

        Question. A 2023 RAND study of the Medicare Advantage Value-Based
    Insurance Design Model found the first 2 years of the model did not
    result in improved health outcomes or costs, but there was an
    improvement in the quality of care. This is similar to independent
    analyses of fee-for-service value-based models.

        What is the scope of value-based contracts in Medicare Advantage
    and their effectiveness in reducing costs and improving outcomes?

        Answer. Adoption of value-based contracts between Medicare
    Advantage plans and providers are reported informally to the Health
    Care Payment Learning and Action Network. Summary reports on the
    adoption of alternative payment model contracts for the past several
    years are available here: https://hcp-lan.org/apm-measurement-effort/
    2023-apm/.

        Their effectiveness in reducing costs and improving outcomes would
    be accessible via the individual health plans--that data is not
    currently publicly available as far as we are aware.

        In our experience, we are fully delegated for risk in Medicare
    Advantage, allowing us to support our providers across Medicare
    Advantage and Medicare ACOs. We are able to synthesize measures and
    operational workflows to ease the provider burden when participating in
    multiple programs. We have been successful in this space in reducing
    costs and improving outcomes for Medicare Advantage and Medicare ACO
    beneficiaries alike.

                                     ______

                   Questions Submitted by Hon. Maria Cantwell
        Question. The Medicare program accounts for about 20 percent of
    national health-care spending, and Medicare physician payments account
    for 26 percent of all national payments for physician and clinical
    services. Despite the enormous amount we spend on health care, health
    outcomes, especially for our seniors, are not better than comparable
    wealthy countries. In fact, the United States has the highest rate of
    people with multiple chronic conditions out of all high-income
    countries.

         As the baby boomer generation ages, Medicare expenditures will
    only continue to rise. We must be looking at innovative ways to reduce
    costs for the government while improving health outcomes at the same
    time. One of these innovations is Accountable Care Organizations, or
    ACOs. An ACO is a group of health-care providers who voluntarily come
    together to provide coordinated, high-quality care for Medicare
    patients. By increasing coordination, ACOs help reduce duplication of
    services and prevent medical errors, leading to higher health outcomes.
    ACOs also help reduce costs by reinvesting a portion of the savings
    they generate into the Medicare trust fund. In Washington State, there
    are 44 ACOs serving more than 260,000 Medicare beneficiaries. These
    ACOs saved $104.5 million for Medicare in 2021 and 2022, which amounted
    to $235 in savings per beneficiary.

        This is the type of innovation that we need to consider as we
    tackle the problem of ballooning medical expenditures. We need to start
    moving away from volume-based care that prioritizes the quantity of
    services provided, to value-based care that prioritizes quality of care
    and increased health outcomes.

        Do you agree that Medicare could see even more savings and improve
    the quality of care for seniors by encouraging more providers to join
    ACOs?

        Answer. Yes. ACOs have demonstrated the ability to generate savings
    for Medicare and improve the health outcomes for the populations that
    they serve. By adopting policies, such as extending the Advanced
    Alternative Payment Model (AAPM) bonus, that encourage greater provider
    participation in ACOs, Medicare could see exponential growth in the
    savings generated by these programs.

        Question. Are there any issues or roadblocks that are preventing
    more providers from joining ACOs?

        Answer. There are several roadblocks to increased provider
    participation in ACOs. Some of the biggest roadblocks are:

              Infrastructure and resources: Participating in an ACO often
            requires robust infrastructure and resources to manage data,
            track performance metrics, and coordinate care effectively.
            Smaller practices or those with limited technological
            capabilities may find it challenging to meet these
            requirements, making ACO participation less feasible.

              Regulatory and compliance burdens: ACOs comply with complex
            regulatory requirements, including those related to data
            reporting, quality measures, and beneficiary communications
            Navigating these regulatory requirements can be time-consuming
            and resource-intensive for providers, acting as a barrier to
            participation.

              Incentive alignment: Ensuring that incentives are aligned is
            essential for the success of ACO Models. Misaligned incentives
            or conflicting policy changes can create challenges in
            achieving shared goals and may discourage providers from
            joining or remaining actively engaged in an ACO.

              Rural and underserved: To improve access to health care in
            rural and underserved settings, Congress should create more
            pathways for providers in rural settings to adopt APMs. There
            are significant barriers to providers who are currently paid
            via cost-based reimbursement to be able to successfully
            participate in ACOs. In the last decade we have seen
            significant adoption among rural providers, with more than
            4,400 Federally Qualified Health Centers (FQHCs), 2,200 Rural
            Health Clinics (RHCs), and 460 Critical Access Hospitals
            participating in MSSP or ACO REACH.

        Question. What types of policies or programs should we be promoting
    to incentivize more providers to join ACOs?

        Answer. There are many policy changes that would encourage greater
    participation in ACOs such as the Value in Healthcare Act, which would
    implement numerous policies that would incentivize greater
    participation in ACOs. These policies include the extension of the APM
    incentive payment, establishes guardrails for CMS to ensure that the
    process to set financial benchmarks is transparent and appropriately
    accounts for regional variations in spending, and removes the revenue-
    based designation in the Medicare Shared Savings Program (MSSP) that
    penalizes certain ACOs, especially those including rural and safety net
    providers.

                                     ______

                    Questions Submitted by Hon. John Cornyn
        Question. Too often our health-care system looks at patients'
    medical needs as separate and unrelated issues rather than looking at
    the full picture of someone's health.

        Value-based care recognizes the importance of coordinating
    patients' care for better health outcomes. It both holds providers
    accountable for their services and rewards good patient care. Patient
    heath-care services are not just boxes to be checked.

        Accountable Care Organizations provide this type of care to over
    593,000 Medicare beneficiaries in Texas. You have extensive experience
    in value-based care.

        Can you elaborate on how alternative payment models like ACOs
    incentivize more personalized care for patients?

        Answer. Alternative payment models like Accountable Care
    Organizations promote personalized care for patients through various
    strategies.

        ACOs establish financial incentives based on performance against
    quality metrics, encouraging providers to deliver high-quality,
    personalized care to improve patient outcomes. By aggregating data and
    providing performance scorecards, ACOs enable providers to track their
    performance and make data-driven improvements, fostering a culture of
    continuous quality improvement.

        Moreover, many ACO models offer benefit enhancements to patients,
    such as extended services or to support improved access to care. These
    can be in the form of beneficiary incentives to engage in care
    programs. This further supports personalized care initiatives by
    addressing specific patient needs and preferences.

        Additionally, the Advanced Alternative Payment Model (AAPM) bonus
    allows for investment in infrastructure enhancements, such as
    additional staff or technology improvements. This investment supports
    personalized care initiatives like care management programs and
    interdisciplinary care teams, which work collaboratively to develop
    specific care plans tailored to individual patient needs.

        Through these mechanisms, ACOs create an environment that
    incentivizes and supports personalized care delivery, leading to better
    health outcomes and enhanced patient satisfaction.

        Question. How does coordinating care both improve the patient
    experience and reduce wasteful spending?

        Answer. Coordinating care plays a vital role in improving the
    patient experience and reducing wasteful spending by optimizing health-
    care delivery and addressing Social Determinants of Health (SDOH).

        Firstly, through ACOs, care management programs can identify trends
    within practice groups, such as the overutilization of emergency
    departments (ED) for conditions like urinary tract infections (UTIs).
    By providing information on these trends, ACO care teams collaborate
    with providers to implement strategies that reduce ED visits. For
    instance, educating patients on alternatives like telehealth for non-
    emergency conditions can redirect care to more appropriate and cost-
    effective settings, reducing wait times, improving patient
    satisfaction, and reducing unnecessary health-care expenditures.

        Additionally, coordinating care involves addressing SDOH, such as
    housing instability, food insecurity, and lack of access to
    transportation. These factors significantly impact health outcomes and
    health-care utilization. By implementing programs that target SDOH,
    health-care organizations can improve patient health outcomes, reduce
    the need for acute care services, and ultimately lower health-care
    costs.

        Coordinating care enhances the patient experience by ensuring
    timely and appropriate access to care while also curbing wasteful
    spending through targeted interventions that address both health-care
    utilization trends and SDOH.

                                     ______

                     Questions Submitted by Hon. John Thune
        Question. As part of the Merit-based Incentive Payment System
    (MIPS), physicians must be compliant in promoting interoperability as
    part of their reimbursement, which helps to facilitate the sharing of
    data between various providers.

        I have long been an advocate for health IT initiatives that can
    improve efficiencies and reduce costs in the health-care system, and I
    believe that sharing information between providers through an
    interoperable network has immense upside, so long as there are
    safeguards to protect patient privacy and ensure taxpayer funds are
    spent appropriately.

        However, there continue to be challenges to physicians meeting
    interoperability metrics, like information blocking for example in
    which an individual or entity impedes the delivery or utilization of an
    electronic health record, making interoperability impossible.

        In your view, how have practices been impacted by information
    blocking?

        Answer. Information blocking has had a profound impact on health-
    care practices, particularly smaller provider organizations that lack
    robust information technology (IT) resources. The burden of achieving
    interoperability often falls heavily on these entities as larger
    systems prioritize their own operational efficiencies. This dynamic can
    result in significant challenges and increased costs for smaller
    providers who must rely on outsourcing for building and managing
    interoperability solutions.

        One of the key issues is the absence of dedicated programs to
    support smaller, community-based provider organizations. These
    entities, often consisting of independent primary care practices, face
    the dual challenge of meeting stringent reporting and data sharing
    requirements while lacking adequate funding to invest in the necessary
    IT infrastructure. This imbalance can lead to suboptimal patient care
    outcomes and hinder the ability of these providers to fully leverage
    digital tools for improved health-care delivery.

        For instance, in communities primarily composed of small,
    independent primary care providers, the strain is palpable. These
    providers are essential pillars of local health-care ecosystems but are
    often constrained by financial limitations when it comes to adopting
    and maintaining interoperable IT systems. Consequently, they may
    struggle to meet regulatory demands, share patient data seamlessly, and
    offer high-quality, coordinated care.

        To address these challenges effectively, it's crucial to establish
    a supportive program that provides funding and resources specifically
    tailored to the needs of smaller provider organizations. By offering
    financial assistance and guidance for IT investments, such a program
    can empower these providers to enhance their interoperability
    capabilities, streamline data sharing processes, and ultimately improve
    patient outcomes across communities.

        Question. Are you aware of instances in which the timeliness or
    quality of the care physicians are able to provide patients has been
    impacted by a limited ability or complete inability to access
    electronic health records?

        Answer. The limited ability or complete inability to access
    electronic health records (EHRs) can indeed impact the timeliness and
    quality of care that physicians are able to provide to patients.
    Specifically, instances regarding Rural Health Clinics (RHCs) and their
    inability to submit CPT II codes in traditional Medicare can have a
    substantial impact.

        When RHCs are restricted from submitting these codes for quality
    metrics, it creates a skewed perception that their outcomes are poorer
    compared to non-RHC groups. However, this discrepancy doesn't
    accurately reflect the care provided. It leads to duplicated efforts
    and adds a significant overhead and administrative burden on these
    rural systems, diverting valuable resources away from patient care.

        Moreover, these limitations in funding and resources can have
    broader repercussions. Patients may perceive a lack of comprehensive
    care in rural areas and feel compelled to seek treatment in urban
    centers where access to advanced health-care services may be perceived
    as better. This migration of patients towards urban areas due to
    perceived gaps in care further strains the health-care system and can
    result in individuals who cannot afford such travel opting to forgo
    necessary medical attention altogether.

        This situation underscores the critical importance of addressing
    barriers to EHR accessibility and interoperability, particularly for
    rural health-care settings. Investing in technology infrastructure,
    providing adequate funding and support for rural providers to implement
    and maintain EHR systems, and ensuring standardized reporting
    mechanisms can all contribute to improving the timeliness and quality
    of care delivered to patients in these underserved areas. Such efforts
    can also help mitigate the administrative burdens that currently hinder
    optimal patient care in rural healthcare settings.

        Question. Furthermore, beyond information blocking, what other
    challenges persist in physicians accessing patients' health information
    electronically despite the billions of dollars spent to implement
    electronic health IT and interoperability?

        Answer. Several challenges persist in physicians accessing
    patients' health information electronically despite significant
    investments in electronic health IT and interoperability.

        One major challenge is the exorbitant cost associated with
    electronic medical records (EMRs). While EMRs are essential for digital
    health information management, their initial implementation and ongoing
    maintenance expenses can be high and difficult to maintain.
    Additionally, the need for customization to suit specific workflows or
    requirements further drives up costs, creating financial barriers for
    smaller providers.

        In rural communities, another significant challenge emerges due to
    reliance on larger health systems to purchase the technology. This
    reliance can create a monopoly in the market, where rural providers are
    limited to the options and functionalities offered by the dominant
    systems. As a result, these providers may not have access to tailored
    solutions that address their unique patient population or operational
    needs, impacting their ability to effectively leverage electronic
    health information for better patient care.

        Addressing these challenges requires a multifaceted approach.
    Initiatives aimed at reducing the cost of EMRs, such as incentivizing
    standardized systems or providing subsidies for implementation, could
    make these technologies more accessible to a broader range of
    providers. Investments could also be made in this area by developing
    programs that provide a greater level of funding to small and rural
    providers attempting to meet the interoperability requirements.

                                     ______

                 Question Submitted by Hon. Sheldon Whitehouse
        Question. I am working on a bill to relieve providers excelling in
    the Medicare Shared Savings Program (MSSP), from prior authorization
    (PA) requirements in MA. The bill rewards providers in Accountable Care
    Organizations (ACOs) that generate savings for Medicare by granting an
    exemption from PA requirements for their MA beneficiaries. If an
    insurer believes there is a rationale for maintaining PA in such
    instances, this bill would require them to seek prior approval from the
    Centers for Medicare and Medicaid Services. I would welcome your
    thoughts and comments on this idea.

        Answer. There has been great discussion as to the administrative
    burden that the prior authorization process imposes on providers. We
    recognize the burden imposed to the providers as well as to the
    beneficiaries who see the process as a potential impediment or barrier
    to timely access to care. In the worst case scenario, prior
    authorization requirements can sometimes lead to the delay or denial of
    medically necessary care that compromises the outcome of a patient.

        The Medicare Advantage program utilizes prior authorizations as a
    means to ensure that certain designated services meet established
    criteria before approval. This allows the Medicare Advantage
    Organization to safeguard against unnecessary procedures and
    treatments, reduce the risk of inappropriate or ineffective care, and
    encourage providers to explore equally effective but less costly
    alternative treatment options. By ensuring that efficacious quality
    care is being approved for delivery, Medicare Advantage plans help
    improve beneficiary outcomes--but only if the prior authorization
    process is efficient and effective.

        We view the proposal to exempt well performing MSSP providers from
    all Medicare Advantage prior authorizations as ambitious and
    innovative, but potentially harmful to operations. The burden of
    knowing who is in or who is out of the program at the provider level at
    any given time provides additional abrasion and could consume resources
    that could otherwise be spent on investments in interoperability of the
    prior authorization process. Also, this approach would exempt a
    provider from all prior authorization requirements which may not be the
    most effective approach. A provider may be a successful MSSP
    participant without having made the same cost-effective, high-quality
    decisions for treating all conditions across the board. This exemption
    may be more effective at reducing provider burden while still managing
    cost by building an structure where a provider must apply for this
    exemption that is approved by a decision-making body. The decision-
    making body could then review the provider's practices and determine if
    an exemption should be offered for certain conditions or for the
    provider's entire range of practice.

        If carried out effectively, this exemption would be an additive,
    nonfinancial incentive for providers to join ACOs and offer more
    streamlined access to their practices that meet care coordination and
    utilization standards. Tying the qualification to advanced APM
    eligibility could also help to standardize some of the nonfinancial
    incentives available for clinicians that choose to participate in APMs.

                                     ______

                  Questions Submitted by Hon. Marsha Blackburn
        Question. It is important that Congress continue to promote
    policies that accelerate the movement toward alternative payment models
    (APMs). The Consolidated Appropriations Act of 2024 included a 1-year
    extension of the incentive payments for participation in eligible APMs
    at a reduced rate of 1.88 percent.

        How will the continuation of the APM incentive payments help
    promote the movement toward value-based care? What can Congress or CMS
    do to encourage more physicians, especially specialists, to adopt APMs?

        Answer. The continuation of the APM incentive payments will help
    providers invest in infrastructure that will allow them to be
    successful in an APM. Many of our small, independent providers used the
    APM incentive to help them pay staff wages and keep their doors open
    throughout the pandemic. Now, providers who have been able to stabilize
    their revenue can use the incentive payment to invest in new technology
    or additional resources that help them care for the community.

        Congress and CMS could encourage greater APM participation by
    reinstating the full APM incentive payment and promoting policies that
    integrate specialists into ACOs. These policies would also need to
    redesign the requirements to achieve the APM incentive to account for
    specialists. Currently, ACOs with specialists in their network are
    unable to meet the thresholds required for the APM incentive payment.
    By developing a long-term APM incentive solution that accounts for
    specialists alongside primary care, Congress and CMS would see an
    increase in participation and in investments toward improving the
    health outcomes of patients.

        Question. Every year, we see an alarming decline in physicians
    offering essential care services. This trend is partly fueled by
    soaring costs for practices, already high yet constantly increasing
    administrative burden, and low reimbursement rates, often well below
    the cost of providing care.

        How has the cost of providing lifesaving care changed over the
    years for your practice, and how has the payment for those services
    caught up or not caught up?

        Answer. The cost to provide lifesaving care has continued to
    increase over the years. The years following the pandemic have been
    especially challenging with the combination of increased pricing and
    struggle to maintain resources. The payment for these services have not
    kept up, causing numerous independent providers to close their doors or
    sell to a larger organization. Without a payment system that maintains
    pace with increasing costs and incentives such as the APM incentive
    payment to drive provider participation in APMs, we will continue to
    see a high rate of closure among independent providers. Many of our
    providers have relied on the APM incentive payment to keep their doors
    open through the pandemic. It is crucial to support the Value in
    Healthcare Act to extend important policies such as the APM incentive
    payment.

        Question. How does the yearly scramble to delay or reduce CMS
    payment cuts to the PFS impact your ability to plan for the future?
    What would it mean for you and practices like you if these cuts were
    fully implemented and not scaled back?

        Answer. The yearly scramble to mitigate CMS payment cuts to the
    Medicare Physician Fee Schedule has a substantial impact on our ability
    to plan for the future. The changes in the Medicare Physician Fee
    Schedule often dictate if a provider's participation in an ACO will be
    financially viable and impacts the resources that a provider must
    invest in to participate. With how late in the year these policy
    changes are released, providers are forced to have already signed
    contracts to participate in ACOs or made the decision to not
    participate for the upcoming year by the time the changes are released.
    This makes it near impossible to accurately project the financial
    viability of ACO participation and poses a substantial barrier to
    increased provider participation. Also, if many of these large proposed
    cuts are not scaled back due to our efforts, independent providers
    would not be able to maintain pace with rising costs and would be
    forced to shut their doors. Our organization spends a great deal of
    time with our advocacy groups to mitigate the payment cuts, but this
    takes time and resources away from our original mission to enhance the
    patient experience and improve the quality of care for those that we
    serve.

        Question. As a value-based purchasing program, MIPS was supposed to
    reward physicians who achieved quality and cost-efficient care.
    However, for years physicians have raised concerns about the program,
    including that it increases administrative burden and does not
    accurately capture quality.

        What has been your experience with MIPS and the administrative
    burden that it entails?

        Answer. Due to its complexity, one of the many advantages to
    participating in APMs is the opportunity to be excluded from MIPS
    reporting. We believe it is essential that APM providers continue to
    have the opportunity to be excluded from MIPS. However, recent policy
    changes in the Physician Fee Schedule rule are attempting to impose
    burdensome MIPS reporting elements, such as reporting Promoting
    Interoperability, onto APM providers. This increased burden has no
    impact on the quality of care that is provided to patients.

        Question. Is it time to consider replacing the program with a more
    valuable alternative? If so, what are some of the program's benefits
    that should be considered when designing its replacement?

        Answer. A valuable alternative to MIPS already exists in the form
    of APMs. We support reducing program complexity by mitigating the
    duplicative work that providers engage in when participating in an APM.
    This would be accomplished by maintaining that APM providers be
    excluded from MIPS reporting and ensuring that new policy changes do
    not impose elements of MIPS reporting onto APM providers. Future
    reforms to MIPS should be used to prepare providers for participation
    in APMs and encourage them to transition from MIPS to APMs. A clear
    direction with clear incentives must be outlined for the pathway from
    MIPS to APM participation for providers, allowing them to adjust their
    efforts accordingly.

        Question. Part of the Physician Fee Schedule's MIPS program
    measures interoperability, which is impeded by information blocking by
    providers, vendors, or others wanting to hoard patient data, which can
    affect MIPS performance and reduce reimbursement to providers.

        How have your practices been impacted by information blocking?

        Answer. Information blocking has had a profound impact on our
    health-care practices, particularly smaller provider organizations that
    lack robust information technology (IT) resources. The burden of
    achieving interoperability often falls heavily on these entities as
    larger systems prioritize their own operational efficiencies. This
    dynamic can result in significant challenges and increased costs for
    smaller providers who must rely on outsourcing for building and
    managing interoperability solutions.

        One of the key issues is the absence of dedicated programs to
    support smaller, community-based provider organizations. These
    entities, often consisting of independent primary care practices, face
    the dual challenge of meeting stringent reporting and data sharing
    requirements while lacking adequate funding to invest in the necessary
    IT infrastructure. This imbalance can lead to suboptimal patient care
    outcomes and hinder the ability of these providers to fully leverage
    digital tools for improved health-care delivery.

        For instance, in communities primarily composed of small,
    independent primary care providers, the strain is palpable. These
    providers are essential pillars of local health-care ecosystems but are
    often constrained by financial limitations when it comes to adopting
    and maintaining interoperable IT systems. Consequently, they may
    struggle to meet regulatory demands, share patient data seamlessly, and
    offer high-quality, coordinated care.

        To address these challenges effectively, it's crucial to establish
    a supportive program that provides funding and resources specifically
    tailored to the needs of smaller provider organizations. By offering
    financial assistance and guidance for IT investments, such a program
    can empower these providers to enhance their interoperability
    capabilities, streamline data sharing processes, and ultimately improve
    patient outcomes across communities.

        Question. Have you had experiences where your ability (or
    inability) to access health records has impacted the timeliness or
    quality of the care you are able to provide your patients?

        Answer. The limited ability or complete inability to access
    electronic health records (EHRs) can indeed impact the timeliness and
    quality of care that physicians are able to provide to patients.
    Specifically, instances regarding Rural Health Clinics (RHCs) and their
    inability to submit CPT II codes in Traditional Medicare can have a
    substantial impact.

        When RHCs are restricted from submitting these codes for quality
    metrics, it creates a skewed perception that their outcomes are poorer
    compared to non-RHC groups. However, this discrepancy doesn't
    accurately reflect the care provided. It leads to duplicated efforts
    and adds a significant overhead and administrative burden on these
    rural systems, diverting valuable resources away from patient care.

        Moreover, these limitations in funding and resources can have
    broader repercussions. Patients may perceive a lack of comprehensive
    care in rural areas and feel compelled to seek treatment in urban
    centers where access to advanced health-care services may be perceived
    as better. This migration of patients towards urban areas due to
    perceived gaps in care further strains the health-care system and can
    result in individuals who cannot afford such travel opting to forgo
    necessary medical attention altogether.

        This situation underscores the critical importance of addressing
    barriers to EHR accessibility and interoperability, particularly for
    rural health-care settings. Investing in technology infrastructure,
    providing adequate funding and support for rural providers to implement
    and maintain EHR systems, and ensuring standardized reporting
    mechanisms can all contribute to improving the timeliness and quality
    of care delivered to patients in these underserved areas. Such efforts
    can also help mitigate the administrative burdens that currently hinder
    optimal patient care in rural health-care settings.

        Question. Do existing Federal quality and payment incentive
    programs under Medicare, like ``Promoting Interoperability'' under the
    Merit-based Incentive Payment System, enable up-to-date, consolidated
    longitudinal health records accessible without special effort?

        Answer. Existing Federal quality and payment incentive programs
    under Medicare, such as the ``Promoting Interoperability'' initiative
    under the Merit-based Incentive Payment System (MIPS), do not
    necessarily enable up-to-date, consolidated longitudinal health records
    that are easily accessible without special effort.

        The challenge lies in the practical implementation of these
    programs, especially for single-provider practices with limited
    technical expertise among their office staff. These practices often
    operate under tight budget constraints, making it difficult to allocate
    additional resources towards building and maintaining sophisticated
    health record systems that meet interoperability standards.

        The costs associated with implementing and sustaining such systems
    can be prohibitive for small practices, preventing them from fully
    participating in Federal incentive programs aimed at promoting
    interoperability. As a result, these practices may struggle to achieve
    the level of data integration and accessibility necessary for seamless
    patient care coordination and quality reporting.

        To address this issue, it's crucial for Federal incentive programs
    to consider the unique challenges faced by small practices and provide
    adequate support, both in terms of funding and technical assistance.
    Simplifying the requirements, offering subsidies or grants specifically
    tailored to smaller providers, and facilitating partnerships with
    technology vendors or regional health information exchanges can all
    help bridge the gap and make longitudinal health records more
    accessible without imposing overwhelming financial burdens on these
    practices.

        Question. With over $40 billion spent and nearly 2 decades of
    effort put into implementing electronic health information technology,
    fax machines remain widely used for sharing health data in our health-
    care system.

        Why is this the case and what challenges persist in accessing
    patients' health information electronically?

        Answer. The persistent reliance on fax machines can be attributed
    to several factors, and challenges in accessing patients' health
    information electronically play a significant role in this dynamic.

        One key reason for the continued use of fax machines is the
    financial and technological barriers faced by small providers. Many
    smaller practices lack the necessary funding and technical expertise to
    implement advanced Health Information Technology (HIT) solutions. The
    upfront investment required for transitioning to electronic data
    sharing platforms, such as secure messaging systems or interoperable
    electronic medical records (EMRs), can be substantial for these
    practices. As a result, fax machines remain a more manageable and
    familiar communication tool, especially when considering the limited
    resources available to small providers.

        Additionally, the complexity and fragmentation of electronic health
    information systems pose ongoing challenges in accessing patients'
    health information electronically. Interoperability issues between
    different EMR systems, varying data formats, and inconsistent data
    standards can hinder seamless data sharing and integration across
    health-care entities. This lack of standardized processes and
    interoperable technologies contributes to the continued reliance on fax
    machines as a relatively simple and universally compatible means of
    exchanging health information.

        Furthermore, regulatory and privacy concerns, such as HIPAA
    compliance requirements and concerns about data security breaches, also
    impact the adoption and utilization of electronic data sharing
    solutions. Small providers may be hesitant to embrace new technologies
    without assurances of data privacy and security, further contributing
    to the persistence of fax-based communication methods.

        Addressing these challenges requires a concerted effort to support
    small providers in overcoming financial, technical, and regulatory
    barriers to adopting electronic health information technologies. This
    may involve providing financial incentives, offering technical
    assistance and training programs, promoting interoperability standards,
    and enhancing data security measures to foster a more seamless and
    secure electronic data sharing environment in health care.

                                     ______

    Prepared Statement of Amol S. Navathe, M.D., Ph.D., Professor of Health
        Policy, Medicine, and Healthcare Management, Perelman School of
          Medicine and The Wharton School, University of Pennsylvania
            To really help address the needs of patients with chronic
            diseases, we need information systems and teams that can help
            patients in between office visits, and we need financial
            incentives that reward providers for adopting them.

            --Dr. Thomas Lee, M.D., M.Sc., Network President for Partners
            Healthcare System and Chief Executive Officer, Partners
            Community HealthCare, Inc.

        Chairman Wyden, Ranking Member Crapo, and distinguished members of
    the committee, thank you for the opportunity to testify today. My name
    is Dr. Amol Navathe. I am a primary care-trained internal medicine
    physician and a Ph.D.-trained health economist. I would like to
    highlight why the Medicare program needs to better address chronic care
    for its beneficiaries and how changes to physician payment can support
    improvements. As a practicing physician, I have a front row seat in
    witnessing the challenges that Medicare beneficiaries face in receiving
    optimal care for chronic conditions.

        Take for example, my patient Mr. L. He is a wonderful, elderly
    gentleman suffering from diabetes, heart failure, kidney disease, and a
    concern for kidney cancer. Most notably, he lives alone with no living
    spouse or children to help care for him. While I do my best to help Mr.
    L get his medications on time and make it to his specialist
    appointments, our fragmented system does not make it easy. Mr. L has to
    manage his chronic conditions on his own, spending up to an average of
    2 hours a day coordinating his medications, traveling to appointments,
    and interacting with the health system.\1\ He is an archetypal Medicare
    patient who would benefit from a more proactive and supportive model of
    care, ensuring that he gets his routine care to avoid long, avoidable,
    and expensive hospitalizations, like the one he had last month for
    acute kidney failure. In learning from Mr. L's situation, I would like
    to share three key points.
    ---------------------------------------------------------------------------
        \1\ Jowsey T, Yen L, W PM. Time spent on health related activities
    associated with chronic illness: A scoping literature review. BMC
    Public Health. 2012 Dec 3;12:1044. doi: 10.1186/1471-2458-12-1044.
    ---------------------------------------------------------------------------
        i. chronic diseases may be the single most important challenge
         affecting medicare beneficiaries and thus the medicare program
        The U.S. has the highest rate of individuals with multiple chronic
    conditions.\2\ Some of the most common conditions include heart
    disease, cancer, dementia, diabetes, and chronic kidney disease. More
    than two-thirds (69 percent) of the Medicare population is diagnosed
    with two or more chronic conditions, with one in seven beneficiaries
    (15 percent) having six or more conditions.\3\ These 15 percent alone
    account for $92 billion in emergency visits, hospitalizations, and
    post-acute care, with their overall care resulting in over $150 billion
    dollars of Medicare spend.\4\ Across the entire U.S. adult population,
    27 percent are estimated to have multiple chronic conditions, costing
    the American health-care system more than $1 trillion
    annually.\5\, \6\ When incorporating the costs associated
    with lost economic productivity, this number balloons to $3.7
    trillion.\7\ The overall financial impact is likely to increase moving
    forward, given projections related to an aging U.S. population.
    ---------------------------------------------------------------------------
        \2\ Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II,
    U.S. Health Care from a Global Perspective, 2022: Accelerating
    Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://
    doi.org/10.26099/8ejy-yc74.
        \3\ Centers for Medicare and Medicaid Services. Medicare Multiple
    Chronic Conditions 2015 data. https://www.cms.gov/research-statistics-
    data-and-systems/statistics-trends-and-reports/
    chronic-conditions/MCC_Main.html.
        \4\ Centers for Medicare and Medicaid Services. Chronic Conditions
    among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD.
    2012. https://www.cms.gov/research-statistics-data-and-systems/
    statistics-trends-and-reports/chronic-conditions/downloads/2012chart
    book.pdf.
        \5\ Boersma P, Black LI, Ward BW. Prevalence of multiple chronic
    conditions among U.S. adults, 2018. Prev Chronic Dis. 2020;17:E106.
        \6\ Waters H, Graf M, editors. The costs of chronic disease in the
    U.S. 1st ed. Milken Institute; 2018. https://milkeninstitute.org/sites/
    default/files/reports-pdf/ChronicDiseases-HighRes-FINAL_2.pdf.
        \7\ Ibid.

        This financial impact also affects patients directly. For example,
    patients with chronic disease have increased adverse financial outcomes
    compared with healthier patients.\8\ Of individuals with medical debt,
    those with 7 or more conditions owed an estimated $1,252 compared with
    $784 for those with no chronic diseases.\9\ Patients experiencing
    chronic diseases face additional difficulties, such as the inability to
    work due to symptoms, managing their disease, and other health
    implications.\10\ The experiences of beneficiaries living with chronic
    conditions, as well as the experiences of the clinicians caring for
    them, convey a compelling case for why the Medicare program must
    address the challenges of chronic disease care in a timely fashion.
    ---------------------------------------------------------------------------
        \8\ Becker NV, Scott JW, Moniz MH, Carlton EF, Ayanian JZ.
    Association of Chronic Disease With Patient Financial Outcomes Among
    Commercially Insured Adults. JAMA Intern Med. 2022;182(10):1044-1051.
    doi:10.1001/jamainternmed.2022.3687.
        \9\ Slomski A. Chronic Disease Burden and Financial Problems Are
    Intertwined. JAMA. 2022;328(13):1288-1289. doi:10.1001/jama.2022.15440.
        \10\ Boersema HJ, Hoekstra T, Abma F, Brouwer S. Inability to Work
    Fulltime, Prevalence and Associated Factors Among Applicants for Work
    Disability Benefit. J Occup Rehabil. 2021 Dec;31(4):796-806. doi:
    10.1007/s10926-021-09966-7. Epub 2021 Mar 12. PMID: 33710457; PMCID:
    PMC8558289.
    ---------------------------------------------------------------------------
                   ii. dramatic fragmentation in care makes
                      addressing chronic disease a burden
        One of the most important challenges in managing chronic conditions
    is the extremely fragmented nature of the U.S. health-care system. As
    an illustrative fact, over a third of Medicare beneficiaries (35
    percent) received care from five or more physicians in 2019, a number
    likely to be higher among beneficiaries with chronic conditions.\11\
    That reflects not only a substantial number of physician visits,
    diagnostic tests, treatments, and prescriptions that beneficiaries have
    to keep track of, but also the many opportunities for care details to
    slip through the cracks. For a primary care physician (PCP) to
    effectively coordinate care for a single medical condition it can
    require upwards of 50 interactions in a 3-month period (through various
    modes of communication) between patient, primary care physician, and
    other physicians.\12\ Moreover, there has been a substantial increase
    in the total number of other clinicians a PCP's Medicare panel of
    patients saw between 2000 and 2019, from a median of 52 to 1 of 95
    physicians.\13\ While having multiple physicians can tailor treatment
    to the needs of a patient's condition, it can also increase the
    likelihood of medical errors, redundant visits, preventable
    hospitalizations, and substandard care due to incomplete communication
    and differing treatment strategies. Each individual interaction adds
    complexity. This demonstrates the challenging role of a PCP,
    highlighting a structural complexity in managing care for those with
    chronic conditions amidst a backdrop of increasing specialization and
    resulting fragmentation.
    ---------------------------------------------------------------------------
        \11\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
    Care for Medicare Beneficiaries and Implications for Primary Care, 2000
    to 2019. Ann Intern Med. 2021 Dec;
    174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
    Ann Intern Med. 2022 Oct;175(10):1492. PMID: 34724406; PMCID:
    PMC8688292.
        \12\ Press MJ. Instant Replay--A Quarterback's View of Care
    Coordination. New England Journal of Medicine. 2014;371:489-491. doi:
    10.1056/NEJMp1406033.
        \13\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
    Care for Medicare Beneficiaries and Implications for Primary Care, 2000
    to 2019. Ann Intern Med. 2021 Dec;
    174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
    Ann Intern Med. 2022 Oct;175(10):1492. PMID: 34724406; PMCID:
    PMC8688292.

        A study involving patients with diabetes and chronic kidney disease
    revealed significant repercussions of fragmented care on emergency
    department (ED) utilization. Every 0.1-unit increase in the
    fragmentation of care (encompassing number of different providers
    visited, the proportion of attended visits to each of those providers,
    and the total number of visits) was associated with a 15-percent
    increase in the number of ED visits (incidence rate ratio, 1.15; 95
    percent CI, 1.09-1.21).\14\ Another study, specifically focused on
    Medicare beneficiaries with chronic conditions, similarly reported that
    incremental and heightened fragmentation significantly increased the
    risk of both ED visits and hospital admissions (by 14 percent for each;
    adjusted P < .05 for each comparison).\15\
    ---------------------------------------------------------------------------
        \14\ Liu CW, Einstadter D, and Cebul RD. ``Care fragmentation and
    emergency department use among complex patients with diabetes.'' The
    American journal of managed care 16.6 (2010): 413-420.
        \15\ Kern LM, et al. ``Fragmented ambulatory care and subsequent
    healthcare utilization among Medicare beneficiaries.'' Am J Manag Care
    24.9 (2018): e278-e284.

        Beneficiaries with chronic conditions face the burden of
    fragmentation across the care continuum. Among patients with 5 or more
    chronic conditions, patients experiencing the highest degree of care
    fragmentation underwent roughly twice as many radiology and other
    diagnostic procedures as those experiencing the lowest level of
    fragmentation, translating to an additional 284 tests per 100 patients,
    or an increase of 110 percent (adjusted p < 0.01).\16\ A study from the
    Harvard Chan School of Public Health assigned patients a fragmentation
    index based on their PCP's practice style, measured by the number of
    other physicians seen by their PCP's panel. The authors found increased
    departures from clinical best practice, higher rates of preventable
    hospitalizations, and higher health-care spending in the highest
    fragmentation quartile versus the lowest fragmentation quartile
    ($10,396 versus $5,854, p < 0.001) (Exhibit 1).\17\
    ---------------------------------------------------------------------------
        \16\ Kern LM, et al. ``Healthcare fragmentation and the frequency
    of radiology and other diagnostic tests: A cross-sectional study.''
    Journal of general internal medicine 32 (2017): 175-181.
        \17\ Frandsen BR, et al. ``Care fragmentation, quality, and costs
    among chronically ill patients.'' Am J Manag Care 21.5 (2015): 355-362.

    [GRAPHIC] [TIFF OMITTED] T1124.001

         .epsiii. the american care system prioritizes producing more
                 health care, rather than producing more health
        The prevailing fee-for-service (FFS) reimbursement system is a key
    driver in producing such a fragmented system. FFS reimbursement pays
    physicians and other health-care providers based on volume of
    activities, creating a system that incentivizes each clinician to focus
    on increasing the number of visits and procedures.\18\ The complex task
    of coordinating care, especially for beneficiaries with chronic
    conditions, is not directly reimbursed and therefore gets
    overlooked.\19\
    ---------------------------------------------------------------------------
        \18\ Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-Offs in
    High-Volume Primary Care Practice. J Fam Pract. 1998;46:397-402.
        \19\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
    Family Physicians' Work Is Not Reflected by Current Procedural
    Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
    10.3122/jabfm.2017.06.170155.

        With good intentions, the Centers for Medicare and Medicaid
    Services (CMS) have tried to fill this gap by adding more billing codes
    in an attempt to more comprehensively tie payment to effort.
    Unfortunately, it is a fraught effort to reduce the important work of
    physicians and other health-care providers to a list of codes. This has
    resulted in an administratively burdensome system of ``ticky tack''
    codes that get underused because the cost of submitting the bill
    exceeds the payment doctors receive. I sometimes call this ``death by a
    thousand codes.'' For example, the billing cost for a visit has been
    estimated to be $20.49,\20\ exceeding CMS's initially proposed $15 FFS
    payment for a phone call or other ``virtual check-in'' visit. This
    places PCPs in a difficult situation: shoulder substantial
    administrative burden to deliver and bill for these services, deliver
    but do not bill for these services, or do not provide these services at
    all. Either of the first two options is financially perverse and the
    third is clinically perverse. Consequently, the core issue of
    fragmentation does not get systematically addressed.\21\
    ---------------------------------------------------------------------------
        \20\ Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA.
    Administrative costs associated with physician billing and insurance-
    related activities at an academic health care system. JAMA.
    2018;319(7):691-697. doi:10.1001/jama.2017:19148.
        \21\ Berenson R, Shartzer A. The Mismatch of Telehealth and Fee-
    for-Service Payment. JAMA Health Forum. 2020;1(10):e201183.
    doi:10.1001/jamahealthforum.2020.1183.

        Adding billing code upon billing code increases administrative
    complexity while failing to appropriately pay primary care practices
    for all the services they provide off of the fee schedule, an estimated
    25 percent of their activities.\22\ Studies show that 60 percent of
    primary care visits deliver services that are not reportable in CPT
    (Current Procedural Terminology) codes.\23\ Examples of these services
    include checking insurance coverage for patients, addressing social
    determinants of health during visits, and discussing medication
    options. All of these are critical for effective delivery of medical
    care, but providers are not compensated for them.
    ---------------------------------------------------------------------------
        \22\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
    Family Physicians' Work Is Not Reflected by Current Procedural
    Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
    10.3122/jabfm.2017.06.170155.
        \23\ Ibid.

        What can we do to fix this? Despite the challenge facing
    beneficiaries, doctors, and policymakers, there are some potential
    ---------------------------------------------------------------------------
    options we can consider.

        Any effort to improve chronic disease care will require a change in
    the way health care is delivered, a different ``model of care'' to
    address fragmentation. It will require physician groups to be able to
    invest in new capabilities; use technologies like telehealth when they
    are safe, efficient, and effective; and expand the role of staff
    practices, including care coordinators and case managers. For example,
    there is a growing workforce of nurse practitioners in primary care who
    help bolster access and improve care coordination, demonstrating
    successful care model shifts. A crucial element to enable a new model
    of care, however, is substantial change to physician payment. Simply
    adding more dollars to the current system is unlikely to address the
    chronic care crisis in Medicare. Instead, thoughtful care redesign is
    needed.

        A natural place to start is to invest more in primary care,
    empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
    patient's care team. Robust primary care has consistently demonstrated
    an improvement in population health and reduction in health
    disparities.\24\ Despite this, the United States systemically
    underinvests in primary care. Expenditure on primary care in the U.S.
    has declined over the past decade, ranging from 6.2 percent in 2013 to
    4.6 percent in 2020 across all insurance types. Medicare spends an
    estimated 4 percent of its total spending on primary
    care,\25\, \26\, \27\ about $15 billion per year,
    which is half that of many other developed countries.\28\ In contrast,
    we spend more on inpatient care and hospitalizations than other
    nations. Within the U.S., primary care is systematically underinvested
    relative to other specialties,\29\, \30\ despite the fact
    that PCPs play the central role in a patient's health and face the
    cognitively and logistically complex task of care coordination and
    integration. Procedural specialties are compensated significantly more
    than primary care and other office-based specialties.\31\,
    \32\, \33\ Changing fee schedule weights alone will not fix
    this; studies demonstrated that a recent upweighting of reimbursement
    for office visits led to only a 2-percent decrease in the Medicare
    payment gap between primary care and specialty physicians (from a gap
    of $40,259.80 to one of $39,434.70).\34\
    ---------------------------------------------------------------------------
        \24\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \25\ New ``Scorecard'' Finds Primary Care Funding and Physician
    Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
    https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
    scorecard.html.
        \26\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \27\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
    1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
    8747.
        \28\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
    health-systems/primary-care.htm.
        \29\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
    980. doi:10.1001/jamainternmed.2018.8747v.
        \30\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
    and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
    to Achieve Payment Equity Among Specialties, Expand the Supply of
    Primary Care Physicians, and Improve the Value of Care for
    Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
    Systems Inc.
        \31\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
    Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
    319:835-41.
        \32\ Katz S, Melmed G. How Relative Value Units Undervalue the
    Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
    Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
        \33\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
    Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
    20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
        \34\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
    of Evaluation and Management Payment Policy Changes with Medicare
    Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
    doi:10.1001/jama.2023.0879.

        Beyond mobilizing more dollars into primary care, we need to enable
    PCPs to invest in new capabilities and grant them more flexibility. One
    potential path would be to provide PCPs with consistent per-beneficiary
    per-month (PBPM) payments in addition to certain fee-for-service
    payments.\35\ These PBPM payments would be designed to cover the
    estimated 25 percent of PCP activities that are not currently captured
    in the Medicare Physician Fee Schedule, such as care coordination,
    communication with other providers, addressing social determinants of
    health, and improving patient and caregiver health literacy.
    Consequently, a benefit of such an approach is that it would unshackle
    PCPs from a system that tries to capture every activity across
    thousands of codes, since the litany of codes would no longer be
    necessary (since the associated clinical activities would be included
    in the monthly payment). This would also balance the goals of
    preserving access through FFS payments while enabling PCPs to practice
    more patient-centered, rather than visit-
    centered, care. The PBPM payments would allow PCPs to invest in
    sustainable practice infrastructure transformation such as hiring case
    managers and care coordinators or integrating technology and team-based
    care. Such care model redesign is of particular importance for
    improving the health of patients with multiple chronic conditions while
    reducing wasteful administrative complexity.
    ---------------------------------------------------------------------------
        \35\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
    Implementing a primary care hybrid payment model in Medicare. Health
    Affairs Scholar. 2023 Aug;1(2):qxad024.

        Hybrid primary care payments cannot be implemented at scale without
    congressional action. The Centers for Medicare and Medicaid Services
    (CMS) have conducted several demonstration projects implementing hybrid
    payments (e.g., Comprehensive Primary Care Plus). It also has the
    authority to--and should--implement hybrid payments in the Medicare
    Shared Savings Program (MSSP),\36\ the largest accountable care program
    in Medicare. The ACO Primary Care Flex Model is a step in that
    direction.\37\ However, moving past demonstrations to impact Medicare
    beneficiaries nationwide will require Congressional action to grant CMS
    the appropriate authority.
    ---------------------------------------------------------------------------
        \36\ Commonwealth Fund. Response to Request for Information on HHS
    Initiative to Strengthen Primary Health Care from the Office of the
    Assistant Secretary for Health, Department of Health and Human
    Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
    TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20Care
    %20RFI_7.29.22.pdf.
        \37\ https://www.cms.gov/priorities/innovation/innovation-models/
    aco-primary-care-flex-model.

        The evidence for hybrid payments is promising. Blue Cross Blue
    Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
    conducted what is perhaps the most rigorous test of hybrid payments for
    primary care to date in its Population-based Payments for Primary Care
    (3PC) model. The 3PC model is a hybrid model that shifted the majority
    of payments to PCPs to a risk-adjusted per-member per-month payment,
    ---------------------------------------------------------------------------
    while continuing to pay some services as FFS.

        The transformative elements of HMSA's 3PC model relate to its large
    market share; across its commercial, Medicare Advantage, and Managed
    Medicaid lines of business, HMSA retains large shares of patients and
    revenue for most of its PCPs. The model led to marked improvements in
    quality, greater use of telehealth that predated the COVID-19 pandemic,
    and fewer low-value imaging tests.\38\ This included increased rates of
    cost-effective prevention such as blood pressure control among patients
    with diabetes (2.7-percent differential increase), as well as greater
    cost-saving care such as a 5.5-percent differential increase in advance
    care planning (Exhibit 2).\39\ In fact, unlike other states where
    primary care practice finances were massively disrupted by the COVID-19
    pandemic, practices in Hawaii were protected financially, as PCPs were
    well-equipped to care for patients effectively in a remote fashion
    because they had already made such infrastructure investments. The
    experience and transformative successes in Hawaii underscore the
    stability and ability to invest that hybrid payments can impart to
    primary care practices.
    ---------------------------------------------------------------------------
        \38\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
    Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
    S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
    Navathe AS. Changes in Outpatient Imaging Utilization and Spending
    Under a New Population-Based Primary Care Payment Model. J Am Coll
    Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
    j.jacr.2019.08.013. PMID: 31918865.
        \39\ Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel
    A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi
    M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Stollar M, Tom J, Gold M,
    Volpp KG. Association Between the Implementation of a Population-Based
    Primary Care Payment System and Achievement on Quality Measures in
    Hawaii. JAMA. 2019 Jul 2;322(1):57-68. doi: 10.1001/jama.2019.8113.

        Notes: Significant differential improvement in blood pressure
    control among patients with diabetes and advance care planning in
    hybrid payment group versus control group. Source: Navathe AS et al.
    Association Between the Implementation of a Population-Based Primary
    Care Payment System and Achievement on Quality Measures in Hawaii.
    ---------------------------------------------------------------------------
    JAMA. 2019 Jul 2;322(1):57-68.

        Beyond private payers in Hawaii, CMS has been testing ``advanced
    primary care models'' at a national level using hybrid payments in
    Medicare for over a decade with promising ``leading indicator''
    results. These models led to fewer emergency department visits and
    hospitalizations, while producing modest gains in chronic disease
    management and prevention. In Comprehensive Primary Care (CPC, 2012-
    2016), hospitalizations and emergency department visits increased by 2
    percent less among participating practices.\40\ This represented a
    statistically significant relative reduction of 8,150 hospitalizations
    and 15,472 outpatient emergency department (ED) visits over the 4 years
    of the program. Importantly, practices with greater access to resources
    or more experience with care delivery transformation were more likely
    to reduce growth in expenditures (2 percent). This highlights the
    importance of providing practices with resources for successful and
    sustainable transformation.
    ---------------------------------------------------------------------------
        \40\ Evaluation of the Comprehensive Primary Care Initiative:
    Fourth Evaluation Report. Mathematica. 2018 May. https://
    downloads.cms.gov/files/cmmi/CPC-initiative-fourth-annual-report.pdf.

    [GRAPHIC] [TIFF OMITTED] T1124.002

        .epsComprehensive Primary Care Plus (CPC+, 2017-2021) similarly saw
    a 2-percent reduction in ED visits that emerged early and persisted
    across the 5 program years.\41\ A 2-percent reduction in
    hospitalizations emerged in program years 3 and 4 and was driven by
    reductions in medical admissions, suggesting that these admissions were
    prevented by improved outpatient care. Furthermore, over the 5 years of
    the program, the percentages of beneficiaries who received all
    recommended services for diabetes increased by about 1 percentage point
    and of females who received breast cancer screening increased by about
    1 percentage point. CPC+ had more favorable effects among concurrent
    MSSP participants, again suggesting that practices can build experience
    with care transformation with time and proper investment. These
    demonstrations suggest that transforming primary care payment can have
    important implications for beneficiaries with multiple chronic
    conditions, such as decreasing emergency department visits and
    hospitalizations while improving the delivery of robust well-integrated
    and well-coordinated primary care.
    ---------------------------------------------------------------------------
        \41\ Independent Evaluation of Comprehensive Primary Care Plus
    (CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
    www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
    annual-eval-report.

        Another approach would be to continue expansion of alternative
    payment models (APMs), which increase accountability for cost and
    quality outcomes onto providers, shifting provider focus to value. This
    will require continued support for the CMS Innovation Center. There is
    some evidence that APMs can improve care for beneficiaries with both
    high and low burdens of chronic disease. A great example has been the
    ---------------------------------------------------------------------------
    Accountable Care Organization (ACO) model.

        The ability of ACOs to improve quality measures and drive savings
    is particularly evident through their performance in the MSSP. Notably,
    physician-led ACOs are more successful than other ACOs. An evaluation
    studying differential changes in annual per-beneficiary utilization and
    total Medicare spending found that physician-led ACOs demonstrated
    significant improvements and growing savings for Medicare over a 3-year
    period in the MSSP.\42\ Among the physician-group led ACOs, the study
    reported statistically significant reductions (differential change) for
    annual per-
    beneficiary any-cause hospitalization (-0.008), ED visits (-0.018), and
    post-acute facility stays. In contrast, hospital-led ACOs showed
    statistically significant reductions in ED visits (-0.009) only. Per-
    beneficiary spending reductions were significant in both ACO types, but
    larger for physician-led ACOs.\43\ The spending reductions observed in
    ACOs led by physicians resulted in a net savings of $256.4 million for
    Medicare in 2015, while the corresponding spending reductions in ACOs
    integrated with hospitals were offset by bonus payments.\47\ The
    integration facilitated by ACOs, particularly those led by physicians,
    can be important among beneficiaries with chronic conditions, as
    fragmented management of these conditions is known to drive a
    significant portion of overall Medicare spending.
    ---------------------------------------------------------------------------
        \42\ McWilliams JM, et al. Medicare Spending After 3 Years of the
    Medicare Shared Savings Program. New England Journal of Medicine 379.12
    (2018): 1139-1149.
        \43\ Ibid.

        Another evaluation analyzed outcomes of ACOs entering MSSP in 2012
    through 2014, stratifying beneficiaries as either low-risk or high-risk
    based on the number of chronic conditions. The authors identified
    improvements in quality measures such as a reduction in annual
    hospitalizations, with statistically significant reductions among the
    high-risk patients in 2012 only and reductions for low-risk patients in
    both 2012 and 2013. Among hospitalizations for ambulatory care-
    sensitive conditions in the 2012 cohort, participation in MSSP was
    linked with a decrease in the proportion of patients hospitalized for
    chronic obstructive pulmonary disease or asthma (-0.05 percentage
    points, or 4.8 percent of the precontract mean). However, there were
    significant increases in the proportion hospitalized for congestive
    heart failure (0.05 percentage points, or 3.6 percent) and
    cardiovascular disease or diabetes (0.07 percentage points, or 3.5
    percent).\44\ High-risk patients experienced a substantially greater
    absolute decrease in spending (-$686 versus -$207), while relative
    reductions were similar between the two groups (-3.0 percent versus
    -2.9 percent). The notable decrease in spending and admissions observed
    in the 2013 cohort predominantly stemmed from reductions among patients
    classified as low-risk.
    ---------------------------------------------------------------------------
        \44\ McWilliams, JM, Chernew ME, and Landon BE. Medicare ACO
    program savings not tied to preventable hospitalizations or
    concentrated among high-risk patients. Health Affairs 36.12 (2017):
    2085-2093.

        In another evaluation of nearly a dozen ACOs, PCP clinical staffing
    type played a pivotal role in influencing financial gains within
    ACOs.\45\, \46\ An increase of one primary care visit per
    beneficiary-year administered by PCPs resulted in significant average
    gains of $49.65, $40.84, and $27.31 in earned shared savings per
    beneficiary for hybrid, hospital-led, and physician-led ACOs,
    respectively (p < 0.001). These findings underscore the impact of
    primary care providers within the ACO framework, especially for
    managing chronic conditions.
    ---------------------------------------------------------------------------
        \45\ Lemaire N and Singer SJ. Do Independent Physician-Led ACOs
    Have a Future? NEJM Catalyst 4.1 (2018).
        \46\ Coyne J, et al. Financial Performance of Accountable Care
    Organizations: A 5-Year National Empirical Analysis. Journal of
    Healthcare Management 69.1 (2024): 74-86.

        To date, the MSSP has saved CMS $1.8 billion by its own
    estimates.\47\ When advanced primary care models have overlapped with
    ACOs, the synergies have yielded even larger savings, up to 3 percent
    lower Medicare spending per beneficiary or about $300 in annual savings
    per beneficiary.\48\ This provides supportive evidence for CMS using
    its existing authority to implement hybrid primary care payment in
    MSSP.
    ---------------------------------------------------------------------------
        \47\ Medicare Shared Savings Program Saves Medicare More Than $1.8
    Billion in 2022 and Continues to Deliver High-quality Care. CMS. 2023
    Aug 24. https://www.cms.gov/newsroom/press-releases/medicare-shared-
    savings-program-saves-medicare-more-18-billion-2022-and-continues-
    deliver-high.
        \48\ Independent Evaluation of Comprehensive Primary Care Plus
    (CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
    www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
    annual-eval-report.

        ACOs are an exemplar of the positive shifts in care that APMs can
    create for Medicare beneficiaries. Other APMs have also been successful
    in changing practice patterns toward greater quality and cost-
    efficiency. However, we should also note that most, if not all, APMs
    still rely on the Medicare Physician Fee Schedule. This can create
    complexities and conflicts in the financial incentives for many
    ---------------------------------------------------------------------------
    physicians.

        This leads me to point out that CMS needs additional tools to
    manage the FFS program more effectively. The FFS system is only getting
    more complicated as new technologies and drugs emerge and as clinical
    care becomes increasingly specialized and sub-specialized.\49\ There
    are many factors to consider in improving physician payment, and no
    single entity has all of the required expertise. Payment changes will
    require multidisciplinary experts to provide input to CMS who could be
    convened as a panel.\50\ Ultimately, CMS needs the ability to catalyze
    a new care model and that will require adapting the fee schedule to
    accommodate approaches like a PBPM payment.
    ---------------------------------------------------------------------------
        \49\ Hunter K, Kendall D, Ahmadi L. ``The Case Against Fee-for
    Service Health Care,'' September 9, 2021. https://thirdway.imgix.net/
    pdfs/the-case-against-fee-for-service-health-care.pdf.
        \50\ National Academy of Medicine; Finkelman EM, McGinnis JM,
    McClellan MB, et al., editors. Vital Directions for Health & Health
    Care: An Initiative of the National Academy of Medicine. Washington
    (DC): National Academies Press (U.S.); 2017. 9, Payment Reform for
    Better Value and Medical Innovation. Available from: https://
    www.ncbi.nlm.nih.gov/books/NBK595162/.

        A recent effort to address the undervaluation of primary and
    outpatient care led to evaluation and management (office visit) weights
    being increased in 2021 by up to 20 percent. This also resulted in a
    corresponding decrease in weights to other services to maintain budget
    neutrality. However, this was a refinement in the current payment
    structure rather than enablement of a shift. Looking forward, it will
    be important to give CMS the ability to scale payment approaches that
    ---------------------------------------------------------------------------
    support better care for beneficiaries with chronic diseases.

        Telehealth represents one example of an opportunity for improved
    care management of patients with multiple chronic conditions. When so
    much of patients' time is spent traveling to and from office visits,
    capitalizing on technological advancements could offer one means by
    which this burden can be reduced, and health outcomes can be improved.
    For example, one care coordination approach using telehealth for
    chronically ill Medicare beneficiaries demonstrated significant savings
    of approximately 7.7-13.3 percent ($312-$542) per person per
    quarter.\51\ Reforms to primary care payment, which enable investment
    in practice-transforming programs such as telehealth in this study, can
    improve the care of beneficiaries with multiple chronic conditions.
    While telehealth is a great potential area of opportunity, implications
    of accessibility and feasibility must be taken into consideration given
    the nuances of supporting an aging population. Furthermore, telehealth,
    like other services, may be susceptible to overuse if paid for in the
    usual FFS structure.
    ---------------------------------------------------------------------------
        \51\ Baker LC, Johnson SJ, Macaulay D, Birnbaum H. Integrated
    telehealth and care management program for Medicare beneficiaries with
    chronic disease linked to savings. Health Aff (Millwood). 2011
    Sep;30(9):1689-97. doi: 10.1377/hlthaff.2011.0216. PMID: 21900660.

        Primary care practices can also improve the health of patients with
    multiple chronic conditions by hiring community health workers (CHWs).
    A CHW is a ``front-line public health worker who is a trusted member of
    the community served, which enables the worker to serve as a liaison
    between health/social services and the community to facilitate access
    and improve the quality and cultural competence of service
    delivery.''\52\ CHW visits can help patients improve their self-
    efficacy and health literacy in managing multiple chronic conditions.
    Randomized controlled trials of CHWs have demonstrated improvements in
    hospital admissions, hospital length of stay, chronic disease control,
    and mental health for patients with chronic conditions.\53\ These
    programs have also improved measurable health outcomes such as
    hemoglobin A1C, Body Mass Index, cigarettes per day, and blood
    pressure.\54\ In Medicaid, CHWs have been estimated to return an annual
    $2.47 for every dollar invested.\55\ Hospital-based health systems
    across the country have begun to incorporate CHW programs, such as the
    IMPaCT (Individualized Management for
    Patient-Centered Targets) program at the University of Pennsylvania.
    Reforming primary care payment can enable practices to invest in CHW
    programs, one such innovation in care management to improve the care of
    patients with chronic disease.
    ---------------------------------------------------------------------------
        \52\ ``Community Health Workers.'' American Public Health
    Association. https://www.apha.org/apha-communities/member-sections/
    community-health-workers/.
        \53\ Kangovi S, Mitra N, Grande D, et al. Patient-Centered
    Community Health Worker Intervention to Improve Posthospital Outcomes:
    A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):535-543.
    doi:10.1001/jamainternmed.2013.14327.
        \54\ Kangovi S, Mitra N, Grande D, Huo H, Smith RA, Long JA.
    Community Health Worker Support for Disadvantaged Patients With
    Multiple Chronic Diseases: A Randomized Clinical Trial. Am J Public
    Health. 2017 Oct;107(10):1660-1667. doi: 10.2105/AJPH.2017.303985.
        \55\ Kangovi S, Mitra N, Grande D, Long JA, Asch DA. Evidence-Based
    Community Health Worker Program Addresses Unmet Social Needs and
    Generates Positive Return on Investment. Health Aff (Millwood). 2020
    Feb;39(2):207-213. doi: 10.1377/hlthaff.2019.00981.

        Acting now is paramount to improve the landscape of chronic
    condition care management and payment. Unlike in Medicare Advantage,
    where we have seen substantial innovation to meet beneficiary needs on
    a near real-time basis, traditional Medicare requires Congressional
    action to stay up to date. It is imperative to give CMS the tools and
    authorities it requires to address chronic diseases among Medicare
    beneficiaries. Thank you for the opportunity to share my testimony with
    you today.

    Acknowledgements

        I would like to express sincere thanks to Vrushabh P. Ladage, Aidan
    Crowley, Maura Boughter-Dornfeld, and Torrey Shirk for research
    assistance in preparing my testimony.

    Disclosures

        I report grants from Hawaii Medical Service Association, grants
    from Commonwealth Fund, grants from Robert Wood Johnson Foundation,
    grants from Donaghue Foundation, grants from the Veterans Affairs
    Administration, grants from Arnold Ventures, grants from United
    Healthcare, grants from Blue Cross Blue Shield of NC, grants from
    Humana, personal fees from Navvis Healthcare, personal fees from
    Elsevier Press, personal fees from Medicare Payment Advisory
    Commission, personal fees from Analysis Group, personal fees from
    Advocate Physician Partners, personal fees from the Federal Trade
    Commission, personal fees from Catholic Health Services Long Island,
    equity from Clarify Health, personal fees and board membership for The
    Scan Group, and non-compensated board membership for Integrated
    Services, Inc. outside the submitted work in the past 3 years.

        Disclaimer: This testimony does not necessarily represent the views
    of the U.S. Government, Medicare Payment Advisory Commission,
    Department of Veterans Affairs, or the University of Pennsylvania
    Health System and Perelman School of Medicine.

                                     ______

       Questions Submitted for the Record to Amol S. Navathe, M.D., Ph.D.
                     Questions Submitted by Hon. Mike Crapo
        Question. Advanced Alternative Payment Models (AAPMs) hold
    significant promise as a means of driving improved value while ensuring
    appropriate and targeted stewardship of Federal Medicare dollars for
    both beneficiaries and taxpayers.

        What specific steps should Congress or CMS take in order to improve
    uptake of these models, including for specialties with low
    participation rates?

        Answer. Alternative payment models (APMs) serve as a form of value-
    based payment (VBP) that continues to demonstrate promise as a
    potential avenue forward for the American health-care system,
    particularly within care model delivery and financing. Over the past
    few decades, APMs have evolved as a key model to drive value while
    saving Federal dollars, with programs using two-sided risk creating the
    greatest impact.\1\ While there have been concerns and challenges
    throughout the development of various attempts testing APMs
    implementation, the two that have shown the most promise are those that
    are population-based and episode-based.\2\ The transition to value-
    based systems requires substantial time, research, and effort to best
    determine methodology; as such, seeing additional potential within both
    care transformation and improved value in the form of savings will
    support further success.\3\
    ---------------------------------------------------------------------------
        \1\ Final Rule Creates Pathways to Success for the Medicare Shared
    Savings Program. [Press release]. U.S. Centers for Medicare and
    Medicaid Services. Retrieved from https://www.cms.
    gov/newsroom/fact-sheets/final-rule-creates-pathways-success-medicare-
    shared-savings-program.
        \2\ Liao JM, Navathe AS, Werner RM. (2020). The Impact of
    Medicare's Alternative Payment Models on the Value of Care. Annual
    Review of Public Health, 41(1), 551-565. doi:10.1146/annurev-
    publhealth-040119-094327.
        \3\ McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME.
    (2018). Medicare Spending after 3 Years of the Medicare Shared Savings
    Program. N Engl J Med, 379(12), 1139-1149. doi:10.1056/NEJMsa1803388.

        Advanced Alternative Payment Models (AAPMs) are models that are
    exemplary and can demonstrate most clearly the potential ability for
    these programs to be spread more widely. If CMS dedicates additional
    resources to encourage the uptake of these models, particularly in
    areas where low participation has been observed, further development is
    ---------------------------------------------------------------------------
    likely for such models in diverse sectors and climates.

        Along with my peers at Leonard Davis Institute, we developed a
    suggested roadmap for CMS to bolster efforts needed to evolve VBP
    systems, including APMs and AAPMs, suggesting the following:

                I.  CMS must articulate a clear vision for the future of
            value-based payment.
               II.  CMS must dramatically simplify the current value-based
            payment landscape and engage late-adopting providers.
              III.  For health systems already participating in value-based
            payment, CMS must accelerate the movement from upside-only
            shared savings to risk-bearing, population-based alternative
            payment models while curtailing the ability of providers to opt
            out of value-based payment altogether.
              IV.  CMS must not only pull providers toward Advanced
            Alternative Payment Models, but also structure incentives to
            push providers away from fee-for-service payment.
               V.  Achieving health equity must be a central feature and
            goal of value- based payment.\4\
    ---------------------------------------------------------------------------
        \4\ Werner RM, Emanuel EJ, Pham HH, Navathe AS. (2021). The Future
    of Value-Based Payment: A Road Map to 2030. Leaonard Davis Institute.
    https://ldi.upenn.edu/our-work/research-updates/the-future-of-value-
    based-payment-a-road-map-to-2030/.

        These suggestions still hold true, with an evident need for
    concerted effort and improved coordination across model design to
    ---------------------------------------------------------------------------
    further the potential ability for continued success.

        Additional key lessons building upon that we propose for improving
    current systems in place include modification of design flaws in
    existing programs and how to address implementation challenges to
    encourage further participation in CMS's VBP programs.

        Regarding design flaws, we review the following three as most
    problematic:\5\
    ---------------------------------------------------------------------------
        \5\ Navathe AS, Emanuel EJ, Shenfeld DK. Expanding VBP: Fixing
    Design Flaws. Health Affairs Forefront, April 23, 2024. DOI: 10.1377/
    forefront.20240418.617238.

            1.  Many VBP incentive designs require participants to forgo
            revenue for the opportunity to earn just a fraction of it back
            as shared savings. To address the issue of forgone revenue, VBP
            designs must target wasteful or inefficient spending outside
    ---------------------------------------------------------------------------
            the intended participant.

            2.  Many VBP models are vulnerable to ``ghost savings,''
            savings that occur when calculated on a risk-adjusted basis due
            to more intense coding but that are not present on a nominal
            (raw or unadjusted) basis.\6\ To address the issue of ghost
            savings, payers should require ``real savings'' to earn shared
            savings.
    ---------------------------------------------------------------------------
        \6\ Shenfeld DK, Navathe AS, Emanuel EJ. The Promise and Challenge
    of Value-Based Payment. JAMA Internal Medicine. Forthcoming May 2024.

            3.  Most VBP experimental models are voluntary. To address the
            issues of voluntariness, the presumption for every new VBP
            model should be mandatory participation. In cases where
            mandatory enrollment is not feasible, building on regionalized
            demonstrations such as Medicare's Comprehensive Primary Care
            Plus model, voluntary models should be deployed in reasonably
            small geographic areas using randomization to offer
            participation in the model, preserving the ability to examine
    ---------------------------------------------------------------------------
            population-level effects.

        To encourage further participation in VBP programs tailored to
    difficulty within implementation, we review the following areas and
    propose potential solutions for each: (1) consolidation and use of
    management service organizations; (2) paucity of data and modeling for
    actuarial risk; and (3) experimentation and protection from failure.\7\
    ---------------------------------------------------------------------------
        \7\ Shenfeld DK, Navathe AS, Emanuel EJ. Expanding VBP: Overcoming
    Implementation Barriers. Health Affairs Forefront, April 24, 2024. DOI:
    10.1377/forefront.20240422.791880.

        Specific steps that Congress or CMS should take to improve the
    uptake of these models include ongoing conversations with stakeholders
    and participants about reasons for participation to further improve and
    strengthen considerations from the aforementioned highlighted lessons.
    Up-front investment is also crucial, as changing care patterns to
    conform with these models often requires initial transformation such as
    hiring care coordinators and altering practice workflow if change is to
    ---------------------------------------------------------------------------
    be sustainable.

        Question. What specific flexibilities would help Accountable Care
    Organizations to improve patient care quality and reduce costs, and
    what steps could Congress take to advance these types of flexibilities?

        Answer. ACOs are a strong example of value-based care (VBC) models
    that have seen success with investment from CMS in testing various
    structures and dedication effort to revise as needed. The CMS Medicare
    Shared Savings Program (MSSP) has selected the most high-performing
    ACOs to evaluate the factors leading to increased success of these
    models on improving quality and reducing cost. We suggest that by
    allowing for further ACO-led innovation, without a ``one-size-fits-
    all'' approach, fitting the needs of each population served per ACO
    will be more attainable.

        The newly announced ACO Primary Care Flex model beginning in
    January 2025 is one example of a well-designed model that offers
    increased flexibility for primary care. It includes a prospective
    primary care payment (PPCP) that will shift payment for primary care
    away from visit-based FFS payment to enhance the predictability and
    amount of primary care funding for low revenue ACOs, increasing their
    flexibility to meet the needs of people with Medicare.\8\ It also
    includes a one-time up-front advanced shared savings payment to cover
    onboarding practice transformation costs of joining the model.
    ---------------------------------------------------------------------------
        \8\ ACO Primary Care Flex Model. https://www.cms.gov/priorities/
    innovation/innovation-models/aco-primary-care-flex-model.

        Another flexibility to help ACOs improve quality and reduce costs
    is improving their overlap with episode-based models through
    hierarchical payment structures.\9\ Creating flexibility for patients
    in ACOs to still be treated through episode-based payments as proposed
    in the new TEAM model is one example of how this can be accomplished,
    as well as by facilitating improved data sharing between ACOs and
    specialists.
    ---------------------------------------------------------------------------
        \9\ Shrank WH, Chernew ME, Navathe AS. Hierarchical Payment
    Models--A Path for Coordinating Population- and Episode-Based Payment
    Models. JAMA. 2022 Feb 1;327(5):423-424. doi: 10.1001/jama.2021.23786.

        Lastly, additional flexible support should be directed toward ACOs
    serving beneficiaries who face higher social burden. This approach is
    seen in ACO REACH with its Health Equity Benchmark Adjustment. However,
    these approaches will require empirical justification beyond solely
    conceptual support.\10\
    ---------------------------------------------------------------------------
        \10\ Navathe AS, Liao JM. Embedding Equity in Financial Benchmarks:
    Changes to the Health Equity Benchmark Adjustment. Health Affairs
    Forefront. 28 Sep 2023. https://www.
    healthaffairs.org/content/forefront/embedding-equity-financial-
    benchmarks-changes-health-equity-benchmark-adjustment.

        Question. Artificial intelligence (AI) has the potential to
    mitigate administrative burden and enhance health-care quality,
    including in the context of Medicare. That said, some clinicians have
    raised concerns around the program's inability to keep pace with AI-
    enabled tool development through its coverage and payment policies,
    ---------------------------------------------------------------------------
    undercutting access, especially for smaller practices.

        What use cases for AI-enabled tools and technologies seem most
    promising in the context of clinician care?

        Answer. AI-enabled tools have the potential to handle more menial
    and repetitive tasks for clinicians. There is a lot of promise in
    imaging specifically, with tools trained to detect signs of disease to
    be flagged for a more detailed review by clinicians. This type of
    technology is already being introduced to interpret imaging for
    pulmonary nodules, intracranial hemorrhage risk, diabetic retinopathy,
    cardiac ultrasound, and others.\11\, \12\ This type of AI-
    enabled tools supplement physician practice and create efficiencies
    which allow clinicians to spend more time performing higher-level
    tasks.
    ---------------------------------------------------------------------------
        \11\ Gonzalez-Smith J, Shen H, Silcox C. Moving Ahead of the Pack:
    Understanding Health System Priorities on AI-Enabled Clinical Decision
    Support. Biomedical Instrumentation & Technology. 2022;56(4):119-23.
        \12\ Halabi, SS. Artificially Practical in Every Way. Journal of
    the American College of Radiology. Volume 17, Issue 11. 2020, Pages
    1361-1362. ISSN 1546-1440. https://doi.org/10.1016/j.jacr.2020.09.063.

        Beyond established uses for imaging, AI is currently being piloted
    in primary care settings to draft responses to patient portal messages
    and draft clinic notes with ambient listening technology. This can
    enable physicians to spend less time on the computer and more time with
    their patients, a win-win for the system, clinician well-being, and
    patient satisfaction. Furthermore, AI can be used to streamline
    administrative requirements such as billing and documentation as well
    as prior authorization requirements. However, it is imperative to train
    these algorithms on a representative dataset with continual monitoring
    of outcomes to promote equity. These topics were discussed in an
    executive order from President Biden as well as a Health Plan
    Management System memorandum from CMS.\13\, \14\
    ---------------------------------------------------------------------------
        \13\ Executive Order on the Safe, Secure, and Trustworthy
    Development and Use of Artificial Intelligence. 30 Oct 2023. https://
    www.whitehouse.gov/briefing-room/presidential-actions/2023/10/30/
    executive-order-on-the-safe-secure-and-trustworthy-development-and-use-
    of-artificial-intelligence/.
        \14\ Frequently Asked Questions Related to Coverage Criteria and
    Utilization Management Requirements in CMS Final Rule (CMS-4201-F).
    CMS. 6 Feb 2024. https://www.aha.org/system/files/media/file/2024/02/
    faqs-related-to-coverage-criteria-and-utilization-management-
    requirements-in-cms-final-rule-cms-4201-f.pdf.

        Question. What steps should CMS and Congress take to ensure
    adequate coverage and reimbursement for appropriate AI-enabled tools in
    ---------------------------------------------------------------------------
    this context?

        Answer. Value-based models create incentives to use new AI
    technologies that improve efficiency. Rather than adding new codes for
    each new technology, a hybrid payment with a population-based payment
    would enable practices to decide which AI technologies best fit their
    needs and those of their patients. The use of AI-
    enabled tools can in some contexts be self-funding, as the efficiencies
    they create will allow clinicians to provide more care to more
    patients, drawing in more reimbursement without major changes in
    funding structure. Appropriately designing incentives outside of value-
    based models can be much more challenging.

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. The Center for Medicare and Medicaid Innovation (CMMI)
    receives $10 billion in mandatory funding every decade. The nonpartisan
    Congressional Budget Office (CBO) has found that CMMI has not lowered
    Medicare spending. Separately, CBO has found the Medicare Shared
    Savings Program (MSSP) was not a factor in the slower growth of Federal
    health-care spending.

        Are the spending impacts on Medicare from CMMI and MSSP each
    validated by an independent, third-party organization? If not, why
    would that be important?

        Answer. While no independent organization has been formally
    commissioned to conduct an evaluation of MSSP outside of CBO, many
    academic scholars have independently evaluated the effects of MSSP and
    found favorable results concentrated among physician-led ACOs.\15\ What
    appears to be a lack of contribution by MSSP to the growth of Federal
    health spending may actually be created by a measurement challenge.
    Practice change among clinicians both within and outside of
    demonstration projects, as well as overlapping demonstrations, creates
    ``control group contamination,'' making it look like demonstration
    projects did not save money when in reality they catalyzed broader
    systemwide transformation observed in the flattening of national health
    spending.\16\
    ---------------------------------------------------------------------------
        \15\ McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME.
    Medicare Spending after 3 Years of the Medicare Shared Savings Program.
    N Engl J Med. 2018 Sep 20;379(12):1139-1149. doi: 10.1056/
    NEJMsa1803388. Epub 2018 Sep 5. PMID: 30183495; PMCID: PMC6269647.
        \16\ Navathe AS, Boyle CW, Emanuel EJ. Alternative Payment Models--
    Victims of Their Own Success? JAMA. 2020;324(3):237-238. doi:10.1001/
    jama.2020.4133.

        While the spending impacts of CMMI as a whole were measured by CBO,
    CMMI itself commonly commissions government-contracted entities such as
    the Lewin Group and Mathematica to evaluate its demonstration projects.
    Furthermore, it is important to note that the purpose of CMMI is not
    solely to lower spending, but also to improve quality.\17\ Growth in
    spending is only a problem if it is not accompanied by commensurate
    gains in outcomes. For example, while some of CMMI's demonstration
    projects may not have decreased spending overall, they did decrease
    hospitalizations and emergency department visits,\18\ suggesting that
    we are realizing quality gains for those dollars spent.
    ---------------------------------------------------------------------------
        \17\ Innovation Center Strategy Refresh. 2021. CMMI. https://
    www.cms.gov/priorities/innovation/strategic-direction-whitepaper.
        \18\ Independent Evaluation of Comprehensive Primary Care Plus
    (CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
    www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
    annual-eval-report.

        Question. Congress and the Centers for Medicare and Medicaid
    Services (CMS) have access to several advisory committees to inform us
    on how to move Medicare's fee-for-service payment system to a more
    outcomes-based model. These committees include the American Medical
    Association's RVS Update Committee, the Medicare Payment Advisory
    Commission--which you serve on--and the Physician-Focused Payment Model
    ---------------------------------------------------------------------------
    Technical Advisory Committee.

        Are these committees effective at providing actionable
    recommendations to move our health-care system to be outcomes-based? If
    not, what reforms should be made to them?

        Answer. Each of these committees have an important role to play in
    advising Congress and CMS. I believe that the roles of the RVS Update
    Committee, the Medicare Payment Advisory Commission are well defined,
    and that they are able to be effective in their mission. The Physician-
    Focused Payment Model Technical Advisory Committee (PTAC) role has been
    less clear as their recommendations have not been implemented. To
    implement the recommendations of PTAC there needs to be a greater
    ability to create Value Based Models which are designed to engage
    specialists. By having a more proactive system CMS will have a greater
    ability to get reforms into practice.

        Further, in order to be more effective, CMS requires a
    reexamination of the fee-for-service weights, but also the methodology
    and process by which the weights are created. I propose an independent
    group, comprised of experienced representatives from many specialties,
    and free of any interest in the results themselves. A group of this
    kind will be well suited to the task of creating weights which
    incentivize the form of practice which will achieve the greatest
    outcomes most efficiently.

        Question. CMS has the authority to add additional procedure codes,
    which can allow for additional medical services to be covered under
    Medicare. Data shows that CMS rulemaking expanded annual Medicare
    spending by $6 billion in 2016, $10 billion in 2017, and $6 billion in
    2018.

        Should Congress be concerned about these regulatory spending
    increases? How does this impact Medicare's long-term solvency?

        Answer. CMS's introduction of procedural codes with the intent of
    improving care coordination--especially among beneficiaries with
    chronic conditions--has unfortunately resulted in additional
    administrative burden for physicians and other health-care providers;
    thereby affecting care quality and worsening fragmentation. Adding
    billing code upon billing code increases administrative complexity
    while failing to appropriately pay primary care practices for all the
    services they provide off of the fee schedule, an estimated 25 percent
    of their activities. Studies show that 60 percent of primary care
    visits deliver services that are not reportable in CPT (Current
    Procedural Terminology) codes.\19\ Examples of these services include
    checking insurance coverage for patients, addressing social
    determinants of health during visits, and discussing medication
    options.
    ---------------------------------------------------------------------------
        \19\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
    Family Physicians' Work Is Not Reflected by Current Procedural
    Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
    10.3122/jabfm.2017.06.170155. 23.

        In the short term, the deferred depletion of the Hospital Insurance
    (HI) trust fund coming at within 6 years of project depletion
    (projected depletion at 2026 in 2020, 2026 in 2021, and 2028 in 2022)
    can, in part, be attributed to the COVID-19 pandemic.\20\ However, the
    Medicare trustees reported that the pandemic led to a significant rise
    in unemployment, causing a decline in payroll tax revenue to the HI
    trust fund. Spending grew due to expenses for COVID-19 treatment,
    testing, and vaccine distribution, along with advance payments to
    providers. Trustees project that the spending effects of the pandemic
    will not have a large effect on the financial status of the Medicare
    program beyond 2028.
    ---------------------------------------------------------------------------
        \20\ #s from--https://www.kff.org/medicare/issue-brief/what-to-
    know-about-medicare-spending-and-financing/.

        In the long run, Medicare faces financial strain from rising
    health-care costs, increasing beneficiary enrollment, and an aging
    population. This growth in Medicare spending stresses the Federal
    budget, hastens the depletion of the Part A trust fund, and raises
    Medicare premiums, deductibles, and cost sharing for beneficiaries.\21\
    Various changes have been suggested to tackle Medicare's fiscal issues.
    Proposals include raising the Medicare eligibility age and shifting to
    a premium support model. Additionally, the Inflation Reduction Act of
    2022 seeks to limit Medicare's prescription drug spending by having the
    Federal Government negotiate drug prices in Medicare and requiring drug
    companies to provide rebates for price hikes that exceed inflation. CBO
    projects that the drug price negotiation measures in the Inflation
    Reduction Act will save Medicare $98.5 billion over a decade (2022-
    2031).\22\
    ---------------------------------------------------------------------------
        \21\ Ibid. [KFF].
        \22\ Explaining the Prescription Drug Provisions in the Inflation
    Reduction Act--KFF.

        In summary, it is understandable to be concerned about spending
    increases and to assess the value. The spending that increases value to
    beneficiaries and taxpayers may be warranted. These spending increases
    have not resulted in big impacts to the HI trust fund but rather come
    from general revenue from Medicare. Of note, however, is the need for
    CMS to have authority to bring new technologies and services into
    ---------------------------------------------------------------------------
    Medicare, as this the only way that Medicare FFS can evolve.

        Question. You stated in your written testimony that ``simply adding
    more dollars to the current system is unlikely to address the chronic
    care crisis in Medicare. Instead, thoughtful design is needed.''

        Can you point to an example where less Medicare outlays produced
    better health outcomes? How was that efficiency achieved?

        Answer. Investing in a robust primary care infrastructure may be
    crucial for a cost-efficient system that produces more health for each
    dollar spent. The U.S. already systematically underinvests in primary
    care, declining from 6.4 percent in 2013 to 4.6 percent in 2020.
    Medicare spends an estimated 4 percent of its total spending on primary
    care.\23\ Despite this, geographic regions within the U.S. that have
    more primary care providers achieve greater health with lower total
    spending. For example, Medicare spends 25 percent less per beneficiary
    in states with many primary care providers compared to those with
    few.\24\ There are examples of State-level investments in primary care
    that yielded overall savings. For example, Oregon's Primary Care Home
    Program produced $13 in savings for every $1 increase in primary care
    expenditures, saving $240 million during its first 3 years.\25\
    ---------------------------------------------------------------------------
        \23\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
    1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
    8747.
        \24\ Baicker K, Chandra A. Medicare Spending, the Physician
    Workforce, and Beneficiaries' Quality of Care. Health Affairs
    (Millwood). 2004 Jan-Jun; Suppl Web Exclusives: W4-184-97. doi:
    10.1377/hlthaff.w4.184.
        \25\ Gelmon S, Wallace N, Sandber B, Petchel S, Bouranis N. 2016
    September. Implementation of Oregon's PCPCH Program: Exemplary Practice
    and Program Findings. https://www.
    oregon.gov/oha/HPA/dsi-pcpch/Documents/PCPCH-Program-Implementation-
    Report-Sept2016.
    pdf.

        CMS's Medicare Shared Savings Program (MSSP) saved Medicare $1.8
    billion in 2022 compared to spending targets for the year. The program
    has generated savings for a substantial number of years. In 2022, an
    estimated 63 percent of MSSP participating ACOs earned payments for
    their performance, with low-revenue ACOs (with at least 75 percent
    primary care clinicians) had $294 per capita in net savings. These
    promising results emphasize achieved efficiency, showing the ability
    ---------------------------------------------------------------------------
    for saved dollars to align and bolster improved care outcomes.

        Question. In your written testimony, you stated, ``the billing cost
    for a visit has been estimated to be $20.49, exceeding CMS's initially
    proposed $15 FFS payment for a phone call or other `virtual check-in'
    visit.''

        Is it possible to lower the cost burden of submitting a bill for a
    provider? How do we make the billing more efficient and cost less?

        Answer. The most efficient way to lower the cost burden of
    submitting a bill is by eliminating the need to submit a bill at all.
    This is the approach of population-based payments (PBP), the capitated
    portion of hybrid payments. Folding payments for selected fee-based
    activities into a PBP can relieve providers of the time and effort
    required to submit a bill for reimbursement. They can instead be
    reimbursed for that same activity through a stable and predictable
    population-based payment and spend that extra time on direct patient
    care.

        Beyond folding fees for certain services into a population-based
    payment, the PBP itself can support a physician practice to hire an
    administrator whose job it is to submit claims to Medicare or purchase
    an AI technology system which can streamline bill submission. A portion
    of the estimated cost of billing is in the opportunity cost of spending
    time with patients.\26\, \27\ PBPs may free up physicians to
    practice at the top of their license and spend their time with
    patients, hiring administrators to focus on streamlining billing for a
    given practice. However, this approach is less than ideal, because it
    is still spending Medicare's dollars on administrative costs. Other
    approaches may include a single transparent set of payment rules with
    clear explanations and descriptions, a single claim form, and standard
    rules of submission.\28\, \29\
    ---------------------------------------------------------------------------
        \26\ Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA.
    Administrative Costs Associated With Physician Billing and Insurance-
    Related Activities at an Academic Health Care System. JAMA.
    2018;319(7):691-697. doi:10.1001/jama.2017.19148.
        \27\ Gottlieb JD, Shapiro AH, Dunn A. The Complexity of Billing and
    Paying for Physician Care. Health Aff (Millwood). 2018 Apr;37(4):619-
    626. doi: 10.1377/hlthaff.2017.1325. PMID: 29608348.
        \28\ Blanchfield BB, Heffernan JL, Osgood B, Sheehan RR, Meyer GS.
    Saving billions of dollars--and physicians' time--by streamlining
    billing practices. Health Aff (Millwood). 2010 Jun;29(6):1248-54. doi:
    10.1377/hlthaff.2009.0075. Epub 2010 Apr 29. PMID: 20430822.
        \29\ Young RA, Bayles B, Hill JH, Kumar KA. Family physicians'
    opinions on the primary care documentation, coding, and billing system:
    a qualitative study from the residency research network of Texas. Fam
    Med. 2014 May;46(5):378-84. PMID:24915481.

        Question. A common concern from Iowa providers is the lack of
    preparation and notice for final payment rules from CMS. When final
    payment rules are set a couple of months or less from the start of the
    payment rule's implementation date, providers do not have time to
    prepare or adjust to new payment policies and administrative
    ---------------------------------------------------------------------------
    requirements. This includes changes to value-based care efforts.

        Should there be a longer preparation period (e.g., 6 months, 1
    year) for providers to adjust to new payment policies and
    administrative requirements under Medicare? What effect would that
    have? Alternatively, should payment policies and administrative
    requirements remain consistent for more than 1 year except for newer
    input data (e.g., inflationary or economic factors)?

        Answer. Continual consideration for improvements to current payment
    rules and concurrent regulations will benefit stakeholders across
    Medicare. CMS should continue efforts to balance providing sufficient
    time for notice while also allowing for the ability for modifications
    to best evolve the program and meet beneficiaries needs.

                                     ______

                    Questions Submitted by Hon. John Cornyn
        Question. There are approximately 700,000 Texans and 12.2 million
    Americans who are jointly enrolled in Medicaid and Medicare. This
    includes many people with multiple chronic conditions. Medicare and
    Medicaid currently often don't coordinate care for these individuals.
    This can lead to poorer outcomes for patients and a more costly and
    ineffective health-care system overall.

        I introduced the Delivering Unified Access to Lifesaving Services
    (or DUALS) Act with Senators Cassidy, Carper, Warner, Scott of South
    Carolina, and Menendez last month. This bill would require States to
    develop a unified health plan for these beneficiaries to help
    streamline our health-care system. The DUALS Act would also ensure this
    vulnerable patient population receives comprehensive care for their
    chronic health conditions.

        Can you speak to how improving care coordination for dual eligible
    beneficiaries will help those with chronic conditions in particular?

        Answer. Chronic conditions, like diabetes and hypertension, require
    consistent care to prevent acute hospitalizations. Barriers to primary
    care reduce consistency in the provision of care, and may lead to an
    acute hospitalization. Beneficiaries with chronic conditions, and those
    who are dual eligible, encounter more barriers to primary care.\30\
    Improving care coordination has the potential to reduce these barriers
    by shifting some of the burden of managing their care from the patient
    to care providers. Coordinated care also fosters collaboration between
    specialists. Coordinated care has been shown to reduce ED and acute
    care hospitalizations in beneficiaries generally,\31\, \32\
    and in chronic care beneficiaries specifically.\33\, \34\
    ---------------------------------------------------------------------------
        \30\ Chatterjee P, Liao JM, Wang E, Feffer D, Navathe AS.
    Characteristics, utilization, and concentration of outpatient care for
    dual-eligible Medicare beneficiaries. Am J Manag Care. 2022 Oct
    1;28(10):e370-e377. doi: 10.37765/ajmc.2022.89189. PMID: 36252177;
    PMCID: PMC100
    84394.
        \31\ Tessa van Loenen, Michael J van den Berg, Gert P Westert,
    Marjan J Faber. Organizational aspects of primary care related to
    avoidable hospitalization: A systematic review, Family Practice, Volume
    31, Issue 5, October 2014, Pages 502-516. https://doi.org/10.1093/
    fampra/cmu053.
        \32\ Aldo Rosano, Christian Abo Loha, Roberto Falvo, Jouke van der
    Zee, Walter Ricciardi, Gabriella Guasticchi, Antonio Giulio de Belvis.
    The relationship between avoidable hospitalization and accessibility to
    primary care: A systematic review, European Journal of Public Health,
    Volume 23, Issue 3, June 2013, Pages 356-360. https://doi.org/10.1093/
    eurpub/cks053.
        \33\ Oh NL, Potter AJ, Sabik LM, et al. The association between
    primary care use and
    potentially-preventable hospitalization among dual eligibles age 65 and
    over. BMC Health Serv Res 22, 927 (2022). https://doi.org/10.1186/
    s12913-022-08326-2.
        \34\ R.J. Wolters, J.C.C. Braspenning, M. Wensing. Impact of
    primary care on hospital admission rates for diabetes patients: A
    systematic review, Diabetes Research and Clinical Practice, Volume 129,
    2017, Pages 182-196, ISSN 0168-8227. https://doi.org/10.1016/
    j.diabres.2017.
    05.001.

        Question. How does streamlining care coordination support providers
    ---------------------------------------------------------------------------
    in addition to patients?

        Answer. Streamlining care coordination has the potential to reduce
    administrative burden on providers. Physicians spend a significant
    amount of time performing administrative tasks which drains mental
    energy and draws time away from patients.\35\ Streamlining these
    burdens can reduce physician burnout.\36\ Less time spent in
    administrative tasks can also increase physician throughput, allowing
    physician to attend to more patients but also earn more dollars for
    their practice while providing useful care.\37\
    ---------------------------------------------------------------------------
        \35\ J. Marc Overhage, David McCallie. Physician Time Spent Using
    the Electronic Health Record During Outpatient Encounters: A
    Descriptive Study. Ann Intern Med.2020;172:169-174. [Epub 14 January
    2020]. doi:10.7326/M18-3684.
        \36\ Kelly J. Thomas Craig, Van C. Willis, David Gruen, Kyu Rhee,
    Gretchen P. Jackson, The burden of the digital environment: A
    systematic review on organization-directed workplace interventions to
    mitigate physician burnout, Journal of the American Medical Informatics
    Association, Volume 28, Issue 5, May 2021, Pages 985-997. https://
    doi.org/10.1093/jamia/ocaa301.
        \37\ Youn S, Geismar HN, Pinedo M. (2022). Planning and scheduling
    in healthcare for better care coordination: Current understanding,
    trending topics, and future opportunities. Production and Operations
    Management, 31(12), 4407-4423. https://doi.org/10.1111/poms.13867.

                                     ______

                     Questions Submitted by Hon. John Thune
        Question. In your testimony, you emphasize that in order to improve
    chronic disease outcomes, there must be changes in the way physicians
    deliver care. Specifically, you highlight issues with fragmentation
    within the fee-for-service reimbursement system that places overly
    burdensome administrative challenges onto providers.

        I know you allude to this in your testimony, but can you just
    expand on some of these fragmentation issues and, specifically, some of
    the day-to-day effects of seemingly endless new billing codes being
    added by CMS and how that affects providers and their ability to care
    for their patients?

        Answer. Some of these fragmentation issues emerge because of the
    sheer number of physicians that each patient with chronic disease sees
    per year. Over one-third of all Medicare beneficiaries saw 5 or more
    different physicians in 2019, a number that is likely higher among
    patients with chronic disease.\38\ As the clinical workforce becomes
    increasingly subspecialized, a patient with diabetes, chronic
    obstructive pulmonary disease (COPD), and chronic kidney disease may
    see a primary care physician, endocrinologist, dietitian,
    pulmonologist, and nephrologist. The PCP is tasked with serving as a
    ``quarterback,'' communicating with multiple different physicians. This
    can require upwards of 50 distinct interactions between a PCP and other
    providers to manage one condition for one patient over a 3-month
    period.\39\ Each of these interactions risks information falling
    through the cracks. Despite the fact that this communication is one of
    the most important roles of the PCP, it is something they cannot
    directly bill for in the current FFS system. Implementing a population-
    based hybrid payment would compensate the PCP for spending time on
    these critical activities as well as financially support them to hire a
    care coordinator or case manager to smooth these interactions.
    ---------------------------------------------------------------------------
        \38\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
    Care for Medicare Beneficiaries and Implications for Primary Care, 2000
    to 2019. Ann Intern Med. 2021 Dec;
    174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
    Ann Intern Med. 2022 Oct;175(10):1492.
        \39\ Press MJ. Instant Replay--A Quarterback's View of Care
    Coordination. New England Journal of Medicine. 2014;371:489--491. doi:
    10.1056/NEJMp1406033.

        Beyond fragmentation between multiple specialists, fragmentation
    also arises because of the increasing number of billing codes. CMS
    continues to add new codes in a valiant effort to compensate PCPs for
    their work. While this is well-intentioned, simply adding more dollars
    and more billing codes to the existing system will not address the
    challenge of fragmentation; rather, it will exacerbate it. Adding more
    billing codes places a band-aid on the problem of primary care
    compensation--namely, that it is a fee-for-service system operating in
    a health-care environment that is increasingly fast-paced, technology
    dependent, subspecialized, and complex. Instead, the system must be
    reimagined with a new type of compensation altogether to account for
    the rapidly changing demands of modern care delivery for patients with
    chronic disease. Hybrid payments offer a promising approach to increase
    financial stability and reverse fragmentation and administrative burden
    ---------------------------------------------------------------------------
    created by ``ticky tack'' codes.

        Question. As part of the Merit-based Incentive Payment System
    (MIPS), physicians must be compliant in promoting interoperability as
    part of their reimbursement, which helps to facilitate the sharing of
    data between various providers.

        I have long been an advocate for health IT initiatives that can
    improve efficiencies and reduce costs in the health-care system, and I
    believe that sharing information between providers through an
    interoperable network has immense upside, so long as there are
    safeguards to protect patient privacy and ensure taxpayer funds are
    spent appropriately.

        However, there continue to be challenges to physicians meeting
    interoperability metrics, like information blocking for example in
    which an individual or entity impedes the delivery or utilization of an
    electronic health record, making interoperability impossible.

        In your view, how have practices been impacted by information
    blocking?

        Are you aware of instances in which the timeliness or quality of
    the care physicians are able to provide patients has been impacted by a
    limited ability or complete inability to access electronic health
    records?

        Furthermore, beyond information blocking, what other challenges
    persist in physicians accessing patients' health information
    electronically despite the billions of dollars spent to implement
    electronic health IT and interoperability?

        Answer. The 21st Century Cures Act, enacted in 2016, had an
    important component to improve the exchange of electronic health
    information by promoting interoperability, preventing information
    blocking, and enhancing the usability, accessibility, privacy, and
    security of health information technology.\40\ Yet, interoperability
    remains a challenge in health care, impacting the efficiency and
    quality of care. A recent observational study revealed a significant,
    positive, and cyclic relationship among three capabilities of health
    information exchange, interoperability, and medication reconciliation,
    suggesting that a decline in one could lead to declines in the others,
    highlighting the need for policies to address these gaps to ensure
    improved medication reconciliation and overall patient safety.\41\
    Policy measures targeting key elements of high-functioning EHRs, like
    interoperability, could have broad impacts on other system
    capabilities.
    ---------------------------------------------------------------------------
        \40\ The Office of the National Coordinator for Health Information
    Technology (ONC)'s Cures Act Final Rule. Federal Register as 85 FR
    25642, May 1, 2020.
        \41\ Gerald E, Herrin J, and Horwitz LI. An Observational Study of
    the Relationship Between Meaningful Use-Based Electronic Health
    Information Exchange, Interoperability, and Medication Reconciliation
    Capabilities. Medicine 96.41 (2017): e8274.

        Hindered access to electronic health records leads to delays in
    patient care while limiting a physician's ability to make timely
    informed decisions. However, the expense of implementing EHRs continues
    to be a significant obstacle to their adoption. According to the
    Michigan Center for Effective IT Adoption, initial and ongoing annual
    costs for EHR implementation can vary from $15,000 to $70,000 per
    provider, influenced by whether the deployment is server-based or web-
    based.\42\
    ---------------------------------------------------------------------------
        \42\ Reisman M. EHRs: The Challenge of Making Electronic Data
    Usable and Interoperable. Pharmacy and Therapeutics 42.9 (2017): 572.

                                     ______

                Questions Submitted by Hon. Robert P. Casey, Jr.
        Question. In your testimony, you noted that Medicare spends an
    estimated 4 percent of its total spending on primary care, which is
    about half of what other developed countries spend. You also noted,
    more than two-thirds of the Medicare population is diagnosed with two
    or more chronic conditions, and 15 percent of the Medicare population
    has six or more conditions.

        Can you expand on why increased and more functional investments in
    primary care could result in better outcomes for patients, especially
    for older adults? How is this likely to result in long-term costs
    savings?

        Answer. Increased and more functional investments in primary care
    could result in better outcomes for patients by focusing on prevention
    to keep them healthy and out of the hospital. Any effort to improve
    chronic disease care will require a change to the way health care is
    delivered, a different ``model of care'' to address fragmentation. It
    will require physician groups to be able to invest in new capabilities;
    use technologies like telehealth when they are safe, efficient, and
    effective; and expand the role of staff practices, including care
    coordinators and case managers. For example, there is a growing
    workforce of nurse practitioners in primary care who help bolster
    access and improve care coordination, demonstrating successful care
    model shifts. A crucial element to enable a new model of care, however,
    is substantial change to physician payment. Simply adding more dollars
    to the current system is unlikely to address the chronic care crisis in
    Medicare. Instead, complete care redesign is needed.

        A natural place to start is to invest more in primary care,
    empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
    patient's care team. Robust primary care has consistently demonstrated
    an improvement in population health and reduction in health
    disparities.\43\ Despite this, the United States systemically
    underinvests in primary care. Expenditure on primary care in the U.S.
    has declined over the past decade, ranging from 6.2 percent in 2013 to
    4.6 percent in 2020 across all insurance types. Medicare spends an
    estimated 4 percent of its total spending on primary
    care,\44\, \45\, \46\ about $15 billion per year,
    which is half that of many other developed countries.\47\ In contrast,
    we spend more on inpatient care and hospitalizations than other
    nations. Within the U.S., primary care is systematically underinvested
    relative to other specialties,\48\, \49\ despite the fact
    that PCPs play the most central role in a patient's health and face the
    cognitively and logistically complex task of care coordination and
    integration. Procedural specialties are compensated significantly more
    than primary care and other office-based specialties.\50\,
    \51\, \52\ Changing fee schedule weights alone will not fix
    this; studies demonstrated that a recent upweighting of reimbursement
    for office visits led to only a 2 percent decrease in the Medicare
    payment gap between primary care and specialty physicians (from a gap
    of $40,259.80 to one of $39,434.70).\53\
    ---------------------------------------------------------------------------
        \43\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \44\ New ``Scorecard'' Finds Primary Care Funding and Physician
    Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
    https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
    scorecard.html.
        \45\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \46\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
    1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
    8747.
        \47\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
    health-systems/primary-care.htm.
        \48\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
    980. doi:10.1001/jamainternmed.2018.8747v.
        \49\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
    and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
    to Achieve Payment Equity Among Specialties, Expand the Supply of
    Primary Care Physicians, and Improve the Value of Care for
    Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
    Systems Inc.
        \50\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
    Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
    319:835-41.
        \51\ Katz S, Melmed G. How Relative Value Units Undervalue the
    Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
    Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
        \52\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
    Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
    20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
        \53\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
    of Evaluation and Management Payment Policy Changes with Medicare
    Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
    doi:10.1001/jama.2023.0879.

        Beyond mobilizing more dollars into primary care, we need to enable
    PCPs to invest in new capabilities and grant them more flexibility. One
    potential path would be to provide PCPs with consistent per-beneficiary
    per-month (PBPM) payments in addition to certain fee-for-service
    payments.\54\ These PBPM payments would be designed to cover the
    estimated 25 percent of PCP activities that are not currently captured
    in the Medicare Physician Fee Schedule, such as care coordination,
    communication with other providers, addressing social determinants of
    health, and improving patient and caregiver health literacy. This would
    balance the goals of preserving access through FFS payments while
    enabling PCPs to practice more patient-centered, rather than visit-
    centered, care. Ultimately, it would unshackle PCPs from a system that
    tries to capture every activity across thousands of codes. PBPM
    payments enable PCPs to invest in sustainable practice infrastructure
    transformation such as hiring case managers and care coordinators or
    integrating technology and team-based care. This care model redesign is
    of particular importance for improving the health of patients with
    multiple chronic conditions while reducing wasteful administrative
    complexity.
    ---------------------------------------------------------------------------
        \54\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
    Implementing a primary care hybrid payment model in Medicare. Health
    Affairs Scholar. 2023 Aug;1(2):qxad024.

        Hybrid primary care payments cannot be implemented at scale without
    congressional action. The Centers for Medicare and Medicaid Services
    (CMS) have conducted several demonstration projects implementing hybrid
    payments (e.g., Comprehensive Primary Care Plus). It also has the
    authority to--and should--implement hybrid payments in the MSSP \55\
    the largest accountable care program in Medicare. However, moving past
    demonstrations to impact Medicare beneficiaries nationwide will require
    congressional action to grant CMS the appropriate authority.
    ---------------------------------------------------------------------------
        \55\ Commonwealth Fund. Response to Request for Information on HHS
    Initiative to Strengthen Primary Health Care from the Office of the
    Assistant Secretary for Health, Department of Health and Human
    Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
    TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20Care
    %20RFI_7.29.22.pdf.

        The evidence for hybrid payments is promising. Blue Cross Blue
    Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
    conducted what is perhaps the most rigorous test of hybrid payments for
    primary care to date in its Population-based Payments for Primary Care
    (3PC) model. The 3PC model is a hybrid model that shifted the majority
    of payments to PCPs to a risk-adjusted per-member per-month payment,
    ---------------------------------------------------------------------------
    while continuing to pay some services as FFS.

        The transformative elements of HMSA's 3PC model relate to its large
    market share; across its commercial, Medicare Advantage, and Managed
    Medicaid lines of business, HMSA retains large shares of patients and
    revenue for most of its PCPs. The model led to marked improvements in
    quality, greater use of telehealth that predated the COVID-19 pandemic,
    and fewer low-value imaging tests.\56\ This included increased rates of
    cost-effective prevention such as blood pressure control among patients
    with diabetes (2.7 percent differential increase), as well as greater
    cost-saving care such as a 5.5-percent differential increase in advance
    care planning (Exhibit 2).\57\ In fact, unlike other States where
    primary care practice finances were massively disrupted by the COVID-19
    pandemic, practices in Hawaii were protected financially, as PCPs were
    well equipped to care for patients effectively in a remote fashion
    because they had already made such infrastructure investments. The
    experience and transformative successes in Hawaii underscore the
    stability and ability to invest that hybrid payments can impart to
    primary care practices.
    ---------------------------------------------------------------------------
        \56\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
    Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
    S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
    Navathe AS. Changes in Outpatient Imaging Utilization and Spending
    Under a New Population-Based Primary Care Payment Model. J Am Coll
    Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
    j.jacr.2019.08.013. PMID: 31918865.
        \57\ Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel
    A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi
    M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Stollar M, Tom J, Gold M,
    Volpp KG. Association Between the Implementation of a Population-Based
    Primary Care Payment System and Achievement on Quality Measures in
    Hawaii. JAMA. 2019 Jul 2;322(1):57-68. doi: 10.1001/jama.2019.8113.

        Beyond private payers in Hawaii, CMS has been testing ``advanced
    primary care models'' at a national level using hybrid payments in
    Medicare for over a decade with promising ``leading indicator''
    results. These models led to fewer emergency department visits and
    hospitalizations, while producing modest gains in chronic disease
    management and prevention. In Comprehensive Primary Care (CPC, 2012-
    2016), hospitalizations and emergency department visits increased by 2
    percent less among participating practices.\58\ This represented a
    statistically significant relative reduction of 8,150 hospitalizations
    and 15,472 outpatient emergency department (ED) visits over the 4 years
    of the program. Importantly, practices with greater access to resources
    or more experience with care delivery transformation were more likely
    to reduce growth in expenditures (2 percent). This highlights the
    importance of providing practices with resources for successful and
    sustainable transformation.
    ---------------------------------------------------------------------------
        \58\ Evaluation of the Comprehensive Primary Care Initiative:
    Fourth Evaluation Report. Mathematica. 2018 May. https://
    downloads.cms.gov/files/cmmi/CPC-initiative-fourth-annual-report.pdf.

        Comprehensive Primary Care Plus (CPC+, 2017-2021) similarly saw a
    2-percent reduction in ED visits that emerged early and persisted
    across the 5 program years.\59\ A 2-percent reduction in
    hospitalizations emerged in program years 3 and 4 and was driven by
    reductions in medical admissions, suggesting that these admissions were
    prevented by improved outpatient care. Furthermore, over the 5 years of
    the program, the percentages of beneficiaries who received all
    recommended services for diabetes increased by about 1 percentage point
    and of females who received breast cancer screening increased by about
    1 percentage point. CPC+ had more favorable effects among concurrent
    MSSP participants, again suggesting that practices can build experience
    with care transformation with time and proper investment. These
    demonstrations suggest that transforming primary care payment can have
    important implications for beneficiaries with multiple chronic
    conditions, such as decreasing emergency department visits and
    hospitalizations while improving the delivery of robust well-integrated
    and well-coordinated primary care.
    ---------------------------------------------------------------------------
        \59\ Independent Evaluation of Comprehensive Primary Care Plus
    (CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
    www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
    annual-eval-report.

        Another approach would be to continue expansion of alternative
    payment models (APMs), which increase accountability for cost and
    quality outcomes onto providers, shifting provider focus to value. This
    will require continued support for the CMS Innovation Center. There is
    some evidence that APMs can improve care for beneficiaries with both
    high and low burdens of chronic disease. A great example has been the
    ---------------------------------------------------------------------------
    Accountable Care Organization (ACO) model.

        Question. Your testimony highlighted how fractured our current
    health-care system is and demonstrated that patients, especially those
    with chronic conditions, spend a lot of time trying to navigate that
    system. We also know that individuals who are dually eligible for
    Medicare and Medicaid often experience even more fragmented care due to
    poor care coordination. Additionally, average Medicare spending is
    higher for dual-eligibles across all services.

        How could changes to how primary care services are delivered and
    paid benefit dually eligible beneficiaries?

        Answer. Dual-eligible beneficiaries face a disproportionately high
    burden of chronic conditions compared to non-dual Medicare
    enrollees.\60\ As a result, they seek a higher volume of specialty
    care. Therefore, they would get an outsized benefit from improvements
    in coordination.
    ---------------------------------------------------------------------------
        \60\ Kasper J, Watts MO, Lyons B. Chronic Disease and Co-Morbidity
    Among Dual Eligibles: Implications for Patterns of Medicaid and
    Medicare Service Use and Spending. Kaiser Family Foundation, 2010.
    https://www.kff.org/wp-content/uploads/2013/01/8081.pdf.

        Question. Today's patients navigate a complex health system, while
    also facing the complexities of their own lives. We need a health
    workforce that can meet people where they are and address their
    specific barriers to good health. Community health workers have long
    filled this need by providing health-care navigation and social support
    in diverse communities across the Nation. They are versatile problem
    solvers who take the time to understand each client's situation and
    help restore them to their best possible health. But despite the
    significant value they bring to our health system, community health
    worker programs often rely on a patchwork of funding that comes and
    goes. In your testimony, you discussed how primary care practices can
    improve care for patients with multiple chronic conditions by hiring
    ---------------------------------------------------------------------------
    community health workers.

        What are some barriers primary care providers currently face in
    hiring and sustaining these workers? How could a shift in payment
    models decrease these barriers?

        Answer. CHWs can significantly improve the outcomes of their
    patients, especially those with multiple chronic conditions.\61\
    Barriers that PCPs currently face in hiring CHWs are the lack of
    sustainable funding to support these staff members. Medicare began
    reimbursing for CHW activities effective January 1, 2024, but this
    merely added codes to the existing FFS system to allow CHWs to bill for
    their services. Unfortunately, this will be of no help to practices who
    do not have the capital to invest in these team members in the first
    place. primary care practices do not have the capital to invest in
    these team members. A shift in payment models to hybrid payments could
    decrease these barriers by providing practices with a steady flow of
    population-based payments to support hiring lay health workers.
    ---------------------------------------------------------------------------
        \61\ Knowles M, Crowley AP, Vasan A, Kangovi S. Community Health
    Worker Integration with and Effectiveness in Health Care and Public
    Health in the United States. Annu Rev Public Health. 2023 Apr 3;44:363-
    381. doi: 10.1146/annurev-publhealth-071521-031648. PMID: 37010928.

        As of 2022, 19 States do not allow Medicaid payment for services
    provided by Community Health Workers (CHWs).\62\ Without this funding,
    CHWs must be funded through other means, often times by grants or
    community organizations.\63\ This lack of funding is a barrier to
    utilizing these workers in those States. Value-based care models which
    incentivize providers to keep costs low through preventative care and
    practices will likely find value in hiring and sustaining these
    workers. A study by Penn's own IMPaCT program found that for every $1
    invested in a CHW program $2.47 of savings were generated.\64\
    Additional programs like this could be implemented by providers
    searching for savings through better care coordination.
    ---------------------------------------------------------------------------
        \62\ Sweta Haldar and Elizabeth Hinton. State Policies for
    Expanding Medicaid Coverage of Community Health Worker (CHW) Services,
    KFF, Jan 23, 2023. https://www.kff.org/medicaid/issue-brief/state-
    policies-for-expanding-medicaid-coverage-of-community-health-worker-
    chw-services/.
        \63\ Ibid.
        \64\ Kangovi S, Mitra N, Grande D, Long JA, and Asch DA. Evidence-
    Based Community Health Worker Program Addresses Unmet Social Needs and
    Generates Positive Return on Investment. Health Affairs 2020 39:2, 207-
    213.

        Question. Your testimonies and discussions at the hearing noted
    that the Merit-based Incentive Payment System (MIPS) is cumbersome for
    clinicians. The intention of MIPS is to foster performance
    improvements, leading to better outcomes for patients. You all
    mentioned that MIPS is burdensome and may not accurately capture the
    ---------------------------------------------------------------------------
    quality of care physicians provide.

        Are there policy proposals that could be implemented to make MIPS
    more accurate and less burdensome?

        Answer. Currently, MIPS requires reporting of quality metrics that
    may be out of touch with what providers find best for their patients or
    are excessively burdensome to monitor and report. While monitoring
    quality is important for patient safety and delivering high-quality
    care, the current approach designed by MIPS may create costs that
    outweigh its benefits. One study in JAMA Health Forum of 30 physician
    practice leaders across the U.S. found that an average of $12,811 per
    physician was spent to participate in MIPS in 2019, and clinicians and
    administrators spent more than 200 hours per physician on MIPS-related
    activities.\65\ In its 2018 report to Congress, the Medicare Payment
    Advisory Commission (MedPAC) recommended eliminating MIPS and replacing
    it with a more streamlined quality system that is synergistic and
    supportive of physician effort.\66\ Our own research highlights that
    MIPS may disproportionately negatively impact safety-net and rural
    providers.\67\
    ---------------------------------------------------------------------------
        \65\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino
    LP. Time and Financial Costs for Physician Practices to Participate in
    the Medicare Merit-based Incentive Payment System: A Qualitative Study.
    JAMA Health Forum. 2021 May 14;2(5):e210527. doi: 10.1001/
    jamahealthforum.2021.0527. PMID: 35977308; PMCID: PMC8796897.
        \66\ The Medicare Payment Advisory Commission. Moving beyond the
    Merit-based Incentive Payment System, chapter 15. Report to Congress,
    2018. Accessed April 24, 2024. https://www.medpac.gov/wp-content/
    uploads/import_data/scrape_files/docs/default-source/reports/
    mar18_medpac_ch15_sec.pdf.
        \67\ Liao JM, Navathe AS. Does the Merit-based Incentive Payment
    System disproportionately affect safety-net practices? JAMA Health
    Forum. 2020;1(5):e200452. doi: 10.1001/jamahealth
    forum.2020.0452.

        Beyond reforming MIPS, Congress and HHS may have statutory
    authority to reform physician payment in other ways, including by
    establishing hybrid payments. Congress should clarify CMS's authority
    to broadly implement population-based payment through the Medicare
    Physician Fee Schedule (MPFS). In the meantime, MSSP offers an
    immediate opportunity for this to occur. Section 3022 of the ACA
    established that providers participating in an MSSP ACO are reimbursed
    according to standard Parts A and B payments, including the MPFS.
    However, according to Berenson et al., 2023, any provision of Medicare
    title 18 of the Social Security Act can be waived to carry out the MSSP
    under statutory waiver authority. This statute specifically mentions
    the possibility of implementing new payment methods.\68\
    ---------------------------------------------------------------------------
        \68\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
    implementing a primary care hybrid payment model in Medicare, Health
    Affairs Scholar, 1(2). August 2023. https://doi.org/10.1093/haschl/
    qxad024.

        MedPAC suggested in 2018 that Congress eliminate MIPS to instead
    attempt an alternative approach to incentivize high-quality care for
    traditional Medicare beneficiaries, due to the belief that within it's
    current structure, MIPS will not achieve such a goal. believes that
    MIPS, as currently structured, will not achieve this goal.\69\
    ---------------------------------------------------------------------------
        \69\ MedPAC, March 2018 Report to the Congress: Medicare Payment
    Policy. https://www.medpac.gov/document/http-www-medpac-gov-docs-
    default-source-reports-mar18_medpac_
    entirereport_sec_rev_0518-pdf/.

        Payment policy can help to rebalance quality versus quantity
    incentive for physicians and provider organization motivation. There is
    potential through policy reform to support clinicians' ``intrinsic
    motivation'' by encouraging systematic feedback provided to clinicians
    tied with opportunities for collaboration to improve care; CMS has
    programs such as Partnership for Patients and Conditions of
    Participation that demonstrate existing models that support providers
    to improve quality while avoiding substandard care for
    beneficiaries.\70\
    ---------------------------------------------------------------------------
        \70\ Berenson RA, Rice T. Beyond Measurement and Reward: Methods of
    Motivating Quality Improvement and Accountability. Health Serv Res.
    2015 Dec;50 Suppl 2(Suppl 2):2155-86. doi: 10.1111/1475-6773.12413.
    Epub 2015 Nov 10. PMID: 26555346; PMCID: PMC5114714.

                                     ______

                 Question Submitted by Hon. Sheldon Whitehouse
        Question. I am working on a bill to relieve providers excelling in
    the Medicare Shared Savings Program (MSSP), from prior authorization
    (PA) requirements in MA. The bill rewards providers in Accountable Care
    Organizations (ACOs) that generate savings for Medicare by granting an
    exemption from PA requirements for their MA beneficiaries. If an
    insurer believes there is a rationale for maintaining PA in such
    instances, this bill would require them to seek prior approval from the
    Centers for Medicare and Medicaid Services (CMS). I would welcome your
    thoughts and comments on this idea.

        Answer. Prior authorization is used by insurers to constrain costs
    created by potentially unnecessary or low-value treatment. However,
    providers participating in ACOs should already face incentives to keep
    costs low and would therefore only be using expensive medications if
    they were truly beneficial for patient care. Consequently, prior
    authorization should be less necessary among ACOs who are succeeding in
    MSSP, because they would already be containing costs through the
    incentives created by accountable care arrangements. PA would only add
    to their administrative burden, likely raising costs rather than saving
    them because physicians should already be optimizing prescriptions due
    to ACO incentives.

        One national survey of 49 ACOs found that they accomplish this by
    involving pharmacists directly in care, expanding the use of generics,
    and educating patients on therapeutic alternatives.\71\ Another survey
    of 46 ACOs identified strengths including the ability to integrate
    medical and pharmaceutical data into a single database and maintaining
    a formulary that encourages generic use when appropriate.\72\ However,
    this study found that ACOs will need more support to quantify the
    magnitude of cost offsets and therefore demonstrate the value of
    appropriate medication, use as well as create protocols to avoid
    medication duplication and polypharmacy. Regardless, the most
    successful ACOs are likely those who are most prepared to assume
    accountability for medication costs and optimize prescription value
    without the added burden of PA. Therefore, a bill limiting PA for top
    performers in MSSP could relieve providers of this additional
    administrative work and allow them to focus more on caring for their
    patients.
    ---------------------------------------------------------------------------
        \71\ Wilks C, Krisle E, Westrich K, Lunner K, Muhlestein D, Dubois
    R. Optimization of Medication Use at Accountable Care Organizations. J
    Manag Care Spec Pharm. 2017 Oct;23(10):1054-1064. doi: 10.18553/
    jmcp.2017.23.10.1054. PMID: 28944730; PMCID: PMC10397795.
        \72\ Dubois RW, Feldman M, Lustig A, Kotzbauer G, Penso J, Pope SD,
    Westrich KD. Are ACOs Ready to be Accountable for Medication Use? J
    Manag Care Spec Pharm. 2020 Nov;26(11):1446-1451. doi: 10.18553/
    jmcp.2020.26.11.1446. PMID: 33119446; PMCID: PMC10390926.

                                     ______

                    Question Submitted by Hon. Maggie Hassan
        Question. I am working with my colleagues on the Finance Committee
    to address discrepancies in Medicare reimbursement that disadvantage
    independent doctors. Older adults, and the Medicare program, often pay
    a huge markup for basic services if their provider's office is owned by
    a hospital.

        For example, for a routine allergy test, a patient on traditional
    Medicare will pay around $40 at an independent doctor's office, but
    would pay almost $200 if that office is owned by a hospital, even if
    the actual hospital is miles away. Similarly, the Medicare program
    would pay the doctor around $170 for the allergy test, but would pay a
    hospital-owned practice more than $700 for the same exact service.

        How do these imbalanced payments hold the Medicare program back
    from investing in high-quality, office-based care?

        Answer. In 2021 and again more recently as of June of 2023, MedPAC
    recommended that Congress adopt more site-neutral payment policies for
    certain outpatient services to redistribute these dollars in a more
    balanced fashion.\73\ The Commission recommended more closely aligning
    Medicare payment rates across ambulatory settings--hospital outpatient
    departments, ambulatory surgical centers, and freestanding physician
    offices--for selected services. These imbalanced payments hold the
    Medicare program back from investing in high quality, office-based care
    by setting up wrong incentives, leading to arbitrage as opposed to
    prioritizing access.
    ---------------------------------------------------------------------------
        \73\ MedPAC, June 2023 Report to the Congress: Medicare Payment
    Policy. https://www.
    medpac.gov/document/june-2023-report-to-the-congress-medicare-and-the-
    health-care-delivery-system/.

                                     ______

                  Questions Submitted by Hon. Marsha Blackburn
        Question. As CMS begins implementing the Inflation Reduction Act's
    price-setting scheme, I am concerned about the impact on patient access
    for Part B drugs subjected to price controls beginning in 2028. As
    currently written, CMS will reimburse providers for negotiated Part B
    drugs based on the Maximum Fair Price plus 6 percent rather than the
    standard Average Sales Price (ASP) plus 6 percent. In the words of the
    Community Oncology Alliance, this change will ``drastically cut
    reimbursement for Part B drugs, making it increasingly challenging for
    community oncology practices to administer drugs and keep their doors
    open.'' An analysis conducted by Avalere Health found that the IRA
    would lead to a minimum 49.5-percent Part B reimbursement cut for
    providers.

        Additionally, depending on how CMS implements IRA price controls on
    Part B drugs, these payment cuts in Medicare could also affect the ASP
    of the drug, which is often used by private insurance companies for
    reimbursement to providers.

        Have you examined the potential impact that IRA price controls for
    Part B drugs, if allowed to proceed in 2028, would have on your
    providers, practices, and the Medicare patients you serve?

        Have you assessed the impact it could have on quality of care and
    patient outcomes?

        Answer. This is a new focus area for our research center, and is an
    important topic. We hope to assess this in a more robust fashion to be
    able to report back in the future. Thank you for highlighting this
    relevant and emerging topic area.

        Question. Medicare physician pay and its impact on patient access
    to care remains a significant issue for my constituents. Adjusted for
    inflation in practice costs, Medicare physician pay plummeted 29
    percent from 2001 to 2024. Although Congress did act in the March 8th
    government funding package to reduce the 3.37-percent cut that went
    into effect on January 1, 2024, by an additional 1.68 percent, the 29-
    percent reduction in Medicare payments over the last 2 decades is
    reflective of this most recent congressional action. Plus, physicians
    are now set up for another steep payment cut at the end of this year.

        Nonpartisan government stakeholders recognize the damaging impact
    these cumulative payment cuts have on patient access to care. Multiple
    Medicare trustee reports stated that ``absent a change in the delivery
    system or level of update by subsequent legislation, the trustees
    expect access to Medicare-participating physicians to become a
    significant issue in the long term.''

        Can you discuss some of the impacts of this pressing financial
    instability on physician practices, including consolidation, difficulty
    retaining staff, and trouble keeping their doors open amid rising
    costs?

        Answer. Rising costs in Medicare are in part due to a combination
    of an aging population with rising rates of chronic disease as well as
    increasing administrative and technological burden. Our health system
    in the United States invests much more in hospital and acute care than
    it does in outpatient care, a ratio opposite that of other high-income
    nations such as Denmark and Norway.\74\, \75\ As a result,
    primary care practices may find themselves underfunded and unable to
    deliver the care they aspire to provide, especially in rural and
    underserved areas.
    ---------------------------------------------------------------------------
        \74\ Denmark: Country Health Profile 2023, State of Health in the
    EU, OECD Publishing, https://doi.org/10.1787/e4f0bee3-en.
        \75\ Norway: Country Health Profile 2023, State of Health in the
    EU, OECD Publishing, https://doi.org/10.1787/256fd7cf-en.

        A fee-for-service (FFS) payment system causes PCPs to be dependent
    upon visit volume for revenue to keep their practices afloat. Shifting
    to a hybrid payment model can provide PCPs with stable, predictable
    population-based payments that can support their practices through
    fluctuations in visit volume and enable them to increase after-hours,
    virtual, or weekend care to best meet the needs of their
    population.\76\
    ---------------------------------------------------------------------------
        \76\ National Academy of Sciences, Engineering, and Medicine.
    Implementing High-Quality Primary Care Consensus Study Report, 2021.
    Accessed April 24, 2024. https://www.
    nationalacademies.org/our-work/implementing-high-quality-primary-care.

        Consolidation of primary care practices has been shown to reduce
    total patient health-care spending by 16 percent.\77\ While this
    reduction in spending is primarily driven by a 21-percent reduction in
    inpatient admissions, it is also due to a 13-
    percent reduction in primary care visits. This demonstrates how
    consolidation may decrease access to primary care. Increasing funds
    through population-based payment mechanisms may provide practices with
    the stable financial cash flow to keep their doors open, increasing
    access for Medicare patients with chronic conditions.
    ---------------------------------------------------------------------------
        \77\ Zhang J, Chen Y, Einav L, Levin J, Bhattacharya J.
    Consolidation of primary care physicians and its impact on healthcare
    utilization. Health Econ. 2021 Jun;30(6):1361-1373. doi: 10.1002/
    hec.4257.

        Of note, accounting for inflation in input costs is important, but
    we should be sure to distinguish between keeping pace with inflation
    versus adding more dollars to create better access and outcomes for
    ---------------------------------------------------------------------------
    beneficiaries.

        Question. What available mechanisms do Congress and HHS have within
    current statutory authority to help provide adequate Medicare payments
    to physicians and ensure continued patient access to care? For example,
    alleviating the administrative burden on practices through reforms to
    the Merit-based Incentive Payment System?

        Answer. Reforms to the Merit-based Incentive Payment System (MIPS)
    represent one mechanism to reduce administrative burden on practices.
    It is unclear in the current framework if MIPS can be reformed to be
    effective. Currently, MIPS requires reporting of quality metrics that
    may be out of touch with what providers find best for their patients or
    are excessively burdensome to monitor and report. While monitoring
    quality is important for patient safety and delivering high-quality
    care, the current approach designed by MIPS may create costs that
    outweigh its benefits. One study in JAMA Health Forum of 30 physician
    practice leaders across the U.S. found that an average of $12,811 per
    physician was spent to participate in MIPS in 2019, and clinicians and
    administrators spent more than 200 hours per physician on MIPS-related
    activities.\78\ In its 2018 Report to Congress, the Medicare Payment
    Advisory Commission (MedPAC) recommended eliminating MIPS and replacing
    it with a more streamlined quality system that is synergistic and
    supportive of physician effort.\79\ Our own research highlights that
    MIPS may disproportionately negatively impact safety-net and rural
    providers.\80\
    ---------------------------------------------------------------------------
        \78\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino
    LP. Time and Financial Costs for Physician Practices to Participate in
    the Medicare Merit-based Incentive Payment System: A Qualitative Study.
    JAMA Health Forum. 2021 May 14;2(5):e210527. doi: 10.1001/
    jamahealthforum.2021.0527. PMID: 35977308; PMCID: PMC8796897.
        \79\ The Medicare Payment Advisory Commission. Moving beyond the
    Merit-based Incentive Payment System, chapter 15. Report to Congress,
    2018. Accessed April 24, 2024. https://www.medpac.gov/wp-content/
    uploads/import_data/scrape_files/docs/default-source/reports/
    mar18_medpac_ch15_sec.pdf.
        \80\ Liao JM, Navathe AS. Does the Merit-based Incentive Payment
    System disproportionately affect safety-net practices? JAMA Health
    Forum. 2020;1(5):e200452. doi: 10.1001/jamahealth
    forum.2020.0452.

        Congress and HHS may also need to enable statutory authority to
    reform physician payment in other ways, including by establishing
    hybrid payments. Congress should clarify CMS's authority to broadly
    implement population-based payment through the Medicare Physician Fee
    Schedule (MPFS). In the meantime, MSSP offers an immediate opportunity
    for this to occur. Section 3022 of the ACA established that providers
    participating in an MSSP ACO are reimbursed according to standard Parts
    A and B payments, including the MPFS. However, according to Berenson et
    al. (2023), any provision of Medicare title 18 of the Social Security
    Act can be waived to carry out the MSSP under statutory waiver
    authority. This statute specifically mentions the possibility of
    implementing new payment methods.\81\
    ---------------------------------------------------------------------------
        \81\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
    Implementing a primary care hybrid payment model in Medicare, Health
    Affairs Scholar, 1(2). August 2023. https://doi.org/10.1093/haschl/
    qxad024.

        Question. Do these cuts disproportionately impact access to care in
    ---------------------------------------------------------------------------
    underserved areas?

        Answer. Reductions in Medicare payments may affect access to care
    in rural and underserved areas. Because providers are currently
    dependent on volume, they may be forced to close or be acquired when
    payment rates or visit volumes fall. Establishing a stable population-
    based payment may help rural practices invest in sustainable practice
    transformation and remain open during periods of visit instability. For
    example, a population-based payment in Hawaii enabled them to transform
    their practice to increase the provision of telehealth, improving their
    practice stability when many others faced difficulty during the COVID-
    19 pandemic.\82\
    ---------------------------------------------------------------------------
        \82\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
    Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
    S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
    Navathe AS. Changes in Outpatient Imaging Utilization and Spending
    Under a New Population-Based Primary Care Payment Model. J Am Coll
    Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
    j.jacr.2019.08.013.

        Question. Many patients have chronic heart conditions, and studies
    have shown how better cardiac care and rehabilitation after events
    reduces hospital readmissions. However, uptake for cardiac
    rehabilitation services remains low, which was affirmed by MedPAC's
    March 2024 report showing 1-3 percent across Medicare Advantage and
    ---------------------------------------------------------------------------
    Special Needs Plans, and 5-8 percent in Medicare fee-for-service.

        Can we leverage more strategies focused on adherence and prevention
    to reduce health-care costs, such as the home care model used in
    Sustainable Cardiopulmonary Rehabilitation Services in the Home Act?

        Answer. Some evidence (although limited) suggests an association
    between increased cost sharing and more inpatient care and less
    outpatient care; studies found in evaluating reducing or eliminating
    cost-sharing total costs did not rise.\83\ The Medicare Advantage
    Value-Based Insurance Design (VBID) Model aims to remove certain
    obstacles to optimal health and health care. Examples include offering
    patients supplemental benefits such as lower costs for prescription
    drugs; grocery assistance to help ensure their unmet medical needs and
    nutrition needs are met; transportation services to make sure they can
    attend medical appointments; and support managing chronic health
    conditions.\84\
    ---------------------------------------------------------------------------
        \83\ Fusco N, Sils B, Graff JS, et al. Cost-sharing and adherence,
    clinical outcomes, health care utilization, and costs: A systematic
    literature review. Journal of Managed Care & Specialty Pharmacy 2023
    29:1, 4-16.
        \84\ CMS, Medicare Advantage Value-Based Insurance Design Model.
    https://www.cms.gov/priorities/innovation/innovation-models/vbid.

        Behavioral economics serve to provide insight within developing
    effective incentives for physicians to deliver high-value care, through
    structured incentives with thoughtful design; several principles of
    behavioral economics, such as inertia, loss aversion, choice overload,
    and relative social ranking can be applied to physician incentive
    programs.\85\
    ---------------------------------------------------------------------------
        \85\ Emanuel EJ, Ubel UA, Kessler JB, et al. Using Behavioral
    Economics to Design Physician Incentives That Deliver High-Value Care.
    Annals of Internal Medicine, November 2015. https://doi.org/10.7326/
    M15-1330.

        Question. In Tennessee, our hospital emergency department staff
    grapple with the fourth highest rate of ED utilization in the country.
    It shouldn't be this way. For seniors on Medicare and for all
    Tennesseans, we know an ounce of prevention is worth a pound of care. A
    2022 report by AAFP's Robert Graham Center and Primary Care
    Collaborative provides evidence that access to a usual source of care
    ---------------------------------------------------------------------------
    is associated with fewer ED visits and more preventive services.

        What are your recommendations for reforming Medicare payment to
    connect every Tennessee senior to primary care and prevention--giving
    our EDs some relief and ultimately improving patient health while
    reducing costs?

        Answer. A natural place to start is to invest more in primary care,
    empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
    patient's care team. Robust primary care has consistently demonstrated
    an improvement in population health and reduction in health
    disparities.\86\ Despite this, the United States systemically
    underinvests in primary care. Expenditure on primary care in the U.S.
    has declined over the past decade, ranging from 6.2 percent in 2013 to
    4.6 percent in 2020 across all insurance types. Medicare spends an
    estimated 4 percent of its total spending on primary
    care,\87\, \88\, \89\ about $15 billion per year,
    which is half that of many other developed countries.\90\ In contrast,
    we spend more on inpatient care and hospitalizations than other
    nations. Within the U.S., primary care is systematically underinvested
    relative to other specialties,\91\, \92\ despite the fact
    that PCPs play the most central role in a patient's health and face the
    cognitively and logistically complex task of care coordination and
    integration. Procedural specialties are compensated significantly more
    than primary care and other office-based specialties.\93\,
    \94\, \95\ Changing fee schedule weights alone will not fix
    this; studies demonstrated that a recent upweighting of reimbursement
    for office visits led to only a 2-percent decrease in the Medicare
    payment gap between primary care and specialty physicians (from a gap
    of $40,259.80 to one of $39,434.70).\96\
    ---------------------------------------------------------------------------
        \86\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \87\ New ``Scorecard'' Finds Primary Care Funding and Physician
    Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
    https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
    scorecard.html.
        \88\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
    Center. The Health of US Primary Care: A Baseline Scorecard Tracking
    Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
    https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
    Scorecard_final_V2.pdf.
        \89\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
    1;179(7):977-980. doi: 10.1001/jamainternmed.
    2018.8747.
        \90\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
    health-systems/primary-care.htm.
        \91\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
    Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
    980. doi:10.1001/jamainternmed.2018.8747v.
        \92\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
    and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
    to Achieve Payment Equity Among Specialties, Expand the Supply of
    Primary Care Physicians, and Improve the Value of Care for
    Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
    Systems Inc.
        \93\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
    Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
    319:835-41.
        \94\ Katz S, Melmed G. How Relative Value Units Undervalue the
    Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
    Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
        \95\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
    Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
    20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
        \96\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
    of Evaluation and Management Payment Policy Changes with Medicare
    Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
    doi:10.1001/jama.2023.0879.

        Beyond mobilizing more dollars into primary care, we need to enable
    PCPs to invest in new capabilities and grant them more flexibility. One
    potential path would be to provide PCPs with consistent per-beneficiary
    per-month (PBPM) payments in addition to certain fee-for-service
    payments.\97\ These PBPM payments would be designed to cover the
    estimated 25 percent of PCP activities that are not currently captured
    in the Medicare Physician Fee Schedule, such as care coordination,
    communication with other providers, addressing social determinants of
    health, and improving patient and caregiver health literacy. This would
    balance the goals of preserving access through FFS payments while
    enabling PCPs to practice more patient-centered, rather than visit-
    centered, care. Ultimately, it would unshackle PCPs from a system that
    tries to capture every activity across thousands of codes. PBPM
    payments enable PCPs to invest in sustainable practice infrastructure
    transformation such as hiring case managers and care coordinators or
    integrating technology and team-based care. This care model redesign is
    of particular importance for improving the health of patients with
    multiple chronic conditions while reducing wasteful administrative
    complexity.
    ---------------------------------------------------------------------------
        \97\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
    Implementing a primary care hybrid payment model in Medicare. Health
    Affairs Scholar. 2023 Aug;1(2):qxad024.

        Hybrid primary care payments cannot be implemented at scale without
    congressional action. The Centers for Medicare and Medicaid Services
    (CMS) have conducted several demonstration projects implementing hybrid
    payments (e.g., Comprehensive Primary Care Plus). It also has the
    authority to--and should--implement hybrid payments in the Medicare
    Shared Savings Program (MSSP),\98\ the largest accountable care program
    in Medicare. However, moving past demonstrations to impact Medicare
    beneficiaries nationwide will require Congressional action to grant CMS
    the appropriate authority.
    ---------------------------------------------------------------------------
        \98\ Commonwealth Fund. Response to Request for Information on HHS
    Initiative to Strengthen Primary Health Care from the Office of the
    Assistant Secretary for Health, Department of Health and Human
    Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
    TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20
    Care%20RFI_7.29.22.pdf.

        The evidence for hybrid payments is promising. Blue Cross Blue
    Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
    conducted what is perhaps the most rigorous test of hybrid payments for
    primary care to date in its Population-based Payments for Primary Care
    (3PC) model. The 3PC model is a hybrid model that shifted the majority
    of payments to PCPs to a risk-adjusted per-member per-month payment,
    while continuing to pay some services as FFS; underlining a value-based
    payment (VBP) approach and it's proven success. Continued VBP can
    ---------------------------------------------------------------------------
    incentivize additional investment in primary care.

                                     ______

     Prepared Statement of Patricia L. Turner, M.D., MBA, FACS, Executive
       Director and Chief Executive Officer, American College of Surgeons
        The American College of Surgeons (ACS) thanks the Senate Finance
    Committee for convening a hearing on the challenges of the Medicare
    physician payment system. The ACS remains committed to improving the
    care for all surgical patients, including those living with chronic
    conditions, and to ensuring that Medicare beneficiaries receive the
    highest quality of care. We appreciate the opportunity to describe some
    of the recent work the ACS has undertaken in improving surgical quality
    and value. We hope to continue partnering with Congress on potential
    reforms to the current system to ensure that improving care and access
    for the surgical patient stays at the forefront.

        The ACS and our more than 90,000 members recognize the impact that
    chronic conditions can have on surgical patient outcomes. These
    conditions have a distinct impact on the finances of Federal health
    programs and create additional challenges for providing high-quality
    care. In the United States, more than 130 million adults suffer from at
    least one chronic condition.\1\ These patients often require additional
    preparations or more intensive post-acute care after surgery is
    performed. ACS is focused on improving the quality of care provided and
    achieving the optimal outcome for all our patients.
    ---------------------------------------------------------------------------
        \1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876976/.

        Our surgeon members have firsthand experience with the challenges
    posed by the lack of an inflationary update and more recently the
    continued reductions to fee-for-service Medicare payments. Centers for
    Medicare and Medicaid Services (CMS) policies have resulted in broad
    and arbitrary cuts. These reductions are often the unintended
    consequence of statutory budget neutrality requirements for the
    Physician Fee Schedule. One aspect of budget neutrality falls on the
    Medicare Physician Fee Schedule conversion factor. These conversion
    factor reductions create a strain on physicians working towards value-
    based care and fail to incentivize quality or care coordination. This
    results in the Medicare program taking resources away from certain
    physician specialties in order to finance priorities in other areas. A
    payment model designed in such a way that different specialties are
    pitted against one another is counterproductive, since all specialties
    are doing their best to provide quality care to their patients with
    ever-scarcer resources. Since 2001, physicians have seen their Medicare
    physician payments decrease by 13 percent in real terms between 2001
    and 2024 before indexing for inflation. In addition to these cuts, the
    impact of inflation has raised the overall cost to provide care as
    costs for rent, equipment, staffing and utilities have increased.
    Surgeons and other physicians have also seen an increase in financial
    pressures to meet new bureaucratic barriers such as increased use of
    ---------------------------------------------------------------------------
    prior authorization in Medicare Advantage.

        Since the enactment of the Medicare Access and CHIP Reauthorization
    Act of 2015 (MACRA), ACS has made significant investments to translate
    what we have learned about improving quality of care and outcomes into
    proposals to increase value for surgical patients. Our efforts have
    included:

              The submission and approval of one of the first Advanced
            Alternative Payment Model (APM) proposals to the MACRA-enacted
            Physician-Focused Payment Model Technical Advisory Committee,
            or PTAC, which is the ``first stop'' for adoption of a
            stakeholder-developed APM;
              Ongoing work to increase transparency in pricing through
            standardization of episode definitions; and
              Proposing novel quality measures that incentivize evidence-
            based, team-based care organized around the geriatric hospital
            patient.

        Yet today, many physicians still struggle with the same barriers to
    improving outcomes and transitioning to modern payment systems that
    they did a decade ago:

              Surgeons are faced with a Medicare Physician Fee Schedule
            (PFS) conversion factor for 2024 that remains below the 1998
            level;\2\
    ---------------------------------------------------------------------------
        \2\ https://www.ama-assn.org/system/files/cf-history.pdf.
    ---------------------------------------------------------------------------
              The combination of inflation and a lack of Physician Fee
            Schedule updates to account for the increasing cost of
            providing care means that it costs more to deliver care while
            payments are declining;
              Most physicians in fee-for-service (FFS) are still evaluated
            based on measures that do not assess care delivered to their
            patients or the conditions they treat, meaning no information
            is available for improvement efforts or for patients and
            referring physicians to make care choices; and
              Surgeons wishing to move beyond FFS will find few physician-
            focused alternative payment models are available for them,
            since none of the models submitted to the PTAC have been tested
            as proposed.

        To create stability in the Medicare physician payment system,
    Congress should immediately address cuts already expected in 2025. A
    foundational step necessary to maintain access and improve quality for
    patients is the implementation of positive annual updates reflecting
    the inflation in practice costs. Under current law, and assuming no
    additional cuts result from budget neutrality or other policy
    decisions, it would take decades for the PFS conversion factor to
    return to the same amount it was in the year 2000. Over that same
    period, inflation will have significantly eroded the value of payments.
    Clearly this is not tenable.
                     stabilizing medicare physician payment
        The ACS is committed to working together with Congress to ensure
    the stability of the Medicare PFS through both short- and long-term
    policy improvements. The Medicare PFS suffers from multiple
    shortcomings that have negatively impacted the care provided to our
    patients. It is unique in its lack of a meaningful mechanism to account
    for inflation and is currently in a multiyear window until 2026 where
    any positive updates to physician payment must be legislated. Once the
    positive updates begin in 2026, current law only provides a 0.25-
    percent conversion factor update for non-APM participants and a 0.75-
    percent update for qualified Advanced APM participants, still failing
    to adequately offset the effects of inflation and account for rising
    medical and staff costs. Without congressional action, continued cuts
    will challenge physicians to provide adequate services and high-quality
    care. Additionally, without an annual update for the PFS, it is
    unlikely that future payments will keep pace with medical cost
    inflation. This concerning combination of high inflation and a lack of
    any update for expenses results in a need to deliver expected high-
    quality care while payments are rapidly declining.

        While Congress has taken action to address some of these fiscal
    challenges by mitigating part of the recent PFS cuts, Medicare payment
    continues to decline year after year. The recent 1.68-percent positive
    adjustment only partially offsets the 3.37-percent cut that went into
    effect in early 2024, and further cuts are expected in 2025. These
    yearly compounding cuts, combined with a broad lack of viable
    alternative payment models for surgeons, demonstrate that the Medicare
    payment system is broken and falling short of the goals of MACRA. As a
    starting point to create a more stable foundation for value-based care
    initiatives, ACS supports building an update into the Medicare
    Physician Fee Schedule, comparable to other Medicare payment programs,
    to account for the effects of inflation on the cost of providing care
    to seniors. This inflationary update should be separate and distinct
    from incentives for quality and from the budget-
    neutral Merit-based Incentive Payment System (MIPS) incentives.

        The impact of the lack of inflationary adjustments is further
    compounded by the overly strict nature of the budget-neutrality
    trigger. The budget-neutrality requirement in a system with no
    inflationary updates results in across-the-board cuts for any changes
    to the PFS expected to increase expenditure by as little as $20 million
    annually. This trigger amount has remained the same since its
    implementation in 1992. Updating the trigger for budget-neutrality
    adjustments would help to ensure that comparatively minor changes to
    relative values or the addition of limited new service codes do not
    always require across the board cuts. Congress, at a minimum, should
    amend 42 U.S.C. 1395w-4(c)(2)(B)(ii) to increase the current $20-
    million budget-neutrality adjustment trigger and index it for inflation
    going forward.

        Adjusting the budget-neutrality trigger is an example of a small,
    but important, concrete step Congress could take to improve the
    functioning of the current system. Without meaningful adjustments to
    account for the increased cost of staff, office space, and other
    resources, surgeons will find it increasingly difficult to continue to
    improve care and outcomes. Beyond this, it will be necessary to
    counteract the effects of inflation to help provide stability while
    Congress and the administration provide support to facilitate the
    transition to value-based payment models.

        The ACS supports building a more modern and equitable care
    environment for patients, rewarding value and innovation. Addressing
    well-documented health disparities and ensuring the availability of
    high-quality care across all settings are imperative, and medicine
    should be moving steadily toward a system that truly rewards the value
    of care provided rather than data entry that may not be relevant to the
    patients treated. This could partially be achieved through testing and
    expansion of alternative payment models developed by and for
    specialists. These models should complement primary care focused
    models, not compete with them, and could include primary care
    physicians and other specialists focused on chronic conditions in the
    fiscal attribution model and rewards to encourage care coordination.
    Congress should encourage innovation by incentivizing the testing and
    implementation of physician-developed, value-based payment models.
    Models developed by subject matter experts such as specialty societies
    will be better structured to provide and utilize timely, actionable
    data and allow physicians to improve care.
                  facilitating the transition value-based care
        The ACS believes that medicine should be moving steadily toward a
    system that truly rewards the value of care provided. APMs can
    facilitate better care and could also be used to incentivize physicians
    to practice in rural or underserved areas. Unfortunately, efforts at
    implementing an Advanced APM were hindered by a breakdown of the
    process envisioned in MACRA. Along with dozens of other groups, ACS
    developed and submitted proposals that were reviewed, revised, and
    evaluated by the PTAC. Fourteen proposals have been recommended for
    testing or implementation by the PTAC, but CMS has not tested a single
    model through the Center for Medicare and Medicaid Innovation (CMMI or
    Innovation Center) as proposed. This bottleneck has created a
    disincentive for stakeholder investment into the development of APMs,
    as witnessed by the lack of new proposals on the PTAC website since
    2020.

        The ACS-Brandeis Advanced APM proposal included shared
    accountability for cost and quality for defined episodes of surgical
    care and allowed for the entire care team, including the primary care
    physician, to work together toward shared goals. Information on the
    comprehensiveness of a quality program, along with comparable
    information on the price of that care, are prerequisites for a valid
    depiction of the value of care. The ACS has supported the development
    of standardized episode definitions to foster alignment of both price
    and quality measurement and create shared accountability for the team
    of providers. Our proposal would provide the data and incentives
    necessary to drive value improvement in specialty care. While it is our
    impression that Congress has provided the resources to CMS and the
    Innovation Center that are necessary to stand up and test PTAC
    recommended APMs, there is nothing within the law to compel CMS to try
    out new programs. This creates further barriers to those seeking to
    move to value-based care. Congress should require that at a minimum,
    some portion of the CMS Innovation Center's budget be dedicated to
    testing physician and specialist-developed APMs recommended by the
    PTAC.
                 improving macra to ensure meaningful quality
                    measurement and reduce reporting burden
        The ACS sees quality as a comprehensive program built around the
    patient, and inclusive of the entire team involved in providing care
    for patients with a given condition or diagnosis. The current model of
    individual, disconnected measures is insufficient to achieve
    coordinated, patient-centered, high-value care and provides little
    actionable information for physician improvement or patient decision-
    making when it is time to seek care. This is especially true in rural
    and underresourced areas where regional shortages in surgeons and other
    care providers can lead to reduced access and fewer choices for care.

        Most physicians in the current FFS system are currently evaluated
    on measures that do not reflect the care they deliver to patients or
    the conditions they treat. Further, the payment update associated with
    the reported data applies 2 years after the data has been reported.
    This means that no actionable, recent information is available for
    improvement or to help patients choose the best care for them. In
    contrast, ACS has designed quality programs to overcome barriers faced
    by surgeons and other physicians who want to work together to
    coordinate and improve care. Based on these efforts and the more than
    100-year history of ACS working to improve the quality and value of
    care for surgical patients, the ACS believes addressing the
    shortcomings of traditional Medicare FFS payments will require new
    types of quality measures, facilitated by increased flexibility in the
    facility-based scoring option in MIPS. As described below, such a
    combination will improve care coordination and reduce surgical
    complications.

        The ACS believes that surgical patients deserve to have the right
    structures, processes, and personnel in place to provide optimal care
    and that information should be available to allow them to find and
    access such care. Verification programs like the Quality Verification
    Program (QVP) or the Geriatric Surgery Verification program (GSV) could
    be used as the basis of programmatic measures that more accurately
    assess the ability of a system to provide high-quality care to
    patients. Programmatic quality measures do the following: align
    multiple structure, process, and outcome measures; target condition- or
    population-specific care; apply to multiple quality domains; address
    the continuum of care; and create actionable information for care teams
    and patients.

        Our experience with programmatic measures exhibits applicability to
    diverse care settings, limited burden on care providers, and
    demonstrably better results. Applied correctly, programmatic measures
    will address the quality gaps created by the current measures.

        In early 2023, the ACS submitted a programmatic measure, the Age
    Friendly Hospital Measure, to the CMS Measures Under Consideration
    (MUC) list to demonstrate how programmatic measures could be
    implemented in CMS programs. We are optimistic this measure will be
    included in the Fiscal Year 2025 Inpatient Prospective Payment System
    (IPPS) proposed rule and will hopefully be available for hospital
    reporting in future years. This measure considers the full program of
    care needed for geriatric patients. It incentivizes hospitals to take a
    holistic approach to the provision of care for older adults by
    implementing multiple data-driven modifications to the entire clinical
    care pathway spanning the emergency department, the operating room, the
    inpatient units, and beyond. The measure puts an emphasis on the
    importance of defining patient (and caregiver) goals, not only from the
    immediate treatment decision, but also for long-term health and
    functional status. The measure underscores the importance of aligning
    care with what the patient values. It acknowledges certain processes,
    outcomes, and structures that are necessary for providing high-quality,
    holistic care for older adults across five domains:

              Domain 1: Eliciting Patient Health-care Goals: This domain
            focuses on obtaining patient's health-related goals and
            treatment preferences to inform shared decision-making and goal
            concordant care.
              Domain 2: Responsible Medication Management: This domain
            aims to optimize medication management through monitoring of
            the pharmacological record for drugs that may be considered
            inappropriate in older adults due to increased risk of harm.
              Domain 3: Frailty Screening and Intervention (i.e. Mobility,
            Mentation, and Malnutrition): This domain aims to screen
            patients for geriatric issues related to frailty including
            cognitive impairment/delirium, physical function/mobility, and
            malnutrition for the purpose of early detection and
            intervention where appropriate.
              Domain 4: Social Vulnerability (social isolation, economic
            insecurity, ageism, limited access to health care, caregiver
            stress, elder abuse): This domain seeks to ensure that
            hospitals recognize the importance of social vulnerability
            screening of older adults and have systems in place to ensure
            that social issues are identified and addressed as part of the
            care plan.
              Domain 5: Age Friendly Care Leadership: This domain seeks to
            ensure consistent quality of care for older adults through the
            identification of an age friendly champion and/or
            interprofessional committee tasked with ensuring compliance
            with all components of the measure.

        If adopted and implemented, the Age Friendly Hospital Measure could
    be further enhanced through an expansion of the facility-based scoring
    option of the Quality Payment Program to make the same measure directly
    applicable to physicians.
    Facility-based scoring opportunities are currently limited to very
    specific circumstances. This scoring method should be expanded to cover
    more physicians, more facility settings and reporting programs, and to
    apply it to all four Merit-based Incentive Payment System (MIPS)
    categories (to include Promoting Interoperability and Improvement
    Activities, in addition to Quality and Cost as currently in statute).
    In such a scenario, the score would be determined automatically unless
    physicians prefer to submit additional data and be scored through a
    different scoring option. Then, like in other cases, they would have
    the option of reporting data of their choice.

        The ACS developed programs like GSV and QVP have demonstrated
    marked improvements in patient care in trauma, cancer, bariatric
    surgery, geriatric surgery, and other areas all of which involve the
    clinical team and facilities coming together to improve the delivery of
    care. Alignment with facility reporting is critical for care centering
    the patient. We believe a voluntary expansion of facility-based scoring
    to additional physicians, sites of service, and to all MIPS categories
    could greatly reduce reporting burden while creating the environment
    necessary for meaningful quality programs to be recognized and
    incentivized in the payment environment.
                  surgical quality and impact on chronic care
        The ACS recognizes the impact of chronic conditions on both
    surgical patient outcomes and the finances of Federal health programs.
    Chronic conditions also have a huge impact on the quality of life of
    patients and in many cases, surgeons are best positioned to intervene
    to fix longstanding problems. Patients with chronic, comorbid
    conditions often face additional challenges in surgery and may need
    additional preparation or more intensive post-acute care after surgery.
    ACS's Strong for Surgery initiative provides checklists, tools, and
    resources that can be used to ensure patients are controlling blood
    sugar, managing medications, and stopping tobacco use to reduce the
    risk of adverse events and improve outcomes from surgery. Additionally,
    surgical procedures often play a role in the prevention of chronic
    condition progression or can even serve as curative treatment of some
    chronic conditions. Surgical intervention to address chronic conditions
    comes in many forms and continues to grow with the introduction of
    innovative technologies and procedures, such as groundbreaking work in
    the area of xenotransplantation, which will help save even more lives
    in the future and overcome shortages of viable donor organs for
    transplantation. Curative interventions include orthopaedic surgery for
    chronic joint pain, transplantation for organ failure, and bariatric
    surgery, which can be an effective treatment for obesity, diabetes,
    hypertension, and osteoarthritis. Reducing obesity can further treat or
    prevent other conditions such as cancer etc.\3\
    ---------------------------------------------------------------------------
        \3\ https://asmbs.org/for-patients/explore-conditions-procedures/.

        Even the effects of a traumatic injury can be considered a chronic
    condition, and surgeons play a key role in helping those affected
    emerge from trauma and re-enter normal life, both through surgical
    skill to address the immediate injury, and by being part of a team-
    based approach to managing the injury from stabilization through
    rehabilitation. Simply put, surgery lets people get back to work and
    live fuller, more productive lives. ACS is focused on improving the
    quality of surgical care for all patients and avoiding or managing
    ---------------------------------------------------------------------------
    chronic conditions is an important aspect of this.

        Quality has been the cornerstone of the American College of
    Surgeons since its founding more than a century ago. Through the Power
    of Quality campaign, ACS is on a mission to improve surgical quality
    and patient care for every patient and in every setting across the
    country. This includes expanding the reach of ACS Quality Programs to
    more hospitals, enlisting more surgeons in quality improvement efforts,
    encouraging adoption of quality metrics into public policy, and
    expanding patient recognition of the important role these programs play
    in health care. At the ACS, we believe a strong, united voice for
    surgery is essential to effective advocacy in service of our patient
    and surgeon community. With 13 ACS Quality Programs, the ACS has set
    the standard for high quality, evidence-based surgical care and is the
    definitive marking of quality patients should seek.

        Achieving optimal outcomes for the surgical patient must include a
    highly qualified surgeon and must involve an entire well-functioning
    team. This focus on team-based care includes coordination with primary
    care physicians and other specialists to ensure that the patient's
    chronic conditions are managed to help patients achieve the best
    possible outcomes. This commitment to team-based care is witnessed by
    our verification programs, which include standards related to disease
    management. For example, the ACS Surgical Quality Verification Program
    or QVP includes a standard on ``Disease-Based Management Programs and
    Integrated Practice Units.'' The purpose of this standard is to ensure
    that the surgical management of diseases, procedures, and patient
    populations requiring multispecialty care is integrated, organized, and
    standardized. Another standard on team-based processes in the five
    phases of surgical care requires facilities to document processes to
    optimize patients for surgery through review of medications and
    glycemic controls and processes to ensure continuity of care
    postoperatively. The standard also looks specifically at the unique
    needs of geriatric patients, including management of prescriptions for
    multiple chronic conditions frequently found in this population. ACS
    recognizes hospitals that successfully meet these standards through our
    Power of Quality campaign.

        This focus is not new and was also demonstrated in the ACS-Brandeis
    Advanced APM, where the entire care team including primary care and
    other specialists managing chronic conditions could participate to
    improve value. Unfortunately, the model was never advanced by CMS.
    Team-based APMs with patient-focused measurement represent an
    opportunity to both improve patient outcomes and lower costs for
    Medicare through increased efficiency.
     congressional action is needed to reform medicare payment: in summary
        The value transformation is underway but could greatly benefit and
    accelerate through a combination of improving the foundation of the
    Physician Fee Schedule and efficient investments in the partnership
    between CMS and stakeholders interested in improving the way quality is
    measured and incentivized. Congress has the power to provide CMS with
    direction, flexibility, and additional authority to help achieve the
    goal of improving value. ACS proposes the following specific action
    items for Congress to consider:

              First, prevent pending cuts and implement an update
            mechanism in the Physician Fee Schedule to account for
            inflation. This will create a stable base from which physicians
            can make the leap to models involving risk;
              Eliminate the Medicare PFS budget-neutrality requirement or
            increase the trigger threshold from $20 million to $100 million
            and index it annually to account for inflation;
              Expressly direct that, at a minimum, a portion of the
            Innovation Center's budget be devoted to testing APMs
            recommended by the PTAC; and
              Expand facility-based scoring in MIPS to accommodate the
            type of collaborative measure proposed by ACS. This should
            include expanding the program to additional settings such as
            hospital outpatient departments and ambulatory surgical
            centers.

        These are relatively modest reform ideas that would stabilize the
    Physician Fee Schedule and build upon MACRA to squarely focus on
    providing high-value care to our patients. Surgeons are devoted to
    being part of the solution and to continue to work with Congress to
    advance these critical and necessary reforms. The ACS thanks you for
    convening this important hearing and for the committee's attention to
    improving quality and value, particularly for those with chronic
    conditions. We share this commitment and look forward to working
    collaboratively with the committee to achieve the goal of safe,
    affordable care for all Americans.

                                     ______

     Questions Submitted for the Record to Patricia L. Turner, M.D., MBA,
                                      FACS
                     Questions Submitted by Hon. Mike Crapo
        Question. As you noted in your testimony and responses during the
    hearing, numerous features of the Physician Fee Schedule, as currently
    structured, have resulted in volatility and uncertainty for clinicians.
    Broad utilization overestimates for certain new billing codes, for
    instance, have triggered draconian conversion factor (CF) reductions
    across all specialties and subspecialties, and policy changes aimed at
    ensuring appropriate reimbursement for certain subgroups of clinicians
    necessitate, under budget-neutrality rules, sizable payment cuts for
    others, with no countervailing enhancements for the latter groups.

        What specific legislative steps should Congress consider taking in
    order to provide long-term stability and sustainability for the PFS,
    beyond modifying the current CF update schedule?

        Answer. First, the American College of Surgeons urges Congress to
    correct the unique problem of a lack of a meaningful inflation
    adjustment by implementing an annual update to account for increases in
    the cost of providing care to seniors. The rampant inflationary
    pressure in recent years has exacerbated the underlying problem and has
    damaged physicians' ability to continue to provide the high-quality
    care expected by Medicare beneficiaries in a timely manner. The cost of
    staff salaries, rent, technology upgrades, medical supplies and other
    resources have continued to rise while the per-unit reimbursement to
    physicians has not kept pace and has decreased. This is problematic in
    and of itself, but the effect is compounded by how payments are set
    across the health-care system. Facilities incur many of the same costs
    as physician practices with similar inflation dynamics, particularly
    when it comes to labor costs. But because facilities receive
    inflationary adjustments, it becomes a severely distorted employment
    market for the same staff and labor where facilities receive money from
    Medicare to hire staff in recognition of inflation while physician
    practices do not. This places a greater burden on physician practices
    than on all other providers, making this problem a unique Medicare
    Physician Fee Schedule problem that requires a unique Medicare
    Physician Fee Schedule solution. At a minimum, an annual inflationary
    index to mitigate these increases in costs should be adopted.

        Beyond modifications to the update schedule, ACS also believes that
    it is time to adjust the estimated change in spending that triggers a
    budget-neutrality adjustment. Under current statute, when there is an
    increase annually of $20 million to the fee schedule, it automatically
    requires CMS to implement across-the-board cuts for physicians. This
    dollar amount is not indexed for inflation and has not been updated
    since implementation of the fee schedule in 1992. Increasing this
    amount to $100 million and indexing it for inflation moving forward
    would help to increase stability in Medicare physician payment by
    eliminating the need for cuts when necessary but minor changes are
    implemented to the fee schedule.

        Question. In the absence of these types of steps, what concrete
    impacts will current and future beneficiaries most likely experience?

        Answer. If Congress does not take the steps necessary to ensure
    long-term stability, there will be several damaging developments to
    those providing and receiving care. Due to the increasing financial
    strain faced by self-employed physicians, many of whom are less able to
    make up for the insufficient Medicare payment updates there will be an
    increased likelihood of more providers selling their practices or
    possibly even leaving the practice of medicine. Not only will this lead
    to increased consolidation in health care, but it will also create gaps
    in access, particularly in underserved and rural communities.

        Another foreseeable consequence of failure to stabilize physician
    payments will be to further delay the needed transition to value-based
    care and alternative payment models (APMs). The Medicare Access and
    CHIP Reauthorization Act of 2015 (MACRA) was designed to create a
    ``period of stability'' during which new models and measures would be
    created. Unfortunately, due to the lack of regular updates and the
    budget-neutral nature of the PFS, this period of stability was
    punctuated by a series of cuts to many physicians. Some of these cuts
    were delayed or reversed, but not all. This has created an uncertain
    playing field where it is difficult to make the investments necessary
    in care models and technology for the value transformation to be
    successful. Furthermore, the expected physician developed models and
    quality measures have not materialized, further harming efforts to
    modernize and improve care models.

        Question. Regulations finalized earlier this year aim to streamline
    and standardize prior authorization standards and requirements in
    certain contexts, but the final rule expressly excludes outpatient
    medications, whether administered by clinicians or dispensed to
    beneficiaries via pharmacy. Both the American College of Surgeons (ACS)
    and the American Academy of Family Physicians (AAFP) made note of this
    omission in comments submitted in response to the proposed rule.

        Specifically, ACS ``urge[d] CMS to apply its proposed policies to
    all drugs covered by any of the impacted payers to align PA processes
    and related implementation efforts with those for all other covered
    items and services.'' Similarly, AAFP expressed concern and
    disappointment that ``these proposals do not apply to prior
    authorizations for prescription and outpatient drugs,'' and went on to
    ``strongly [urge] CMS to expand the proposals in this rule to Medicare
    Part D plans and prescription drug coverage across other impacted
    payers.''

        Virtually all clinician organizations concurred with these
    recommendations, including those focused on treating some of the most
    onerous chronic conditions, such as cancer. The Community Oncology
    Alliance, for instance, asserted, ``Addressing the drug treatment for a
    person's cancer should clearly be part of any effective, comprehensive
    regulatory initiative to streamline the current onerous prior
    authorization processes.'' Patient advocates uniformly agreed with
    these concerns, which a number of groups have cited as a key source of
    delays and denials of potentially lifesaving therapeutics, across both
    the provider-administered setting and the retail pharmacy context.

        Studies have found that physician-administered drugs and biologics
    account for a large and growing share of all forms of prior
    authorization and utilization management (UM) under Medicare Advantage
    (MA) plans' medical benefits, and the application of various UM tools,
    such as prior authorization, step therapy, and formulary exclusion, has
    risen dramatically in recent years under Medicare Part D plans.
    Analysts broadly project that these trends will accelerate, rather than
    reverse, in the midst of Part D's benefit redesign.

        What specific components should Congress, or CMS, consider
    including in any effort to streamline and otherwise reform requirements
    and standards for UM tool application to outpatient drugs (both
    physician-administered and pharmacy-
    dispensed)?

        Answer. First and foremost, ACS would urge that it be made clear
    that PA should never be required for maintenance drugs that patients
    have been on for an extended period of time as part of an evidence-
    based form treatment plan for their chronic condition or conditions.
    Such requirements, including for periodic prior authorization for
    insulin for a diabetic patient, add significant burden on the care team
    and create the potential for harmful disruptions in needed medications
    for patients while providing no measurable benefit in the quality and
    appropriateness of care.

        Question. What benefits would these components offer to patients
    and clinicians?

        Answer. Reducing unnecessary burdens would have far-reaching
    benefits for patients and their physicians including reduced stress and
    potentially better adherence to treatment plans as unnecessary
    disruptions in care could be avoided.

        Question. In the absence of reform efforts along these lines for
    medications, what prior authorization and UM burdens and other effects
    will clinicians and beneficiaries continue to experience, even after
    CMS's final rule takes effect?

        Answer. ACS believes that PA adds little value in most cases while
    adding substantial cost and burden. PA requirements should be limited
    to instances where a clear need can be demonstrated. As highlighted by
    the question, these concerns also extend beyond PA to other forms of
    UM, including step therapy, nonmedical switching, and restrictive
    formularies.

        Question. On a number of fronts, CMS has leveraged subregulatory
    guidance as a means of clarifying current-law and regulatory
    requirements for plans, providers, and beneficiaries. In the context of
    Part D, 42 CFR 423.272(b)(2) establishes regulatory requirements for
    plan designs, noting that the agency will not approve a bid if ``the
    design of the plan and its benefits (including any formulary and tiered
    formulary structure) or its utilization management program are likely
    to substantially discourage enrollment by certain Part D eligible
    individuals under the plan.'' Notably, clause (iii) specifies that even
    if a plan adheres to proper category/class inclusion requirements, such
    a plan may still fall short of this standard by virtue of its exclusion
    of certain drugs.

        Patients, providers, and plans, however, have flagged uncertainty
    as to the scope and practical implications of this language. Updates to
    the regulations themselves, or else to the relevant sections of the
    Medicare Prescription Drug Manual, could present a potential avenue for
    clarifications, along with exemplary examples of compliant and
    noncompliant formulary design and UM tool applications.

        What types of clarifications or examples, in this context, could
    CMS provide, either through guidance or regulations, to ensure adequate
    and efficient medication access for Part D enrollees, many of whom take
    multiple prescriptions for chronic diseases?

        Answer. The ACS has previously submitted comments to CMS detailing
    our concerns with the use of utilization management tools in Part D
    that have the potential of disrupting the patient-physician
    relationship and overruling physician judgment in terms of which
    treatment is best for a patient. Physicians prescribe drugs based on
    clinical judgment, patient needs, and evidence-based medicine--not on
    profit incentives.

        One specific area where we have expressed concern would be the use
    of step therapy requirements on immunosuppressive drugs, which are
    often prescribed for transplant patients. The ACS believes that any
    perceived savings that might be achieved by expanding utilization
    management to these drugs would be far outweighed by the potential harm
    both to patients and the Medicare program should changes to coverage
    for immunosuppressants lead to unnecessary hospitalizations, organ
    rejection, or other serious health consequences.

        Question. In some cases, formularies exclude or disadvantage lower-
    cost alternatives to branded medications with higher list prices while
    charging beneficiaries coinsurance tied to said inflated sticker-price
    figures. The Part D statute directs pharmacy and therapeutic (P&T)
    committees to ``base clinical decisions on the strength of scientific
    evidence and standards of practice,'' but it remains unclear to what
    extent these committees or the Part D plans themselves factor cost
    sharing, UM hurdles, or lower-priced alternatives (and the role of
    rebates) in making these types of determinations.

        How does cost-sharing burden affect medication adherence and
    clinical outcomes for patients, and how should plans (and their P&T
    committees) incorporate these types of considerations into their
    recommendation and review processes?

        Answer. Medication adherence before and after surgery is important
    in ensuring optimal outcomes. Excessive cost sharing can have an
    adverse effect on patients being able to afford their medications and
    therefore on adherence. As noted previously with the immunosuppressive
    example above, this can have the opposite effect, costing more rather
    than less while also having dire consequences for patients and their
    health.

        Question. What formulary review mechanisms or reporting
    requirements could CMS implement in order to ensure effective and
    meaningful oversight of formulary design, UM tool application, and the
    clinical basis for these decisions?

        Answer. As mentioned above, ACS strongly maintains that physicians
    should be able to use their clinical judgment in prescribing the most
    appropriate medication for their patient. Expanding UM for drugs can
    have adverse effects on patient care. One specific area where we have
    expressed concern would be the use of step therapy requirements on
    immunosuppressive drugs, which are often prescribed for transplant
    patients. The ACS believes that any perceived savings that might be
    achieved by expanding utilization management to these drugs would be
    far outweighed by the potential harm both to patients and the Medicare
    program should changes to coverage for immunosuppressants lead to
    unnecessary hospitalizations, organ rejection, or other serious health
    consequences. If CMS implements UM, these requirements should be made
    clear to the prescriber in real time.

        Question. Artificial intelligence (AI) has the potential to
    mitigate administrative burden and enhance health-care quality,
    including in the context of Medicare. That said, some clinicians have
    raised concerns around the program's inability to keep pace with AI-
    enabled tool development through its coverage and payment policies,
    undercutting access, especially for smaller practices.

        What use cases for AI-enabled tools and technologies seem most
    promising in the context of clinician care?

        Answer. One promising case for AI-enabled tools would be the
    potential application towards reducing the administrative burden that
    many providers face. This could range from typical administrative
    tasks, insurance related correspondence, record maintenance, and even
    note taking while consulting with a patient. Generative AI has the
    potential to greatly increase the overall productivity of providers and
    create a more efficient health-care sector for our patients. This could
    lead to providers having more time and energy to focus on improving and
    developing the highest possible quality of care. AI tools should always
    be used to aid physicians in their decision-making, not to replace
    them, as regardless of the sophistication of the algorithm used, they
    still lack physician judgment and training.

        Question. What steps should CMS and Congress take to ensure
    adequate coverage and reimbursement for appropriate AI-enabled tools in
    this context?

        Answer. CMS should ensure that approved AI-enabled tools receive
    coverage commensurate with the value that they provide to patients, and
    reflective of the costs associated with acquiring, implementing, and
    updating the tools as well as any costs associated with integrating
    such tools into electronic health records (EHRs).

                                     ______

                   Questions Submitted by Hon. Chuck Grassley
        Question. According to the Medicare Payment Advisory Commission
    (MedPAC), Medicare's Physician Fee Schedule updates have grown more
    slowly than input cost growth in recent years. Yet Medicare spending on
    an annual basis is up 30 percent over 5 years and the Congressional
    Budget Office (CBO) just revised Medicare spending for benefits--for
    this year and last year--up another $272 billion. MedPAC explains this
    is due to an increase in the volume and intensity of Medicare services.

        Can you explain the root cause for higher Medicare spending while
    at the same time, physicians are receiving less in reimbursement?

        Answer. There are numerous factors that account for the increased
    Medicare spending. As you point out, Medicare spending is up 30 percent
    over 5 years. Over that period an additional 2 million Americans have
    entered the program, and CPI increased by approximately 23 percent.
    When these factors are taken into account this increase seems more
    reasonable. Over that same period, updates to the Physician Fee
    Schedule have actually been a net negative. Virtually all the growth in
    overall Part B spending can be accounted for due to increased spending
    on facilities and prescription drugs. The following table, created from
    data in the 2023 Annual Report of the Boards of Trustees of the Federal
    Hospital Insurance and Federal Supplemental Medical Insurance Trust
    Funds, shows the growth in Part B spending from 2013 to 2022 was driven
    largely by spending in hospital outpatient services and Part B drugs
    and virtually none of the growth is attributable to physician services
    (from Table IV.B6.--Aggregate Part B Reimbursement Amounts on an
    Incurred Basis).

    [GRAPHIC] [TIFF OMITTED] T1124.003

                                     .eps__

                   Questions Submitted by Hon. Maria Cantwell
        Question. Adjusted for inflation in practice costs, the American
    Medical Association estimates that Medicare physician payments
    plummeted by 29 percent from 2001 to 2024. As one of the only provider
    groups without an automatic inflation-based update to their Medicare
    payments, physicians are falling farther and farther behind. Medicare
    physician payments and their impact on patient access to care is a
    major issue for my constituents.

        As a gastroenterologist in Vancouver, WA told me, it's become
    increasingly hard for physicians to maintain their practices because
    the costs of labor, equipment, and technology have spiked while
    Medicare payments have remained largely stagnant. One radiologist in
    Seattle told me that her income has effectively stayed the same for her
    entire career, despite inflation and other changes, because of flat
    Medicare reimbursements. A rehab therapy provider in Anacortes, WA said
    that unless physicians get relief, her practice and others like it
    might have to close.

        Nonpartisan government stakeholders are recognizing the damaging
    impact these cumulative payment cuts have on patient access to care.
    Multiple Medicare trustee reports have stated that access to Medicare-
    participating physicians will become a significant issue in the long
    term.

        This access is especially important for people with chronic
    conditions. Care for chronic diseases is expensive: the CDC estimates
    that spending on individuals with chronic disease accounts for about 90
    percent of all health-care spending in the U.S. Providers caring for
    Medicare patients take on a disproportionate amount of that burden
    because older adults have a higher risk of living with or developing
    chronic conditions. A 2022 study found that 66 percent of people aged
    65 and older have at least two common chronic conditions. That means
    that Medicare physician payment relief is directly tied to ensuring
    that chronic care patients can access the care they need.

        What impact does the financial instability from low Medicare
    payments have on access to care for patients with chronic diseases?

        Answer. If Congress does not take the steps necessary to ensure
    long-term stability there will be several damaging developments to
    those providing and receiving care. This includes the more than 130
    million adults that suffer from at least one chronic condition. These
    patients often require additional preparations or more intensive post-
    acute care once the surgery is performed. If long-term stability to the
    Medicare payment system is not achieved there would be several impacts
    to chronic care patients. One immediate impact would be the increased
    barrier to care. Providers that can no longer keep their lights on
    would either opt out of Medicare or worse would close their office.
    Either situation would be increasingly damaging, especially to those in
    underserved areas or care deserts. In other circumstances, the
    practices might fight to continue providing care but be forced into
    ownership models that increase negative consolidation in the market or
    lead to ownership of health-care providers by nonhealth-care entities.

        Question. A recent MedPAC report to Congress recommends that
    Congress increase the 2025 Medicare physician payment rate above
    current law with an
    inflation-based payment update because physician practices cannot
    absorb the increasing costs to practice medicine. Do you agree that
    this policy would help with inadequate reimbursements?

        Answer. Yes, the American College of Surgeons strongly believes
    that the implementation of an inflationary index would help to
    strengthen and stabilize the Medicare payment system. Without some
    acknowledgement of the adverse impact of inflation on a physician's
    ability to care for patients, we will continue to struggle to adapt to
    the need to do more with less, jeopardizing our ability to provide the
    highest quality care to American seniors. However, unlike the MedPAC
    recommendation, the American College of Surgeons believes the Medicare
    Physician Fee Schedule should be updated by a full inflationary update
    factor (and not half of the Medicare Economic Index (MEI) as put
    forward by MedPAC).

                                     ______

                     Questions Submitted by Hon. John Thune
        Question. As part of the Merit-based Incentive Payment System
    (MIPS), physicians must be compliant in promoting interoperability as
    part of their reimbursement, which helps to facilitate the sharing of
    data between various providers.

        I have long been an advocate for health IT initiatives that can
    improve efficiencies and reduce costs in the health-care system, and I
    believe that sharing information between providers through an
    interoperable network has immense upside, so long as there are
    safeguards to protect patient privacy and ensure taxpayer funds are
    spent appropriately.

        However, there continue to be challenges to physicians meeting
    interoperability metrics, like information blocking for example in
    which an individual or entity impedes the delivery or utilization of an
    electronic health record, making interoperability impossible.

        In your view, how have practices been impacted by information
    blocking?

        Answer. Based on feedback from our surgeon members, surgical
    practice has been less impacted by information blocking and more from
    the lack of comprehensive interoperable data standards to allow for
    easy repurposing of clinical data to aid in clinical decision-making at
    the point of care. Further, the sometimes-excessive cost of updating or
    upgrading EHR products to meet certification requirements is burdensome
    and at times prohibitive, especially for small or rural practices.

        Question. Are you aware of instances in which the timeliness or
    quality of the care physicians are able to provide patients has been
    impacted by a limited ability or complete inability to access
    electronic health records?

        Answer. While the flow of clinical data is far from effortless, and
    interoperability and lack of easy access to clinical data remain at
    times problematic for care coordination efforts and long term tracking
    of patients journeys, our surgeon Fellows express greater concern at
    the delays in care created by unnecessary prior authorization
    requirements.

        Question. Furthermore, beyond information blocking, what other
    challenges persist in physicians accessing patients' health information
    electronically despite the billions of dollars spent to implement
    electronic health IT and interoperability?

        Answer. The substantial investment in HIT was well meaning and
    important, but as noted, has struggled to meet its full promise. From
    the outset, the focus on specific technology rather than on the
    standardization and use of data to inform and improve clinical care has
    limited the benefit to patients.

        Question. In your testimony, you allude to the issue of Congress
    being consistently relied upon to take certain action to address
    payment adjustments to the Physician Fee Schedule.

        As you continue to advocate for more stability to the Physician Fee
    Schedule to ensure providers have the certainty they need to continue
    providing high-quality care to their patients, in addition to ensuring
    the fee schedule accounts for the impacts of inflation, could you
    expand on a few other policies referenced in your testimony that you
    believe Congress should consider that could also result in greater
    stability for providers through the fee schedule?

        Answer. There are several steps that Congress can take to ensure
    the long-term stability of Medicare physician payments. First, Congress
    should prevent any future cuts and implement a mechanism into the
    Physician Fee Schedule to account for inflation. Eliminating across-
    the-board cuts, not intended to incentivize higher-
    quality care, as well as implementing a regular update mechanism are
    critical first steps in creating a stable FFS payment system. This
    stability is a prerequisite for physicians to be able to evaluate and
    invest in value-based payment models involving financial risk.

        Second, Congress should eliminate the Medicare PFS budget-
    neutrality threshold requirement or increase the trigger from $20
    million to $100 million annually and index it for inflation moving
    forward. This will help ensure that small but necessary corrections to
    the relative values of services will not necessarily result in harmful
    cuts for others.

        Regarding the transition to value-based care, ACS strongly believes
    that any changes to existing FFS payment programs should ensure that
    they are designed to help further this goal. That is, they should
    provide patients and their physicians with the data on quality and
    price necessary to make decisions based on value as well as for efforts
    to improve outcomes and efficiency. One example of a change that would
    further this goal would be to expand the facility-based scoring option
    in MIPS to accommodate measures explicitly designed to foster team-
    based coordinated care. ACS has developed a geriatric surgery focused
    measure called the Age Friendly Hospital measure, which is included in
    the FY 2025 IPPS proposed rule.

        Furthermore, to ensure that physicians have options when they
    decide to make the leap to advanced APMs, Congress should specify that
    a portion of the CMS Innovation Center's budget be devoted to testing
    advanced alternative payment models (APMs) developed by physicians and
    evaluated by the Physician-Focused Payment Model Technical Advisory
    Committee (PTAC).

        Question. Another issue you touch on in your testimony pertains to
    the frustrations that the Physician Fee Schedule today does not
    adequately reflect the quality of care that physicians provide due to
    certain shortcomings in existing evaluation metrics and data lags.

        To address this, you suggest that new quality measures need to be
    built into fee-for-service payments.

        Could you outline for the committee what some of those quality
    measures are and how you think implementation of them could, in
    practice, improve the quality of care that is provided to patients?

        Answer. The ACS has a more than 110-year history of measuring and
    improving the quality for the surgical patient. Over that time, we have
    come to recognize the importance of shared goals and evaluation in
    spurring quality improvement. We have also used this knowledge to
    develop a number of quality programs aimed at verifying that the
    people, resources, structures, and processes necessary for optimal
    outcomes are in place. Recently, the ACS, in collaboration with the
    American College of Emergency Physicians and the Institute for
    Healthcare Improvement, developed a programmatic measure that builds on
    the successes of the ACS Geriatric Surgery Verification Program and
    incentivizes hospitals to take a holistic approach to care delivery for
    older adults. The measure highlights the importance of implementing a
    clinical framework, using evidence-based best practices, which provides
    goal-centered, clinically effective care for older patients.

        The Age Friendly Hospital Measure is a ``focused-composite'' metric
    that comprises a handful of structural metrics (such as staffing and
    roles specific to geriatrics), process metrics (such as frailty
    assessments and delirium screening), and outcomes focused on activities
    that are essential for effective care in this demographic. If
    finalized, the measure would be a positive step toward incentivizing
    team-based care organized around the geriatric patient.

        As noted previously, expanding the facility-based scoring method in
    MIPS and specifically allowing care teams to be scored on measures such
    as this would go a long way toward improving physician quality
    measurement in surgery.

                                     ______

                Question Submitted by Hon. Robert P. Casey, Jr.
        Question. Your testimonies and discussions at the hearing noted
    that the Merit-based Incentive Payment System (MIPS) is cumbersome for
    clinicians. The intention of MIPS is to foster performance
    improvements, leading to better outcomes for patients. You all
    mentioned that MIPS is burdensome and may not accurately capture the
    quality of care physicians provide.

        Are there policy proposals that could be implemented to make MIPS
    more accurate and less burdensome?

        Answer. Any time that a physician is asked to report on something
    that is not perceived as important to improving patient care it will be
    perceived as burdensome, and this is the case with many of the
    requirements in MIPS. As passed, it appeared that MIPS would be
    developed as an on-ramp to value-based payment, with funding for new
    quality measures to fill in caps and a pathway for creation of APMs.
    Unfortunately, MIPS has proven in many ways to be more of a reshuffling
    of the deck than a transformation, with little progress in developing
    and moving to more meaningful measures and no progress in testing or
    implementing physician developed APMs. Recent proposals to reform the
    program seem to promise more of the same, with the MIPS Value Pathway
    (MVP) proposal being built from the same pieces. ACS has previously
    proposed and submitted an Advanced APM and worked with CMS to explain
    how we would make a more meaningful MVP for surgery. Unfortunately, CMS
    lacks the authority and/or the will to implement novel approaches.

        Within the current MIPS framework, ACS would support implementing
    and expansion of the facility-based scoring method in conjunction with
    new programmatic quality measures. An example of a programmatic measure
    is the Age Friendly Hospital measure developed by ACS, in collaboration
    with the American College of Emergency Physicians and the Institute for
    Healthcare Improvement. This measure builds on the successes of the ACS
    Geriatric Surgery Verification Program and incentivizes hospitals to
    take a holistic approach to care delivery for older adults. The measure
    highlights the importance of implementing a clinical framework, using
    evidence-based best practices, which provides goal-centered, clinically
    effective care for older patients.

        The Age Friendly Hospital Measure is a ``focused-composite'' metric
    that comprises a handful of structural metrics (such as staffing and
    roles specific to geriatrics), process metrics (such as frailty
    assessments and delirium screening), and outcomes focused on activities
    that are essential for effective care in this demographic. If
    finalized, the measure would be a positive step toward incentivizing
    team-based care organized around the geriatric patient.

        The ACS believes that components of this measure, and of
    comprehensive verification programs in general, meet many of the goals
    of the four MIPS categories and that facility-based scoring should be
    expanded beyond quality and cost to include Promoting Interoperability
    and Improvement Activities, and that the program should be expanded to
    other facility types. Such measures show great promise in bringing the
    entire care team together to center the patient.

                                     ______

                 Question Submitted by Hon. Sheldon Whitehouse
        Question. I am working on a bill to relieve providers excelling in
    the Medicare Shared Savings Program (MSSP), from prior authorization
    (PA) requirements in MA. The bill rewards providers in Accountable Care
    Organizations (ACOs) that generate savings for Medicare by granting an
    exemption from PA requirements for their MA beneficiaries. If an
    insurer believes there is a rationale for maintaining PA in such
    instances, this bill would require them to seek prior approval from the
    Centers for Medicare and Medicaid Services (CMS). I would welcome your
    thoughts and comments on this idea.

        Answer. While the ACS would want to review legislative text of such
    a proposal prior to taking a position, we do see a certain logic in
    waiving PA requirements for health systems that have demonstrated
    appropriateness and adherence to best practices through achievement of
    savings to the Medicare program. By achieving savings to the program,
    physicians have shown that they are not inappropriately or excessively
    utilizing care. In addition to savings, the ACS would caution that such
    an exemption should also require that quality benchmarks are attained
    to show that patient outcomes are not adversely affected in efforts to
    achieve shared savings. Achieving the patients' goals of care and
    optimal outcomes should be our ultimate objective. Whether or not
    savings are achieved, PA requirements should not be allowed to get
    between physicians and patients as they strive for this goal. The ACS
    would welcome the opportunity to review and comment on this legislative
    proposal when it becomes available.

                  Questions Submitted by Hon. Marsha Blackburn
        Question. CMS has a track record of overestimating spending
    associated with payment policy changes. For example, in 2013, the
    introduction of Transitional Care Management codes led to a reduction
    of over $700 million in fee schedule payments. This was due to the
    agency projecting utilization of around 5.6 million claims, whereas
    actual claims fell below 300,000 in the first year.

        A similar scenario unfolded with Chronic Care Management codes. CMS
    made budget-neutrality adjustments based on an assumed utilization of
    4.7 million claims, yet actual claim volume totaled less than 1
    million. These assumptions, among others, perpetually reduce the
    aggregate dollars available under the fee schedule, with no mechanism
    for reconciling overestimates or underestimates.

        Do you believe the Physician Fee Schedule should incorporate
    forecast error adjustments to rectify over- and underestimations
    exceeding a certain threshold through subsequent payment modifications?

        Answer. Lacking information on how frequently forecasting errors
    occur and how often they are overestimates versus underestimates, the
    ACS has not taken a formal position on this proposal. However, it is
    important to take steps to ensure that cost and utilization estimates
    are as accurate as possible. While reversing cuts due to overestimates
    of utilization would be beneficial, the ACS also does not believe that
    it makes sense to penalize all providers through budget-neutrality
    adjustments in the first place. If small but necessary adjustments are
    made to the Physician Fee Schedule these changes should not require
    patients with other care needs to sacrifice access or quality of care
    due to unjustified cuts.

        Question. Medicare physician pay and its impact on patient access
    to care remains a significant issue for my constituents. Adjusted for
    inflation in practice costs, Medicare physician pay plummeted 29
    percent from 2001 to 2024. Although Congress did act in the March 8th
    government funding package to reduce the 3.37-percent cut that went
    into effect on January 1, 2024, by an additional 1.68 percent, the 29-
    percent reduction in Medicare payments over the last 2 decades is
    reflective of this most recent congressional action. Plus, physicians
    are now set up for another steep payment cut at the end of this year.
    Nonpartisan government stakeholders recognize the damaging impact these
    cumulative payment cuts have on patient access to care. Multiple
    Medicare trustee reports stated that ``absent a change in the delivery
    system or level of update by subsequent legislation, the trustees
    expect access to Medicare-participating physicians to become a
    significant issue in the long term.''

        Can you discuss some of the impacts of this pressing financial
    instability on physician practices, including consolidation, difficulty
    retaining staff, and trouble keeping their doors open amid rising
    costs?

        Answer. As with any business, independent physicians must have
    enough income and revenue to pay for rent, utilities, and staff as well
    as their own income. In addition, physicians must spend an increasing
    amount of time and money in meeting burdensome mandates both from the
    government and private insurers, including an increasing amount of time
    spent dealing with prior authorization and other utilization
    restricting techniques that interfere in the patient-physician
    relationship. The impact of higher-than-average inflation in recent
    years has contributed greatly to the overall cost to provide care as
    costs to staff these facilities continue to increase year after year.
    Lacking any mechanism within the PFS to account for these increases,
    they contribute to a growing financial strain that may force them to
    make difficult decisions related to staff retention, patient access or
    even whether or not to remain in private practice. These decisions may
    be even more difficult in rural areas, where it is difficult for
    physicians to increase volume to make up for decreasing payments. Loss
    of a practice in a rural area may jeopardize access to care for
    patients without other reasonable alternatives. Further, physician
    practices are often hiring staff in direct competition with hospitals
    and other facilities. When physician practices are not compensated for
    inflationary increases, but hospitals and other facilities are, the
    ability to recruit and retain physician practice staff becomes
    untenable.

        Question. What available mechanisms do Congress and HHS have within
    current statutory authority to help provide adequate Medicare payments
    to physicians and ensure continued patient access to care? For example,
    alleviating the administrative burden on practices through reforms to
    the Merit-based Incentive Payment System?

        Answer. The Merit-based Incentive Payment System (MIPS) as
    implemented falls far short of the goals of tying payment more closely
    to quality and value, while creating the potential for significant
    additional burden or even steep payment reductions, particularly for
    those in small, independent practices.

        Most surgeons currently evaluated in MIPS are employed by a health
    system or large group practice that reports measures on their behalf,
    many of which may be completely unrelated to the care they provide.
    Physicians in such employment situations are statistically more likely
    to score well in MIPS even though the measures reported add little to
    improve patient care.

        Smaller independent practices on the other hand would face the full
    burden of reporting on quality, promoting interoperability, and
    improvement activities. While the measures they select are likely to be
    more meaningful, the burden is also higher and many may choose not to
    fully report or not to participate at all, calculating that the cost of
    compliance is greater than the reduction mandated.

        The ACS believes that the burden on physicians could be greatly
    alleviated by an expansion of the facility-based scoring option.
    Currently, facility-based scoring only applies to quality and cost and
    only measures in very specific circumstances. In order to incentivize
    team-based care and greater coordination of effort toward shared goals,
    this option could be expanded to a larger array of physician
    specialties and to all four categories of the MIPS program. While some
    of these changes would require legislative authority, we think they are
    worthwhile improvements that would reduce burden and improve patient
    experience and outcomes.

        Question. Do these cuts disproportionately impact access to care in
    underserved areas?

        Answer. Cuts to the Medicare physician payment system have led to
    increased instability for physicians that aim to provide high-quality
    care in underserved communities. While finding adequate care in these
    areas can already present a challenge, stagnation in Medicare payments
    has led to an even larger burden. Many of these providers are the only
    care in the area. When they are forced to close their offices, it can
    lead to an immense barrier to care. Patients in these communities are
    then forced to either forgo the care they need or travel immense
    distances to receive care.

        Question. Are there enough APMs approved by CMMI for all physician
    practices to participate? In other words, are all practices ready to
    move to value-based care models? If not, what steps can Congress and/or
    the administration take to promote the value-based care pathway?

        Answer. The current options for participation in Advanced APMs are
    limited to programs developed by CMS, and exclude models proposed and
    developed by physician experts and approved by the PTAC because CMS
    never implemented a single one of them. Existing models may be limited
    in scope, specialty, or geographic location, leaving some physicians
    without access to a model or with too few eligible patients to meet
    participation thresholds. The ACS continues to advocate for a portion
    of the CMMI budget to be dedicated to testing physician stakeholder-
    developed models approved by the PTAC to expand the options available
    to physicians.

        Question. Do you think the Physician-Focused Payment Model
    Technical Advisory Committee (PTAC) has an important role to play in
    the creation of new APMs? Do you know why CMMI to date has not accepted
    any of the PTAC-approved models?

        Answer. ACS in conjunction with Brandeis University developed and
    submitted proposals that were reviewed, revised, and evaluated by the
    PTAC. We found the process of revising and improving the proposal in
    response to PTAC questions and evaluation helpful and in the end our
    proposal was recommended for limited scale testing. In total, at least
    14 proposals have been recommended for testing or implementation by the
    PTAC, but CMS has not tested a single model through the CMMI as
    proposed. This bottleneck has created a glaring disincentive for
    stakeholder investment, as witnessed by the lack of new proposals on
    the PTAC website since 2020. While ACS does believe that there is a
    role for PTAC to play, unfortunately there is no current law to compel
    action from CMS once proposals have been reviewed and recommended.
    Congress should require that at a minimum, some portion of the CMS
    Innovation Center's budget be dedicated to testing physician- and
    specialist-developed APMs recommended by the PTAC.

        Question. Every year, we see an alarming decline in physicians
    offering essential care services. This trend is partly fueled by
    soaring costs for practices, already high yet constantly increasing
    administrative burden, and low reimbursement rates, often well below
    the cost of providing care.

        How has the cost of providing lifesaving care changed over the
    years for your practice, and how has the payment for those services
    caught up or not caught up?

        Answer. Unfortunately, the cost of providing care has continued to
    rise through several factors while the level of compensation has been a
    consistent target to offset other costs. Our surgeon members have
    firsthand experience of the financial challenges posed by the lack of
    an inflationary update as costs for rent, equipment, staffing, and
    utilities have increased. On top of this, surgeons have faced payment
    reductions due to the budget neutrality threshold requirement in the
    MPFS. These conversion factor reductions create a strain on physicians
    working towards value-based care and fail to incentivize quality or
    care coordination. This results in the Medicare program taking
    resources away from certain physician specialties in order to finance
    priorities in other areas. A payment model designed in such a way that
    different specialties are pitted against one another is
    counterproductive, since all specialties are doing their best to
    provide quality care to their patients with ever-scarcer resources.
    Since 2001, physicians have seen their Medicare physician payments
    decrease by 13 percent in real terms before indexing for inflation.

        Question. How does the yearly scramble to delay or reduce CMS
    payment cuts to the PFS impact your ability to plan for the future?
    What would it mean for you and practices like you if these cuts were
    fully implemented and not scaled back?

        Answer. These reoccurring cuts make it incredibly difficult for
    providers and physicians to take a long-term approach and improve the
    care they deliver. Due to the ambiguity in payments, it has led to a
    yearly source of frustration for physicians that still own and operate
    their own practices. While we appreciate Congress stepping in to
    mitigate the cuts, the annual and ongoing uncertainty of whether
    physicians will see relief makes it extremely difficult to operate a
    business. If this trend of yearly cuts continues more often than not,
    privately owned small business providers will continue to either close
    their doors or refuse to accept new Medicare patients. The impact this
    would have on our health-care system and the lifesaving care that is
    performed would be detrimental for patients in these communities.

        Question. As a value-based purchasing program, MIPS was supposed to
    reward physicians who achieved quality and cost-efficient care.
    However, for years physicians have raised concerns about the program,
    including that it increases administrative burden and does not
    accurately capture quality.

        What has been your experience with MIPS and the administrative
    burden that it entails?

        Answer. The ACS experience with MIPS has been punctuated by missed
    opportunities. As envisioned, MIPS would have provided an on-ramp to
    value-based payment models through development of novel quality
    metrics, greater reliance on clinical data from registries and other
    improvements. However, most of the important reforms were lost in
    implementation and the experience of many surgeons has been one of
    increased administrative burden, quality measures nonreflective of the
    care they provide, stagnant or falling reimbursement and lack of
    meaningful data for quality improvement in patient care.

        Question. Is it time to consider replacing the program with a more
    valuable alternative? If so, what are some of the program's benefits
    that should be considered when designing its replacement?

        Answer. CMS has sought to address some of the shortcomings of the
    MIPS program through implementation of MIPS Value Pathways or MVPs.
    When this was first announced, ACS envisioned what we thought a
    surgical MVP should look like. Based on the more than 110 years of
    experience in measuring surgical quality, ACS has developed a number of
    quality programs in both broad and targeted areas of surgery. If ACS
    were to develop a surgical MVP, the core of the payment model would be
    based on evidence-based verification programs that assure that all of
    the resources, structures, processes, and personnel necessary for
    optimal outcomes are present. Such a model would build in the use of
    digital clinical information, improvement efforts, and patient
    experience and outcomes, meeting the key requirements of MIPS. While
    the requirements of such a program would be as intensive or perhaps
    even further reaching than the current program, we believe that they
    would be less burdensome because each component of the program is
    explicitly designed to improve care to the patient and ensure their
    safety.

        If Congress considers reforms to MIPS, it is critical to address
    the core shortcomings with the current FFS payment system. Chief among
    these shortcomings are its lack of a regular payment update mechanism
    to create a stable environment, as well as its current failure to
    create an onramp toward more integrated payment models centered on the
    patient.

        Question. Part of the Physician Fee Schedule's MIPS program
    measures interoperability, which is impeded by information blocking by
    providers, vendors, or others wanting to hoard patient data, which can
    affect MIPS performance and reduce reimbursement to providers.

        How have your practices been impacted by information blocking?

        Answer. Surgical practice has been less impacted by information
    blocking and more from the lack of comprehensive interoperable data
    standards to allow for easy repurposing of clinical data to aid in
    clinical decision making at the point of care. Further, the sometimes
    excessive cost of updating or upgrading EHR products to meet
    certification requirements is also at times burdensome.

        Question. Have you had experiences where your ability (or
    inability) to access health records has impacted the timeliness or
    quality of the care you are able to provide your patients?

        Answer. All physicians have experienced at least minor delays when
    working with clinical patient data and lack of easy access to clinical
    data remains at times problematic for care coordination efforts and
    long-term tracking of patients' journeys. However, our fellows express
    greater concern at the delays in care created by unnecessary prior
    authorization requirements, which can consume immense amounts of time
    and staff resources while adding no clinical benefit.

        Question. Do existing Federal quality and payment incentive
    programs under Medicare, like Promoting Interoperability under the
    Merit-based Incentive Payment System, enable up-to-date, consolidated
    longitudinal health records accessible without special effort?

        Answer. Both the Medicare program and private health plans still
    have a long way to go to achieve the full promise of EHRs and health
    data. Having timely access to current and complete health data for the
    patient in standardized data elements fit for use by multiple purposes
    such as risk calculators, EHRs, registries, clinical decision tools,
    health monitoring devices, and so forth would go a long way toward
    improving care for patients.

        Question. With over $40 billion spent and nearly 2 decades of
    effort put into implementing electronic health information technology,
    fax machines remain widely used for sharing health data in our health-
    care system.

        Why is this the case, and what challenges persist in accessing
    patients' health information electronically?

        Answer. At the time of the initial passage of the HITECH Act much
    of the country's medical records were still solely in paper form. While
    the Federal investments have gone a long way toward shifting the arena
    of medicine into the digital age, progress has not been uniform, and
    interoperability challenges still remain. Though the use of legacy
    technologies is waning, they still do occur both provider-to-provider
    and provider-to-insurer communications. ACS believes that much of the
    problem is attributable to the early focus on the use of specific
    technologies rather than on the standardization of data elements and
    the use of the clinical data, which was the ultimate goal.

                                     ______

                     Prepared Statement of Hon. Ron Wyden,
                           a U.S. Senator From Oregon
        This morning the Finance Committee gathers to discuss how to update
    and strengthen Medicare's guarantee of high-quality health benefits for
    the next generation of America's seniors.

        Colleagues, I want to be clear from the outset: traditional
    Medicare is falling behind when it comes to helping seniors manage
    their health when they are living with multiple chronic conditions.

        I know members of the committee are interested in reforms to the
    way physicians and nonphysician practitioners are paid. In my view, any
    update to the way physicians are paid by traditional Medicare must
    provide a lifeline to the tens of millions of seniors who live with
    chronic conditions and who are struggling to coordinate their health
    care in a fragmented health system that's not putting their health
    first. This hearing is going to jump-start that debate.

        The Finance Committee delivered a wake-up call to America in 2018
    when we passed our first round of reforms to care for chronic
    conditions in Medicare, under the chairmanship of Orrin Hatch, who
    graciously agreed to partner with me, along with Senators Warner and
    Isakson. Together, we sounded the alarm that Medicare is no longer only
    an acute care program. Medicare spending today is dominated by chronic
    conditions. Often, chronic conditions cluster together in ways that
    complicate health and require specific, ongoing management by a
    physician.

        Cardiovascular conditions like high blood pressure and high
    cholesterol most often occur with diabetes, for example. If you add
    conditions like cancer and COPD to the equation, seniors and their
    doctors are left with a crazy quilt of appointments, prescriptions, and
    care plans that lead to confusion and worse health care. When a
    senior's health gets this complicated, care coordination is not
    optional.

        Recent events have underlined the growing cost of chronic disease
    in America. Even before the COVID-19 pandemic, life expectancy began to
    dip in the United States from a 2014 peak of 79 years old. The pandemic
    led to a backlog of preventive care that may only accelerate chronic
    illness in the U.S.

        The way traditional Medicare pays physicians to manage and treat
    these conditions has not kept up with the times. Democrats and
    Republicans were right to tackle the problem in 2018, and it's now time
    to act boldly again.

        In contrast to traditional Medicare, in the past decade Medicare
    Advantage plans have been given a host of tools to incorporate chronic
    disease management into their plan choices. That's because MA was built
    from the ground up to offer more flexible benefits to give seniors the
    option to choose a Medicare plan that was tailored to their needs.
    Plans are able to use rebates--growing from $12 billion in 2014 to $67
    billion in 2024--to support these flexibilities and extra benefits.

        Unfortunately, it's increasingly clear that insurance companies are
    more interested in playing coding games with Medicare's payment rules
    to maximize their bottom line. Medicare Advantage plans seem to be
    using more and more of these excess dollars to juice their marketing
    and enrollment. Experts told this committee that MA plans spend $6
    billion per year on marketing middlemen who sell their plans to
    seniors.

        Just last week, the Centers for Medicare and Medicaid Services
    announced it is cracking down on insurance middlemen selling seniors'
    personal information over and over again, resulting in a blizzard of
    phone calls and high-pressure marketing campaigns during enrollment
    season.

        This time around, I want to make sure that traditional Medicare is
    keeping up with the needs of beneficiaries when it comes to care
    coordination, nonmedical determinants of health, and the like. That
    could include steps such as reducing or eliminating cost sharing for
    care coordination services. Seniors shouldn't have to pick up the tab
    when their primary care doctor works with their cardiologist or
    physical therapist to coordinate a care plan for high blood pressure.

        It also means empowering primary care. Physicians and other
    providers who deliver primary care are on the front lines when it comes
    to helping seniors manage their chronic illnesses. But as everybody in
    this room knows, there is a persistent shortage of primary care
    providers in many parts of the country. That's partially a result of
    out-of-whack payment rules that make primary care a less appealing
    specialty than other fields. Primary care providers need to be valued
    and compensated more fully by Medicare--as they are put in the driver's
    seat alongside seniors to help navigate their health needs.

        In my view, the challenge before the Finance Committee is to
    improve the way Medicare pays for services delivered in the doctor's
    office, or at home, so there is a laser focus on managing those chronic
    conditions that are dominating the health of seniors.
        The Finance Committee has had a lot of success over the last decade
    getting new policies in this area into black-letter law on a bipartisan
    basis, but there's still more to be done. I'm looking forward to
    hearing from our witnesses and getting to work on the next steps.

                                     ______

                                 Communications

                                  ----------

                           Alliance for Home Dialysis

                         750 9th Street, NW, Suite 650

                              Washington, DC 20001

                                 (202) 466-8700

    The Alliance for Home Dialysis (the Alliance) appreciates the Senate
    Finance Committee's focus on ensuring high-quality care for Medicare
    beneficiaries with chronic conditions. Our organization focuses on the
    chronic conditions of chronic kidney disease (CKD) and End Stage Kidney
    Disease (ESKD) with a focus on dialysis treatment choice. We believe
    that these conditions should be of particular interest to this
    Committee not only because of the burden to patients, but also because
    all ESKD patients, regardless of age, are eligible for Medicare.

    As background, the Alliance is a coalition of kidney disease
    stakeholders including patients, clinicians, dialysis facilities, other
    providers, and industry who came together starting in 2012 to advocate
    for policies that would increase access to and uptake of home dialysis
    in the United States.

    Improving the uptake of home dialysis matters for clinical and quality-
    of-life reasons. Research shows that both home dialysis modalities
    (peritoneal dialysis and home hemodialysis) offer quality-of-life and
    clinical advantages--and patients deserve access to these benefits. For
    example, home hemodialysis allows for tailoring the dialysis
    prescription to allow for more frequent or longer-lasting sessions.
    Such more frequent sessions can result in faster recovery and fewer
    side effects,\1\ improved cardiac status,\2\ improved survival
    rates,\3\ and increased rehabilitation opportunities.\4\ Peritoneal
    dialysis patients also experience fewer side effects and have fewer
    dietary restrictions that in-center dialysis patients.\5\ Both home
    modalities also offer significant quality-of-life advantages like ease
    of scheduling, ability to continue to work, ability to travel, and
    reduced dependence on transportation to dialysis clinics.
    ---------------------------------------------------------------------------
        \1\ Heidenheim AP, Muirhead N, Moist L et al. Patient Quality of
    Life on Quotidian Hemodialysis. Am J Kidney Dis. 2003 Jul; 42(1
    Suppl):36-41.
        \2\ Culleton, B et al. Effect of Frequent NHD vs. CHD on Left
    Ventricular Mass and Quality of Life. JAMA 2007;11
        \3\ Foley, R.N., D.T. Gilbertson et al. Long interdialytic interval
    and mortality among patients receiving hemodialysis. New England
    Journal of Medicine. 2011 365, no.12:1099-1107.
        \4\ Blagg, Christopher. ``It's Time to Look at Home Hemodialysis in
    a New Light.'' Hemodialysis Horizons: Patient Safety & Approaches to
    Reducing Errors. (2006): 22-28. Web. 12 Apr 2012. https://www.aami.org/
    docs/defaultsource/uploadedfiles/filedownloads/horizons/home-blagg.pdf.
        \5\ ``A Brief Overview of Peritoneal Dialysis.'' DaVita, Inc., Web.
    16 Jul 2012. https://www.davita.com/treatment-services/
    peritonealdialysis/living-well-on-pd.

    While home dialysis has been growing in recent years, in large part due
    to government and provider commitment to ensuring patients have access
    to all modalities, it still only hovers at a little over 13% of
    patients doing their treatments at home. This is striking given that
    the Government Accountability Office (GAO) shared in 2015 that they
    believe up to 25% of patients could be successful on home dialysis.\6\
    Furthermore, a few years ago, HHS set a far loftier goal that 80% of
    new ESKD patients should be receiving dialysis at home or be
    transplanted by 2025. While we have seen increases in uptake of home
    dialysis in recent years, additional policy changes, including through
    legislation, are needed to ensure that patients can access these
    important treatments and increase the overall number of patients on
    home dialysis in the U.S.
    ---------------------------------------------------------------------------
        \6\ Government Accountability Office. (2015). End-Stage Renal
    Disease: Medicare Payment Refinements Could Promote Increased Use of
    Home Dialysis. (GAO Publication No. 16-125). Washington, D.C.: U.S.
    Government Printing Office.

    We appreciate all Congress has done thus far to increase access to home
    dialysis. Congress has been particularly impactful with regard to
    policy changes in telehealth; the Bipartisan Budget Act of 2018 \7\
    included key elements of the Creating High-Quality Results and Outcomes
    Necessary to Improve Chronic Care Act of 2017 (the CHRONIC Act),
    including a provision that allowed home to be the originating site for
    a telehealth visit. In practice, this means that patients can now see
    their doctors for the monthly capitated payment visit from the comfort
    of their homes, avoiding often lengthy travel to and from the dialysis
    facility. Allowing this expanded access to telehealth makes home
    dialysis more accessible for patients and has helped increase uptake to
    these important therapies. Policy changes like this are key to ensuring
    expansion of home dialysis.
    ---------------------------------------------------------------------------
        \7\ Bipartisan Budget Act of 2018. Public Law 115-123. 2018.
    https://www.congress.gov/115/plaws/publ123/PLAW-115publ123.pdf.

    Congress has a key role in ensuring patients have choices when faced
    with decisions about treating their ESKD through dialysis.
    Specifically, Kidney Disease Education (KDE) is a policy area where the
    Committee could advance policy changes to positively impact the lives
    of patients and ensure that they have choices in their treatment. We
    strongly believe this policy area merits the Committee's further
    ---------------------------------------------------------------------------
    attention.

    Medicare's current KDE benefit provides up to 6 sessions of educational
    services for individuals with Stage 4 chronic kidney disease. KDE
    covers a wide range of topics, including how to take care of your
    kidneys, how to manage other chronic diseases that often come alongside
    CKD, diet, medications, and treatment options for both dialysis and
    transplant.

    Unfortunately, KDE is extremely underutilized with only about 2% of
    eligible patients taking advantage of the benefit. We believe, and the
    Government Accountability Office (GAO) has stated as well, that the
    expansion of KDE could lead to the expansion of home dialysis.\8\ The
    Alliance urges the Senate Finance Committee to consider the following
    legislative policy options for increasing access to KDE:
    ---------------------------------------------------------------------------
        \8\ See citation 1.

        1.  Congress should permit reimbursement for stages 3b and 5 CKD
    ---------------------------------------------------------------------------
    patients to receive the KDE benefit.

    Currently, KDE is only permitted for patients with stage 4 CKD. The
    Alliance believes that reimbursement for such services should be
    allowed for patients with stage 3b and 5 CKD.

    Stage 3b CKD means moderate to severe loss of kidney function, with
    kidneys working somewhere between 30-44% of what the average healthy
    kidneys do.\9\ In addition, health risks get higher at this stage of
    CKD, including the risk of developing co-occurring heart disease or
    high blood pressure and the stage of CKD progressing to stage 4. There
    is also a higher risk of complications at this stage of CKD, like
    anemia, bone disorders, and metabolic acidosis, which is a buildup of
    certain acids in the blood. Patients with CKD stage 3 are likely to
    need dialysis services at some point, though their disease may take
    some time to develop. They deserve to be educated in the same manner as
    patients with stage 4 CKD.
    ---------------------------------------------------------------------------
        \9\ Stage 3b Chronic Kidney Disease. National Kidney Foundation.
    https://www.kidney.org/atoz/content/stage-3b-chronic-kidney-disease-
    ckd#about-stage-3b-ckd. Accessed 11 April 2024.

    Stage 5 CKD actually refers to the first phase of ESKD, or kidney
    failure; these patients have kidneys that are working less than 15% of
    what the average healthy kidneys can do.\10\ Patients at stage 5 have
    the highest risk for comorbidities like heart disease and the CKD
    complications discussed above. They may also have symptoms of kidney
    failure like urinating less or not at all, itchy skin, feeling tired,
    trouble concentrating, numbness, achy muscles. Shortness of breath,
    nausea, loss of appetite, trouble sleeping, and foul-smelling breath.
    These patients require immediate dialysis or a transplant to survive;
    they must be educated about their options, but they are currently not
    allowed KDE.
    ---------------------------------------------------------------------------
        \10\ Stage 5 Chronic Kidney Disease. National Kidney Foundation.
    https://www.kidney.org/atoz/content/stage-5-chronic-kidney-disease-
    ckd#::text=Stage%205%20CKD%20means%20you,or
    %20they%20are%20on%20dialysis. Accessed 11 April 2024.

    Based on these realities about stages 3b and 5, we strongly believe
    that KDE should be allowed for both and ask the Committee to consider
    ---------------------------------------------------------------------------
    this change.

        2.  Congress should expand the providers qualified to provide KDE
    beyond doctors, physician assistants, nurse practitioners, and clinical
    nurse specialists.

    Under current law, only qualified persons can provide kidney disease
    education services, which are defined as certain healthcare entities
    for which payment can be made under the Physician Fee Schedule,
    including physicians, physician assistants, nurse practitioners, and
    clinical nurse specialists, or hospitals, Critical Access Hospitals,
    skilled nursing facilities, home health agencies, or hospices in a
    rural area. Notably, this excludes home dialysis nurses, who are
    arguably some of the most knowledgeable professionals about kidney
    disease. The Alliance urges the Committee to consider expanding who can
    provide KDE to include home dialysis nurses.

    In addition, current law does not allow dialysis facilities to provide
    KDE. We believe that dialysis facilities are an appropriate place for
    KDE services to occur and that they should be allowed to bill for KDE--
    with appropriate guardrails. In our view, these guardrails should seek
    to avoid so-called ``patient steering'' to one facility over another.
    Specifically, we would urge Congress, alongside allowing facilities to
    bill for KDE, to instruct CMS to enact requirements on what kind of
    information can be provided to exclude any provider-specific or
    advertising information. In addition, we recommend that CMS play a role
    in approving educational materials before they are deployed to
    patients.

    Thank you for your work in ensuring that Americans with chronic
    conditions have access to the treatments they need. We appreciate your
    consideration of these requests related to Kidney Disease Education and
    look forward to continuing to work with you to improve the lives of
    Americans with CKD and ESKD.

                                     ______

                   Alliance for Women's Health and Prevention

                         607 14th Street, NW, Suite 675

                              Washington, DC 20005

                     https://womenshealthandprevention.org/

                                                         April 17, 2024

    United States Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510

    Dear Senator Wyden, Senator Crapo, and Members of the Senate Committee
    on Finance,

    The Alliance for Women's Health and Prevention (AWHP) respectfully
    requests that you prioritize the impact of obesity on America's seniors
    as you consider legislative proposals to update and strengthen Medicare
    service payment and delivery, including providing coverage for anti-
    obesity medications (AOMs). As an organization focused on women's
    preventive health, AWHP recognizes that obesity is a chronic disease
    with a significant impact on women, including those with coverage
    through Medicare.

    Obesity is a chronic, treatable disease that affects more than 3 in 10
    women \1\ nationwide and has a disproportionate impact \2\ on women of
    color. It is associated with over 200 other chronic conditions,
    including many that specifically affect women throughout their lives,
    such as breast and ovarian cancers as well as fertility issues. Women
    with obesity are also more likely to face harmful social stigma and
    discrimination. For instance, women with obesity are less likely \3\ to
    be promoted at work, and as many as 69% of women \4\ with obesity face
    weight bias in healthcare settings. Finally, obesity has a tremendous
    economic burden, with economic costs (both direct and indirect)
    totaling $1.72 trillion in 2018.\5\ Given obesity's extensive impact,
    AWHP believes that insurance coverage for the full scope of obesity
    care options is critical to improving women's health. Evidence-based
    obesity care includes counseling or intensive behavioral therapy,
    behavior modification, AOMs, weight loss surgeries, and nutrition
    services.
    ---------------------------------------------------------------------------
        \1\ https://www.kff.org/other/state-indicator/adult-obesity-bysex/
    ?currentTimeframe=0&sort
    Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
        \2\ https://www.niddk.nih.gov/health-information/health-statistics/
    overweight-obesity.
        \3\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6452122/.
        \4\ https://www.obesityaction.org/wp-content/uploads/Weight-Bias-
    in-Healthcare1.pdf.
        \5\ https://milkeninstitute.org/content-hub/research-and-reports/
    reports/modernizing-care-obesity-chronic-disease-how-guide-employers.

    Unfortunately, even though obesity has serious consequences, especially
    for women, it is often misunderstood, leading to health insurance
    barriers that keep the full range of obesity care options out of reach
    for many women--particularly AOMs. In fact, just half of U.S. employers
    currently cover, or are considering covering, the latest generation of
    AOMs. Only 16 state Medicaid programs \6\ cover AOMs. Notably, Medicare
    does not cover \7\ AOMs.
    ---------------------------------------------------------------------------
        \6\ https://files.kff.org/attachment/REPORT-50-State-Medicaid-
    Budget-Survey-for%20State-Fiscal-Years-2023-and-2024.pdf.
        \7\ https://www.cms.gov/medicare-coverage-database/view/
    ncd.aspx?ncdid=38&ncdver=3&
    chapter=all&sortBy=title&bc=18.

    Medicare coverage for comprehensive obesity care is critical to ensure
    that women over 65 living with obesity can access the care they need.
    As such, AWHP strongly supports the passage of the Treat and Reduce
    Obesity Act (TROA), bipartisan legislation that would ensure that
    Medicare beneficiaries have access to the full scope of obesity care
    options, including AOMs. Ensuring that Medicare beneficiaries and the
    providers who care for them have access to all
    evidence-based options for treating this disease is only fair. We
    wouldn't place this type of restriction on care for other chronic
    diseases like cancer or heart disease. As such, AWHP strongly
    encourages the Senate Committee on Finance to prioritize this topic in
    ---------------------------------------------------------------------------
    its future discussions on improvements to the Medicare program.

    AWHP, along with leading stakeholders from across the healthcare
    community, recently launched the EveryBODY Covered campaign, a first-
    of-its-kind initiative aiming to activate women to advocate for
    insurance coverage of comprehensive obesity care. We believe that
    addressing obesity requires a comprehensive approach that includes
    equitable access to all evidence-based treatments and interventions. We
    encourage you to refer to the resources available on our website
    (https://everybodycovered.org/) for more information about obesity's
    particular impact on women, and we appreciate your attention to
    addressing obesity and supporting women's health.

    Respectfully,

    Millicent Gorham, CEO

                                     ______

                         Alliance of Specialty Medicine

                       611 Pennsylvania Avenue, SE, #393

                              Washington, DC 20003

                             www.specialtydocs.org

    The Alliance of Specialty Medicine (``Alliance''), a coalition of 16
    medical specialty organizations representing more than 100,000
    specialty physicians, is deeply committed to improving access to
    specialty medical care through the advancement of sound health policy.
    We thank the Committee for convening a hearing to examine how changes
    to Medicare physician payment can bolster chronic care. Today, we
    outline suggested actions that Congress should take to stabilize the
    Medicare physician payment system while ensuring successful value-based
    care incentives are available for specialty physicians. We continue to
    have serious concerns about structural challenges and instability in
    Medicare payments to physicians and request your assistance to begin
    the process of stabilizing and improving Medicare physician
    reimbursement and performance programs through legislative reforms.

    Our statement addresses the major pain points our specialty
    organizations and their members have been facing under the current
    Medicare physician payment system and quality improvement programs. We
    urge Congress to take the following actions to address many of the
    challenges patients and doctors face:

          Replace flat base payment updates and improve nominal base
    payment updates (in CY 2026 and beyond) with annual payment updates to
    the Medicare conversion factor that are based on an appropriate
    inflationary index that reflects rising practice costs, such as the
    Medicare Economic Index (MEI).
          Exempt the following from budget-neutrality adjustments:
              Newly-covered or expanded Medicare benefits,
            items, and services, such as preventative services and new
            technologies,
              Items and services that are delivered in response
            to a public health emergency (PHE), and,
              Changes in relative values due to increased
            practice costs (e.g., clinical labor, professional liability).
          Authorize the Secretary of Health and Human Services the
    flexibility to waive or modify budget neutrality requirements in other
    circumstances, as appropriate.
          Require ongoing and consistent updates of key data inputs used
    to set Medicare payments to physicians (e.g., practice expense and
    liability insurance) and hold physicians harmless from these updates,
    which are outside their control,
          Perform more granular and timely evaluations of the impact of
    the Quality Payment Program (QPP) and Physician-Focused Payment Model
    Technical Advisory Committee (PTAC) on health care quality and value,
    as well as access to care-- particularly as it relates to specialty
    care. While PTAC recently released an environmental scan of value-based
    payment models,\1\ which includes a table listing the percentage of
    physicians participating in Advanced alternative payment models (APMs)
    by specialty, it is missing specialties and only reflects trends from
    2017-2019. Such outdated information is of little value to our members.
    Similarly, the QPP Experience Report data set, which provides aggregate
    participation and performance information related to each year of the
    Merit-based Incentive Payment System (MIPS), is also outdated. As of
    April 2024, the most current data set available to the public relates
    to the 2021 performance year. Given how frequently CMS changes MIPS
    rules, performance thresholds, and measure sets, CMS' more than two-
    year lag in reporting participation and performance trends makes it
    nearly impossible for the public to meaningfully assess the impact of
    the program and to comment on the feasibility of newly proposed
    policies. Additionally, the QPP Experience Report data set, which is
    slightly more current than the recently released PTAC data and includes
    much more granular, individual clinician-level and specialty-specific
    data, includes no information about APM participation through the QPP.
    ---------------------------------------------------------------------------
        \1\ https://aspe.hhs.gov/sites/default/files/documents/
    6d9f300bb4b45d16485d2a2c013a4151/PTAC-Sep-18-Escan.pdf.
    ---------------------------------------------------------------------------
          Make technical improvements to MACRA to strengthen the QPP,
    including:
              Providing CMS with the authority to truly
            dismantle the silos that currently prevent more accurate and
            efficient assessments of value. At the very least, Congress
            should provide CMS with the authority to make MIPS more
            streamlined and flexible, allowing physicians to earn credit
            across the four performance categories of MIPS for certain
            robust activities, such as reporting to and using data from a
            clinical data registry to improve care.
              Providing CMS with the authority to move away
            from the current one-size-fits-all approach to measurement and
            permit more flexibility in regard to measure adoption,
            participation pathways, scoring, and performance thresholds to
            better reflect the diversity of clinical practice in terms of
            settings, specialties, and/or patient populations. This should
            include:
                    t  Providing CMS with the flexibility to adjust the
                    weights of the MIPS performance categories over time to
                    reflect the current state of the health care landscape,
                    shifting gaps in care, and the availability of relevant
                    measures.
                    t  Allowing CMS to set the MIPS performance threshold
                    (i.e., the minimum points needed to avoid a penalty) at
                    an appropriate level each year based on performance
                    trends and stakeholder input, rather than setting it at
                    the mean or median score of all MIPS eligible
                    clinicians during a previous performance period, as
                    mandated by MACRA. Given the program's frequently
                    changing polices and unpredictable disruptions to our
                    healthcare system that impact participation and
                    performance scores, CMS should not be locked into using
                    historic averages as a barometer of success.
                    t  Allowing CMS to set multiple performance thresholds,
                    such as a separate threshold for small and rural
                    practices.
                    t  Providing CMS with the flexibility to provide MIPS
                    credit for more innovative and comprehensive
                    investments in quality and value, such as ongoing data
                    collection and performance feedback for purposes of
                    Board certification, performance measurement taking
                    place under other CMS programs, and quality and cost
                    analyses under APMs, so long as minimum standards of
                    reliability and validity are met.
              Require CMS to better support and encourage the
            use of specialty-focused Qualified Clinical Data Registries
            (QCDRs), the development and use of
            specialty-specific measures, and participation pathways that
            are more meaningful to specialists.
              Enforce MACRA's requirement that CMS provide
            access to Medicare claims data to assist specialties and their
            registries with better understanding existing gaps in care and
            supporting the development of quality and cost measures.
              Allow CMS to modify the MIPS Cost category by:
                      t  Removing the primary care-based total per capita
                    costs measure mandate that continues to hold physician
                    practices--including specialties that are explicitly
                    excluded from the measure--responsible for costs
                    outside of their control.
                      t  Removing the requirement that episode-based cost
                    measures account for at least \1/2\ of Part A and B
                    expenditures to ensure prioritization of episodes with
                    high variability and that specialists can directly
                    impact.
                      t  Requiring that any evaluation of cost also
                    simultaneously account for any changes in quality among
                    the same patient population to ensure cost-containment
                    efforts do not result in poorer quality care or
                    negatively impact access to care.
              Improve the APM pipeline to provide specialists
            more opportunities to participate meaningfully in APMs and
            qualify for the APM track of the QPP.
              Restore and extend the full 5% APM incentive
            payment, which expired following the 2022 performance year/2024
            payment year, and maintain current QP thresholds to facilitate
            specialty physician movement into APMs, including new and more
            relevant models that have not yet materialized.
          Require CMS to release more granular and timely data regarding
    physician participation in MIPS, eligibility for the APM track of the
    QPP, and participation in APMs in general, by specialty.
          Reduce administrative burdens and ensure safe, timely, and
    affordable access to care for patients by streamlining prior
    authorization in the Medicare Advantage program.

    Physician Payment Instability

    Prior to the enactment of MACRA, the costs associated with running a
    physician practice were on the rise, and the price of medical supplies,
    equipment, and clinical and administrative labor remain substantial, as
    demonstrated by the Consumer Price Index (CPI) and MEI (see American
    Medical Association (AMA) Medicare Updates Compared to Inflation (2001-
    2024) \2\). Unlike other Medicare providers that receive annual payment
    updates based on an inflation proxy, such as the CPI, MACRA established
    physician payments to include flat and nominal base updates in the
    initial years, transitioning to a system that emphasizes performance-
    based adjustments. Specifically, from 2016 to 2019, physicians were
    slated to receive a 0.5% increase in their Medicare payments each year,
    0% updates from 2020 to 2025, and based on their participation in the
    QPP, an update of 0.25% or 0.75% in 2026 and beyond.
    ---------------------------------------------------------------------------
        \2\ https://www.ama-assn.org/system/files/2024-medicare-updates-
    inflation-chart.pdf.

    Under MACRA, Congress aimed to create a period of stable, albeit not
    inflation-
    adjusted, payment levels, so physicians would have a predictable
    revenue stream while transitioning to more value-based care models,
    such as MIPS and APMs, which offer additional financial incentives
    based on the quality and efficiency of care. The first problem was the
    decision to undermine the onramp to value-based care by decreasing the
    CY 2019 base update from 0.5% to 0.25.\3\ Then as the CMS
    implementation of MACRA began to unfold (as the chart below shows), in
    most years since MACRA's implementation, the ``budget neutral'' MIPS
    payment incentive failed to close the gap between the change in the
    Medicare conversion factor and practice costs. While some physicians
    may have benefitted from additional incentives provided through an
    ``Exceptional Performance Bonus'' pool, these bonuses were short-term
    and expired with the 2022 performance year.
    ---------------------------------------------------------------------------
        \3\ Sec. 53106 of the Bipartisan Budget Act of 2018, Pub. L. 115-
    123.

                                                           Change from
                                                         previous year in     Actual Medicare
         MIPS  Payment Year       Budget Neutral MIPS        Medicare          Economic Index         Impact \7\
                                     Adjustment \4\     Conversion Factor        (MEI) \6\
                                                               \5\

    2019                                        0.29                 0.11                  1.5                -1.10
    \4\Represents the budget-
     neutral MIPS adjustment for
     those earning a MIPS final
     score at the performance
     threshold; excludes
     additional payment bonuses
     under the Exceptional
     Performance Bonus.
    2020                                        0.31                 0.14                  1.9                -1.45
    \5\See the AMA History of
     Medicare Conversion
     Factors, https://www.ama-
     assn.org/system/files/cf-
     history.pdf.
    2021                                        0.00                 -3.3                  1.4                -4.70
    \6\See Actual Regulation
     Market Basket Updates,
     https://www.cms.gov/files/
     zip/actual-regulation-
     market-basket-updates.zip.
    2022                                        0.01                -0.80                  2.1                -2.89
    \7\Difference in the payment
     rate between a conversion
     factor based on the budget-
     neutral MIPS payment
     adjustment and the payment
     rate adjusted for increases
     in practice costs as
     measured by inflation
     (e.g., MEI-adjusted
     conversion factor).
    2023                                        0.11                  -.0                  3.8                -5.69
    2024                                        2.23            -2.00 \8\                  4.6                -4.37
    \8\Estimated annualized
     reduction in payments
     relative to CY 2023
     factoring in fact that
     Congressional intervention
     did not apply until claims
     with dates of service on or
     after March 9, 2024.

    Beyond the challenges in physician payment created under MACRA, the
    Medicare Physician Fee Schedule (MPFS) is plagued by other challenges,
    including requirements to maintain budget neutrality, and slow,
    irregular updates to practice expense data used to set payments. In
    fact, physicians continue to ``pay down'' the significant budget
    neutrality adjustment prompted by CMS' 2021 and 2023 implementation of
    increased relative values for office and outpatient evaluation and
    management (E/M) services and inpatient and other E/M services,
    respectively, as well as absorb CMS' 2022 implementation of revised
    clinical labor prices (an update that lagged 2 decades). For 2024, CMS
    commenced paying for a new E/M add-on payment that Congress previously
    prohibited CMS from implementing, prompting yet another substantial
    budget neutrality adjustment and concomitant reduction to the PFS
    conversion factor. We appreciate congressional efforts to temporarily
    reduce conversion factor cuts, however, Congress has still allowed year
    after year of cuts to the MPFS conversion factor, and this pattern is
    unsustainable. In addition to
    congressionally-mandated stabilization of the MPFS conversion factor,
    it would be prudent to provide additional direction and authority to
    the Secretary to address these issues; for example, requiring the
    Agency to make consistent, ongoing updates to practice expense inputs
    and authorizing the Secretary to, in certain circumstances, waive or
    modify budget neutrality requirements.

    As we have shared previously, the increasing downward financial
    pressure on physicians is forcing many to sell or merge their practices
    with hospitals, health systems, and private equity groups, which is
    reflected in an April 2022 report \9\ prepared by Avalere. According to
    the report, nearly 70% of all physicians are now employed--a figure
    that spiked 19% in 2021 alone. This follows a 2020 AMA survey \10\
    which found that less than half of physicians are working in physician-
    owned practices. A consequence of increasing market consolidation is
    rising health care costs for payers, patients, and the federal and
    state governments. Indeed, as part of its March 2020 Report to the
    Congress,\11\ MedPAC explained that:
    ---------------------------------------------------------------------------
        \9\ https://www.physiciansadvocacyinstitute.org/Portals/0/assets/
    docs/PAI-Research/PAI%20
    Avalere%20Physician%20Employment%20Trends%20Study%202019-
    21%20Final.pdf?ver=ks
    WkgjKXB_yZfImFdXlvGg%3d%3d.
        \10\ https://www.ama-assn.org/press-center/press-releases/ama-
    analysis-shows-most-physicians-work-outside-private-practice.
        \11\ https://www.medpac.gov/wp-content/uploads/import_data/
    scrape_files/docs/default-source/reports/mar20_medpac_ch15_sec.pdf.

            [G]overnment policies have played a role in encouraging
            hospital acquisition of physician practices. For example, when
            hospitals acquire physician practices, Medicare payments
            increase due to facility fees that Medicare pays for physician
            services when they are integrated into a hospital's outpatient
            department. The potential for facility fees from Medicare and
            higher commercial prices encourages hospitals to acquire
            physician practices and have physicians become hospital
    ---------------------------------------------------------------------------
            employees. (p. 458)

            Physician-hospital integration, specifically hospital
            acquisition of physician practices, has caused an increase in
            Medicare spending and beneficiary cost sharing due to the
            introduction of hospital facility fees for physician office
            services that are provided in hospital outpatient departments.
            Taxpayer and beneficiary costs can double when certain services
            are provided in a physician office that is deemed part of a
            hospital outpatient department. (p. 460)

    To what extent the MPFS contributes to rising health care costs because
    it encourages consolidation is something that warrants thorough
    examination and correction by Congress.

    Ineffective Value Programs

    Implementation of MACRA's two-track value-based payment system, the
    QPP, has been ineffective and, arguably, detrimental to the delivery of
    most specialty medical care. Many specialists perceive the QPP as an
    enormous administrative hassle that simply diverts critical resources
    away from more meaningful activities that could directly impact the
    quality and value of specialty care. Under MIPS, in particular, many
    specialty physicians often have no other choice but to report on
    marginally relevant measures that result in data that is of little use
    to physicians or their patients. Further, CMS has not produced any
    evidence to suggest that quality, efficiency, and outcomes for
    Medicare's seniors, the disabled, and underserved populations has
    demonstrably improved as a result of the MACRA-established quality
    programs.

    As discussed below, most specialty physicians have also struggled to
    meaningfully engage in the APM track of the QPP, as there are only a
    few APMs that are applicable to specialty care. Through discussions
    with Alliance member organizations and the physicians they represent,
    we have found that Accountable Care Organizations (ACOs) are often the
    only option for APM engagement, and usually the result of specialists'
    hospital or health system employment, where any APM incentives are
    directed. Specialists often have little control over their decision to
    participate in these ACOs and the current set of metrics used to
    measure quality of care provided under the ACO do not reflect the more
    focused care provided by specialists.

    Merit-based Incentive Payment System (MIPS)

    In contrast to the promises of MACRA, MIPS has evolved into an overly
    complex, disjointed, burdensome, and clinically irrelevant program for
    many specialists. Even the U.S. Government Accountability Office
    (GAO),\12\ in an October 2021 report, expressed concern that MIPS
    performance feedback is neither timely nor meaningful, questioned
    whether the program helps improve quality and patient outcomes, and
    highlighted the program's low return on investment. In its March 2024,
    environmental scan of value-based payment models,\13\ discussed
    earlier, PTAC notes: ``Overall, there is little evidence that pay-for-
    performance and public reporting of quality measures have improved
    overall quality of care in the United States.'' The Alliance requests
    that Congress consider the following fundamental flaws that continue to
    plague MIPS:
    ---------------------------------------------------------------------------
        \12\ https://www.gao.gov/assets/gao-22-104667.pdf.
        \13\ https://aspe.hhs.gov/sites/default/files/documents/
    dae3de25b874112a649445d6381f527e/PTAC-Mar-25-Escan.pdf.

          Siloed Performance Categories. CMS has failed to produce a more
    unified quality reporting structure, as promised under MACRA. MIPS
    continues to rely on four separate performance categories that each
    have distinct reporting requirements and scoring rules. Additionally,
    for many specialties, what is being measured on the quality side rarely
    aligns with what is being measured on the cost side, resulting in a
    flawed value equation. The Alliance has repeatedly asked CMS to provide
    cross-category credit for more robust value-based activities, such as
    reporting to a clinical data registry, which would minimize duplicative
    reporting and reward more innovative activities. However, CMS continues
    to cite statutory constraints, including the mandate to measure
    clinicians on each of the four MIPS performance categories as dictated
    by MACRA. As a result, the program is not only challenging to navigate
    and comply with, but for many specialties, it does not accurately
    reflect the overall value of care.
          Constantly Shifting Goalposts. Each year, CMS changes not only
    the MIPS eligibility rules and reporting requirements, but also the
    performance thresholds. As a result, it is challenging for physicians
    to keep up with the program and to make year-to-year comparisons
    regarding their performance. It is equally challenging for CMS to
    accurately analyze the overall impact of the program over time.
          Lack of Incentives for Specialty Measures. Many specialties have
    also faced challenges developing more specialty-focused quality
    measures and getting members to report on those measures as a result of
    MIPS scoring policies and other challenging requirements associated
    with maintaining a QCDR;
              QCDRs were authorized by Congress to provide a
            more flexible and rapid pathway for specialties to introduce
            more innovative and clinically relevant measures under MIPS.
            Instead, due to unnecessarily excessive and costly measure
            testing and data validation requirements imposed by CMS, many
            prominent specialty-sponsored registries have been given no
            other choice but to leave the program. This is unfortunate
            since clinician-led registries tend to collect more relevant
            and meaningful clinical outcomes data, including
            patient-reported outcomes data, that cannot be captured through
            claims. They also provide more timely and actionable feedback
            that is often more relevant to participating clinicians and
            their patient populations than what is provided by CMS under
            MIPS.
          Flawed Cost Measures. Cost measures adopted for MIPS are also
    extremely difficult to interpret and take meaningful action on. They
    often reflect care decisions and costs that are outside of a
    specialist's direct control and rarely align directly with quality
    measures other than in title. For example, autoimmune diseases such as
    rheumatoid arthritis and Crohn's disease are managed with highly
    complex medications, including biologics and biosimilars. Depending on
    the patient's unique biology, disease progression, and other clinical
    factors, one therapy may be clinically-indicated, recommended and
    prescribed over another. Regardless of the condition or disease,
    measuring the cost of care in isolation is dangerous as it fails to
    account for the impact that changes in spending have on care quality
    and access to care.
          Lack of Flexibility to Promote Interoperability. The MIPS
    Promoting Interoperability category continues to take a one-size-fits-
    all approach to care that fails to appreciate the diversity and
    readiness of practices across the nation. The category also continues
    to focus on very specific electronic health record (EHR)
    functionalities rather than promote innovative use cases of health
    information technology, such as clinical data registries, clinical
    decision supports tools, and tracking data from wearables and other
    digital devices that are more common among specialty patients.
          Lack of Alignment Across CMS Programs. MIPS physician-level
    reporting requirements and measures largely fail to align with other
    CMS value-based incentive programs, including payment and delivery
    models, that apply to other providers and settings of care. For
    example, specialty practices submitting quality measure data for the
    Bundled Payments for Care Initiative--Advanced (BPCI-A) cannot
    simultaneously receive credit for the same measures under MIPS and must
    submit data for the two programs separately. This results in
    administrative redundancy, duplicative accountability, and conflicting
    incentives-- particularly as it relates to team-based care
    coordination. This misalignment is costly for taxpayers and continues
    to make it challenging for Medicare to move the needle on the overall
    value of care for its beneficiaries.
          Failure to Provide a Glidepath to APM Participation. The intent
    of MIPS, as envisioned by MACRA, was to prepare physicians to move into
    APMs. However, the current program--even as recently revised through
    the MIPS Value Pathways (MVP) Framework-- largely fails to align with
    measures used under APMs and does little to ready specialists to move
    into APMs. Further, there are ongoing barriers to APM participation
    among specialists, as explained below.
          Misguided Efforts to Improve MIPS. Although CMS' recently
    introduced MVP framework was intended to address many of the problems
    outlined above, it simply reshuffles the deck while doing very little
    to address the program's foundational flaws, which increases
    frustration and disillusionment among physicians at a time when worker
    burnout is at an historical high.

    Advanced Alternative Payment Models (Advanced APMs)

    Unfortunately, the APM track of the QPP is no less challenging.
    Alliance organizations continue to hear from their specialty physician
    members that active engagement in APMs is near impossible. Specialty-
    focused APMs exist, but they only consider a limited number of
    conditions or procedures, leaving the vast majority of specialists
    without a dedicated model. Others, such as the BPCI-A program, do not
    align with other physician quality reporting requirements under MIPS
    and fail to provide high performing practices with an incentive to stay
    in the program since they are held to exceedingly high cost targets
    that simply do not support high quality, appropriate care.
    Additionally, as discussed earlier, specialists that are
    ``participants'' in ACOs are usually part of large hospitals or health
    systems, but their role is passive; they do not meaningfully engage in
    quality improvement or cost containment activities specific to the ACO,
    as the accountability measures do not consider the conditions they
    treat, nor services provide. Other specialists that attempt to join
    ACOs are blocked from entry by the primary care physicians who lead
    them.

    These findings are not just speculative. As highlighted in MedPAC's
    July 2022 Data Book,\14\ Health Care Spending and the Medicare Program,
    ---------------------------------------------------------------------------
        \14\ https://www.medpac.gov/wp-content/uploads/2022/07/
    July2022_MedPAC_DataBook_SEC
    _v2.pdf.

            Many specialties account for a larger share of clinicians in
            larger ACOs. This finding may reflect smaller ACOs being more
            often composed of independent physician practices with
            relatively fewer specialists, while larger ACOs are often
            affiliated with hospitals or health systems that have a broader
    ---------------------------------------------------------------------------
            range of specialists. (p. 44)

    MedPAC also explains that,

            Specialists' participation in ACOs relative to their share of
            all clinicians varies by specialty. For example, cardiologists
            comprise about 2 percent of all clinicians participating in FFS
            Medicare, but a larger share of clinicians participating in
            ACOs. By contrast, specialties such as anesthesiology and
            ophthalmology are underrepresented in ACOs relative to their
            share of all FFS clinicians. (p. 44)

    At the outset of the QPP, the Alliance and its member organizations--
    independently and collectively--proactively connected with the ACO
    member organization to discuss opportunities for improving specialists'
    participation in ACOs. One approach discussed, which is contemplated in
    a recent Health Affairs blog post by senior CMS Innovation Center
    officials,\15\ was the development of ``shadow bundles.'' This concept
    of nesting more specific episode-based or condition-specific models in
    population-based total cost of care (PB-TCOC) models was also discussed
    in PTAC's 2023 Request for Information (RFI) on Integrating Specialty
    Care in Population-Based Models \16\ and its follow-up 2024 RFI on
    Implementing Performance Measures for PB-TCOC.\17\ At the time, further
    attempts to coalesce around this concept with the ACO community were
    stalled. Ultimately, we were told that specialty medical care and
    treatment was expensive and hurt ACOs financial performance, and--in
    the case of primary care-led ACOs--there was no appetite for sharing
    ``savings'' with specialists.
    ---------------------------------------------------------------------------
        \15\ https://www.healthaffairs.org/content/forefront/cms-
    innovation-center-s-strategy-support-person-centered-value-based-
    specialty-care.
        \16\ https://aspe.hhs.gov/sites/default/files/documents/
    2cd91b29eac2742fbc9babaf8f3b7962/PTAC-Specialty-Integration-RFI.pdf.
        \17\ https://aspe.hhs.gov/sites/default/files/documents/
    823f7133bbde9de118d693a4330d2645/PTAC-Perf-Meas-RFI.pdf.

    The Alliance appreciates the CMS Innovation Center's recent recognition
    that a comprehensive approach to accountable care must account for both
    primary care and specialty care, and that it is exploring opportunities
    to build on the shadow bundle concept. Some Alliance member
    organizations have already invested in this type of work, yet they
    continue to face challenges in terms of getting CMS to adopt these
    models. The American Society of Cataract and Refractive Surgery
    (ASCRS), for example, developed the Bundled Payment for Same-Day
    Bilateral Cataract Surgery (BPBCS), which aims to promote same-day
    bilateral cataract surgery to appropriate patients at a lower cost for
    both patients and Medicare. Under this model, the Cataract Surgery Team
    (the surgeon, facility, and anesthesiologist) would receive a single
    bundled payment--rather than separate payments--for all services
    associated with the surgery. Importantly, the patient would also have a
    single cost-sharing amount for those services and there would be fewer
    trips needed to the surgery center and to the physician for follow-up
    visits, which would reduce out-of-pocket expenses for the patient and
    family. This model supports a team-based approach to care that promotes
    efficiencies that will result in the best outcomes at the lowest
    possible cost. Despite multiple encouraging meetings where CMS
    leadership expressed support for the model, the agency has yet to take
    any action. As a result, ASCRS has begun to explore alternative
    pathways, including working with Medicare Advantage plans to test the
    model. The BPBCS is an example of a thoughtfully developed framework
    that could work in tandem with CMS population-based, total-cost-of-care
    models--such as ACOs--as a separate voluntary agreement with a cataract
    surgery team, without requiring specialists to be part of an ACO. The
    Alliance continues to urge CMS and the Innovation Center to work more
    closely with the specialty community and to take advantage of
    ---------------------------------------------------------------------------
    investments that have already been made in this space.

    The specialty community has also faced challenges in terms of accessing
    data that will help it to better understand specialty engagement in,
    and barriers to, APM participation. Despite multiple requests, both CMS
    and MedPAC have flat-out refused to provide data on the number and type
    of specialists in APMs to help us better understand and overcome these
    challenges. As noted earlier, just last month, PTAC finally released
    some basic data on the participation rates of select specialties in
    Advanced APMs; however, the data are over 5 years old and provide no
    insight on more current trends.

    Making matters worse is the fact that under MACRA, the 5% Medicare
    incentive payment that has been offered since 2019 (based on 2017 APM
    participation) to clinicians who are Qualifying Participants (QP) in an
    Advanced APM was set to expire after the 2022 performance/2024 payment
    year. Congress subsequently extended this incentive payment an
    additional year, but at a reduced rate of 3.5%, and then again, for the
    2024 performance/2026 payment year, but at a further reduced rate of
    1.75%. Moving forward, as mandated under MACRA, physicians who qualify
    as QPs will only receive a nominal base conversion factor update
    starting in 2025 (0.75 percent vs. 0.25 percent for non-QPs, including
    MIPS participants who are also eligible for upward performance-based
    payment adjustments), limiting their incentives to join APMs going
    forward.

    MACRA also prescribes specific Medicare payment and patient thresholds
    that clinicians must meet to become QPs. Beginning with the 2023
    performance year, the Medicare QP Thresholds were supposed to increase
    to 75% (from 50%) for the payment amount method and 50% (from 35%) for
    the patient count method, making it more challenging for physicians to
    meet the definition of a QP. While Congress froze these thresholds at
    the lower levels for 2023 and 2024, they are scheduled to increase in
    2025 without Congressional action.

    While the Alliance appreciates the steps Congress has taken to date in
    an attempt to continue to support movement of physicians into APMs, it
    is still very concerned about the negative impact these shifting
    policies will have on the already slow movement of specialists into
    APMs. There have been very limited opportunities for specialists to
    participate meaningfully in APMs and qualify as QPs to date. With the
    expiring APM incentive payment, most specialists will never even have
    had the opportunity to qualify for this critical source of funding,
    which has been immensely helpful to physicians who must invest in
    infrastructure and analytics to participate meaningfully in an APM.
    Similarly, higher QP thresholds will result in even fewer specialists
    qualifying for this track.

    Finally, as mentioned earlier in the context of MIPS, CMS suffers from
    internal disorganization in its administration of Medicare value-based
    initiatives. Multiple offices within CMS are responsible for managing
    similar, but separate, value-focused initiatives authorized by MACRA,
    with little apparent coordination. For example, the staff responsible
    for administering the QPP seem disconnected from the CMMI staff
    administering APMs, despite the intrinsic link between the two, which
    results in duplicative reporting and accountability for clinicians.
    Additionally, to carry out these initiatives, CMS relies on numerous
    contractors who are not aligned or coordinated with one another, which
    leads to confusion, inefficiencies, and situations where individuals
    with no institutional historical knowledge and very little
    understanding of the clinical implications of their recommendations and
    actions are making important decisions.

    Recommendations to Improve MACRA

    Congress sought to provide flexible options for clinicians to engage in
    meaningful quality improvement and value-based care in the Medicare
    program. However, the implementation of these statutory quality
    programs has resulted in a rigid system that holds physicians
    accountable for metrics and models that often do not apply to them. We
    contend that MACRA must be overhauled and replaced with a payment
    system that:

          Ensures financial stability and predictability in the Medicare
    Physician Fee Schedule;
          Promotes and rewards value-based care innovation that
    meaningfully improves patient care and outcomes, particularly within
    specialty care; and
          Safeguards timely access to high-quality care by advancing
    health equity and reducing disparities.

    This can be accomplished by acting on the aforementioned
    recommendations. In addition, members of the Alliance participated in
    efforts by the AMA to develop its ``Characteristics of a Rational
    Medicare Payment System''\18\ and urge you to incorporate these
    principles in any physician payment reform solution.
    ---------------------------------------------------------------------------
        \18\ https://www.ama-assn.org/system/files/characteristics-
    rational-medicare-payment-principles-signatories.pdf.

    We look forward to working with the committee to ensure specialty
    physician practice viability and success and will be happy to discuss
    ---------------------------------------------------------------------------
    any other questions you may have going forward.

                                     ______

                  American Academy of Dermatology Association

                    1201 Pennsylvania Avenue, NW, Suite 540

                           Washington, DC 20004-2401

                              Main: (202) 842-3555

                              Fax: (202) 842-4355

                              https://www.aad.org/

    Chairman Wyden and Ranking Member Crapo, on behalf of the more than
    17,000 U.S. members of the American Academy of Dermatology Association
    (AADA), we thank you for the opportunity to submit a statement for the
    record regarding your hearing, ``Bolstering Chronic Care through
    Medicare Physician Payment.''

    As you explore ways to modernize and strengthen Medicare for seniors,
    one critical aspect that needs immediate attention is the instability
    of the Medicare physician payment system and the need for reform. The
    AADA firmly believes that Congress must take action to advance Medicare
    physician payment reform by:

          Establishing a positive annual inflation adjustment.
          Increasing the budget neutrality threshold, supporting a
    lookback period to rectify errors associated with utilization
    assumptions, and allowing specific services to be excluded from budget
    neutrality requirements.
          Reforming the Quality Payment Program (QPP) to increase
    physician input and improve patient care without overly burdensome
    documentation and compliance activity.

    In addition to these reforms, it's important to emphasize that
    Americans should have access to affordable, high-quality dermatologic
    care with the freedom to choose their own physicians and health
    insurance that best meets their needs. The Medicare program must ensure
    beneficiaries have adequate access to networks of specialists and
    subspecialists, including board-certified dermatologists. This goal can
    only be possible when health care policy is driven by the welfare of
    patients over short-sighted and siloed budgetary policies that increase
    overall health care spending and further erode the stability and
    predictability of the Medicare system.

    Inflation and the Siloed Medicare Program Structure

    The failure of the Medicare Physician Fee Schedule (MPFS) to keep up
    with inflation is the greatest threat to maintaining seniors' timely
    access to care in physician offices. Hospitals and other healthcare
    facilities receive Medicare payment updates, but physicians receiving
    payments under the MPFS are excluded from this type of adjustment. In
    fact, CMS finalized a 3.4% cut in the Calendar Year (CY) 2024 MPFS
    final rule. While the AADA appreciates the partial relief Congress
    provided to the MPFS in the Consolidated Appropriations Act, 2024,
    physician payments still ultimately received a cut from 2023.

    Since 2001, the cost of operating a medical practice has increased 47%.
    During this time, Medicare hospital and nursing facility updates
    resulted in a roughly 70% increase in payments to these entities,
    significantly outpacing physician reimbursement. Adjusted for inflation
    in practice costs, Medicare physician reimbursement declined 30% from
    2001 to 2024. This out-of-balance payment structure disproportionately
    threatens the viability of medical practices, especially smaller,
    independent, physician-owned practices, as well as those serving low-
    income or historically marginalized patients. This issue is further
    exacerbated by rising costs and inflation, leading to increased
    consolidation and hospital ownership of physician practices, resulting
    in higher expenses and reduced competition.

    [GRAPHIC] [TIFF OMITTED] T1124.004

    .epsCongress and CMS need to re-examine the siloed approach to
    reimbursement tied to the Medicare program. According to the 2020 and
    2021 Medicare Trustees' report, MPFS spending per enrollee was $2,107
    in 2011 and $2,389 in 2021, growing at an average annual rate of 1.3%.
    However, in contrast, Medicare spending per enrollee in Part A fee-for-
    service (FFS) was $5,178 in 2011 and $5,576 in 2021--a 7.7% increase
    and more than double the cost per patient treated under the MPFS.

    In considering the failure of the MPFS to keep up with the rising costs
    of delivering medical care, it is important to remember that physicians
    rely on reimbursement to cover a multitude of practice expenses. These
    expenses include staff salaries, benefits, federal and state regulatory
    compliance costs, and expenses associated with insurance mandates, such
    as step therapy and prior authorization. Moreover, technology
    requirements associated with compliance of the QPP are costly and
    contribute to the financial strain placed on physician offices.

    Physician practices are often small businesses that contribute to the
    economy of their communities. Other industries can adjust their
    products' pricing to reflect rising costs and increased staff salaries.
    However, physicians do not have the ability to do this. In fact, in the
    face of crippling inflation the MPFS serves to destabilize practices
    with year-after-year cuts. Such a structure is unsustainable, and we
    must not expect physicians delivering essential medical care to
    Medicare beneficiaries and their communities to endure it. Many
    physicians have already had to close their doors, leave their
    communities, retire early, or leave the practice of medicine. The below
    chart demonstrates the staggering numbers of physicians leaving the
    workforce, and this trend will continue as nearly 45% of physicians are
    older than age 55. The loss of experienced physicians is detrimental to
    patient outcomes and the young physicians who rely on them as a
    learning resource.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.definitivehc.com/sites/default/files/resources/
    pdfs/Addressing-the-healthcare-staffing-shortage-2023.pdf.

    [GRAPHIC] [TIFF OMITTED] T1124.005

    .epsThe inability to provide inflationary pay raises to practice
    employees is contributing to the current healthcare workforce crisis in
    which we are seeing increasing burnout rates and a mass exodus of our
    clinical, administrative, and clerical staff into other industries.
    With reduced staff comes a diminished capacity to provide quality care
    and maintain patient access. Reduced staffing leads to barriers in
    communicating and coordinating care, such as scheduling appointments
    and discussing lab reports, which can impact patient satisfaction and
    ---------------------------------------------------------------------------
    outcomes.

    The threat of future additional cuts to Medicare physician
    reimbursement jeopardizes physicians' ability to keep the doors open
    and care for patients in our communities. Fewer physicians in our
    communities means longer wait times for patients to receive care. When
    those patients do receive care, their only option may be non-physician
    providers of care with less training, or more expensive care in
    suboptimal settings including emergency departments and hospital-based
    practices. This is real, not theoretical, and is already occurring in
    our communities. Medicare patients will suffer in the end with delayed
    and second-rate care at a higher cost.

    Physicians need positive, inflation-based reimbursement updates to
    maintain financial stability and ensure patients have continued access
    to care. Inflationary updates tied to the Medicare Economic Index (MEI)
    need to be based on current data. In fact, the Medicare Payment
    Advisory Commission (MedPAC) recommended that Congress tie physician
    payment updates to the Medicare Economic Index (MEI) or practice cost
    inflation rates for 2025.\2\ Specifically, MedPAC recommended that
    Congress update the 2024 Medicare base payment rate for physician and
    other health professional services by the amount specified in current
    law plus 50% of the projected increase in the MEI. Based on CMS's MEI
    projections at the time of the publication of the March 2024 MedPAC
    Report to Congress, the recommended update for 2025 would be equivalent
    to 1.3% above current law.
    ---------------------------------------------------------------------------
        \2\ https://www.medpac.gov/document/march-2024-report-to-the-
    congress-medicare-payment-policy/.

    The AADA appreciates MedPAC's acknowledgment that the current Medicare
    physician payment system has not kept up with the cost of practicing
    medicine. While we value this recognition, Congress should adopt a 2025
    Medicare payment update that fully acknowledges the inflationary growth
    of health care costs. This step is crucial for ensuring financial
    stability in the Medicare physician payment system and maintaining
    ---------------------------------------------------------------------------
    continued access to high-quality patient care.

    The AADA urges Congress to pass H.R. 2474, the Strengthening Medicare
    for Patients and Providers Act, which would provide an inflationary
    update to the conversion factor under the Medicare Physician Fee
    Schedule based on the Medicare economic index.

    Budget Neutrality

    Downward pressure on Medicare reimbursement is due to budget neutrality
    requirements. This has resulted in a decline of 26% since 2001. The
    Medicare statute requires that changes made to fee schedule payments be
    implemented in a budget-neutral manner.

    Furthermore, by law, CMS must also create utilization assumptions for
    newly introduced services. When an overestimation occurs, it remains
    uncorrectable, leading to irreversible reductions in the funding
    allocated to the Medicare physician payment pool. For example, in 2013,
    transitional care management services were added to the MPFS. While CMS
    estimated 5.6 million new claims, actual utilization was under 300,000
    for the first year and less than a million claims after 3 years. This
    overestimation led to a $5.2 billion reduction in Medicare physician
    payments from 2013 to 2021. This example highlights the unintended
    consequences of the current budget policies within the flawed system.
    We firmly believe that CMS should have the authority to rectify
    utilization assumption errors that impact budget neutrality.

    In the absence of eliminating budget neutrality policy, we encourage
    Congress to pass H.R. 6371, the Provider Reimbursement Stability Act,
    to revise the budget neutrality policies to: (a) prevent erroneous
    utilization estimates from leading to inappropriate cuts; (b) clarify
    the types of services subject to budget neutrality adjustments; and (c)
    update the projected expenditure threshold triggering the budget
    neutrality adjustment, which has remained unchanged since 1992.

    Reform Quality Payment Program

    Value-Based Models
    Current value-based programs are burdensome, have not demonstrated
    improved care, and are not clinically relevant to the physician or the
    patient, and we have serious concerns with the viability and
    effectiveness of the Merit-based Incentive Payment System (MIPS)
    program. Numerous studies have highlighted persistent challenges
    associated with MIPS, including practices serving high-risk patients
    and those that are small or in rural areas. A study titled ``Evaluation
    of the Merit-Based Incentive Payment System and Surgeons Caring for
    Patients at High Social Risk,'' examined whether MIPS
    disproportionately penalized surgeons who care for patients at high
    social risk. This study found a connection between caring for high
    social risk patients, lower MIPS scores, and a higher likelihood of
    facing negative payment adjustments.\3\
    ---------------------------------------------------------------------------
        \3\ Byrd JN, Chung KC. Evaluation of the Merit-Based Incentive
    Payment System and Surgeons Caring for Patients at High Social Risk.
    JAMA Surg. 2021;156(11):1018-1024. doi:10.1001/jamasurg.2021.3746.

    Additionally, the Government Accountability Office (GAO) was tasked
    with reviewing several aspects concerning small and rural practices in
    relation to Medicare payment incentive programs, including MIPS. The
    GAO's findings indicated that physician practices with 15 or fewer
    providers, whether located in rural or non-rural areas, had a higher
    likelihood of receiving negative payment adjustments in Medicare
    incentive programs compared to larger practices.\4\
    ---------------------------------------------------------------------------
        \4\ Medicare Small and Rural Practices' Experiences in Previous
    Programs and Expected Performance in the Merit-Based Incentive Payment
    System. Report to Congressional Requesters. United States Government
    Accountability Office. 2018. https://www.gao.gov/assets/gao-18-428.pdf.

    These studies highlight flaws in traditional MIPS, particularly in
    terms of potential disparities in care and the financial burdens placed
    on physicians when caring for high-risk patient populations and
    physicians in small practices. The AADA recommends that Congress
    establish incentives, funding, and flexibility for physician offices
    with targeting small and solo practices.
    MIPS Value Pathways
    Since the passage of the Medicare Access and CHIP Reauthorization Act
    of 2015 (MACRA), CMS routinely introduces new changes to MIPS,
    requiring physicians to adjust continuously. Physicians are
    increasingly frustrated by the frequent modifications to the Quality
    Payment Program (QPP), including the associated administrative burdens
    of adhering to new program requirements and the lack of incentive
    payments to adequately compensate for participation efforts. While the
    AADA acknowledges CMS' attempt to address some of these concerns by
    introducing MIPS Value Pathways (MVPs) aimed at creating more
    meaningful groups of measures and activities to offer a more
    comprehensive assessment of quality of care, this new reporting option
    is falling short of achieving the Agency's goal.

    The AADA has significant concerns with the Agency's approach to
    constructing MVPs, as it is using excessively broad measure sets that
    lack alignment and provide no added benefit in terms of enhancing
    patient care or helping patients determine the value of the clinician
    managing their care. CMS' approach fails to account for the realities
    of clinical practice and adds yet another layer of complexity to an
    already confusing program. Take for example, CMS' candidate MVP for
    Dermatological Care. Despite nearly 2 years of discussions and meetings
    between CMS and the AADA, CMS continues to express interest in the use
    of a single MVP for dermatology. This decision ignores the critical
    problem of a one-size-fits-all approach, as it cannot effectively
    compare costs and quality of care. We have shared with CMS that each
    subspecialty within dermatology provides unique services to distinct
    patient populations with varying practice patterns. This diversity in
    the practice of dermatology makes a one-size-fits-all model ineffective
    for comparing the cost and quality of care. For instance,
    dermatologists who treat psoriasis, which is currently considered in
    the candidate MVP's quality measures may not treat melanoma, which is
    currently the only measure related to cost available in the candidate
    MVP. Regardless of how CMS ultimately scores MVP participants, if CMS
    finalizes an MVP that includes a cost measure for a cancer-related
    disease and quality measures for an inflammatory skin disease, patients
    and clinicians will question its purpose and the extent to which it
    fails to drive value-based care.

    Due to these numerous concerns, the AADA calls on Congress to urge CMS
    to pause on moving forward with the MVPs. The AADA welcomes the
    opportunity to continue working with CMS and the Congress to identify
    opportunities to improve quality, patient outcomes, and efficiencies.

    Burden on Physician Practices

    Furthermore, the QPP must keep a keen focus on preventing physician and
    staff burnout based on the Department of Health and Human Services
    (HHS) \5\ own priorities. This includes providing relief from systems-
    level factors that contribute to healthcare worker burnout by
    instituting measures that:
    ---------------------------------------------------------------------------
        \5\ https://www.hhs.gov/sites/default/files/health-worker-
    wellbeing-advisory.pdf.

          Implement systems changes that reduce administrative paperwork
    overall.
          Facilitate coordination at the systems level without adding
    administrative burden to healthcare practices and healthcare workers.
          Provide funds to purchase human-centered technology that
    facilitates providing value-based care; and
          Ensure engagement in value-based care does not lead to
    additional workload, overhead, and work hours for specialists.

    Conclusion

    On behalf of the AADA and its member dermatologists, thank you for
    holding this hearing, allowing the opportunity for stakeholders to
    submit a statement for the record, and for your commitment to ensuring
    physicians can continue to serve their Medicare patients. The AADA
    looks forward to working with you and asks that you continue to
    consider including physician stakeholders' opinions in your ongoing
    hearings as you work to identify a permanent solution to stabilize the
    Medicare physician payment program. Should you have any questions,
    please contact Adam Harbison, Director of Congressional Affairs at
    aharbison@aad.org.

                                     ______

                     American Academy of Home Care Medicine

                         6728 Old McLean Village Drive

                                McLean, VA 22101

    Members of the United States Senate Committee on Finance, thank you for
    holding this important hearing. We submit this statement for the record
    on behalf of the American Academy of Home Care Medicine (www.aahcm.org)
    to alert the committee about the status of the Independence at Home
    (IAH) demonstration and to provide suggestions for extension and
    revitalization of the model, especially to ensure access to home-based
    primary care for those living with multiple complex chronic conditions.

     History of Independence at Home and the Growing Need for Home-Based
                        Primary Care

    For Medicare, home-based primary care brings multiple rewards--
    enhancing quality of service and access to care for our nation's most
    ill elders and their families while achieving the important side effect
    of cost savings for Medicare. The Independence at Home (IAH)
    demonstration under the Centers for Medicare and Medicaid Services
    Innovation Center (CMMI) began in 2012 as first authorized by Section
    3024 of the Affordable Care Act. Since its inception the demonstration
    received strong bipartisan support and was extended three times by
    Congress in the last decade, though never expanded to bring in
    additional practices.

    Under the demonstration, health care providers are rewarded for
    providing high quality home-based primary care (HBPC) while reducing
    costs. Focused on care for Medicare patients who have multiple chronic
    conditions and disability, the IAH model uses mobile interdisciplinary
    teams of medical and social service professionals to care for patients
    in their homes, delivering high quality clinical care, excellent
    patient experience, and significantly lower costs for the Medicare
    program.

    The demonstration was rooted in the reality that high-need Medicare
    beneficiaries account for a disproportionate share of health care
    spending. The IAH demonstration used simple criteria, apparent to a
    clinician seeing a patient, yet also attributable through claims, to
    identify this group:

          Have two or more chronic conditions, expected to persist for
    more than a year.
          Have coverage from fee-for-serve Medicare A and B.
          Needs personal assistance with 2 or more activities of daily
    living such as bathing, dressing.
          Had a non-elective hospital admission in the last 12 months.
          Received Medicare Part A post-acute skilled services in the last
    12 months.

    At the start of the demonstration, such individuals represented 6% of
    the Traditional Medicare population but accounted for 30% of
    Traditional Medicare spending. Today, those qualified for IAH represent
    nearly 11% of the Traditional Medicare population and account for 44%
    of Traditional Medicare spending. The number of Traditional Medicare
    beneficiaries who would qualify for Independence at Home has increased
    by over 1.2 million since the start of the demonstration, but the
    number receiving home based primary care has increased by less than
    300,000. There are nearly 2 million more seniors who could be
    benefitting from home-based primary care as delivered by the IAH model
    but are not currently receiving these services. This number will only
    grow as the population continues to age, with the first Baby Boomers
    turning 80 in 2026.

    The growing number of seniors in need of home-based primary care, the
    insufficient supply of home-based primary care providers, particularly
    in rural and underserved areas, and the increasing share of Medicare
    costs associated with high need patients all require an effective
    program that can meet the needs of such patients.

     Independence at Home Model Works for Patients, Families, Communities,
                        and Providers

    Patients, Families, and Communities
    Many older adults living with severe chronic illnesses and disability
    have trouble traveling to the doctor's office, forcing them to rely on
    the emergency department or hospital due to cognitive, physical, or
    social barriers. Homebound seniors are more likely to be socially and
    economically disadvantaged, and are often socially isolated, with unmet
    care needs. For seriously ill elders, providing 24/7 medical and social
    services at home allows them to live a life with dignity and respect,
    where they want to be . . . at home. It brings peace of mind to family
    caregivers by coordinating all needed health services, prepares
    patients and families for managing serious illness, and supports them
    until the last day of life.

    IAH practices can deliver many services available in an urgent care
    center or hospital room--portable diagnostic, therapeutic, and
    monitoring technologies that allow the patient to stay at home, rather
    than come to the hospital. These services include urgent medical
    visits, blood tests, X-rays, EKGs, IV medications, oxygen, social work,
    and caregiver education. By providing such services, elders and
    families gain access to skilled primary care, maximize their time at
    home, call 911 less often, and are admitted less often to the hospital.
    For providers and health systems, the practice of house calls is an old
    idea, improved with modern technology. By visiting the home, providers
    build close relationships and trust with patients and families, leading
    to more accurate diagnosis and more effective treatment.

    Through receipt of high-quality care at home, IAH patients experience
    better quality outcomes. IAH providers are measured on six quality
    metrics, including all-cause hospital readmissions, ambulatory
    sensitive hospital admissions, and emergency department visits. In Year
    8 of the demonstration, the median participant reduced readmissions by
    23%, hospital admissions by 41%, and ED visits by 31%. These remarkable
    reductions in healthcare utilization translate into what matters most
    to patients: more time at home, less time cycling in and out of
    healthcare facilities.
    Providers
    IAH was designed to bring home based primary care practices into value-
    based care, with adequate resources to field the mobile teams these
    patients require. IAH providers serve as the ``quarterback'' of a
    mobile team, coordinating medical care and social services that are
    often as important as medical treatment. These mobile teams of
    Physicians, Nurse Practitioners or Physician Assistants, and Social
    Workers address routine and urgent issues and manage nearly all needed
    care in the home. IAH also encourages innovation in telehealth
    services. For example, some IAH sites have implemented tele-video
    after-hours or used specially trained paramedics to keep patients at
    home and out of the hospital. Many of these services are not reimbursed
    by traditional Medicare or are reimbursed at rates well below the cost
    to provide them.

    The IAH model allows health care providers to achieve the following
    goals.

          Spend more time with their patients.
          Perform assessments in a patient's home environment.
          Assume greater accountability for all aspects of a patient's
    care.
          Prevent chronic conditions from getting worse.
          Avoid unnecessary emergency department visits and
    hospitalizations.
          Improve patient and caregiver satisfaction.
          Lower overall costs to Medicare.

    The field of home-based primary care overwhelmingly consists of small
    practices: only 8% of practices have more than 750 patients. Of the
    over 2,400 home-based primary care practices in 2021, 2,200 of them had
    fewer than 500 patients. These practices are small businesses that
    serve a critical role, providing high quality healthcare jobs in their
    local communities. Delivering equivalent quality of care than larger
    practices, small practices are also more likely (19% higher) to be in
    underserved areas--the Area Deprivation Index, a composite metric of
    how socially disadvantaged a geographic area is.

    How the IAH Demonstration Functioned

    According to CMS's independent model evaluation, over the 8 years for
    which results are available, IAH practices have delivered care at $229
    million less than expected, or an average of $3,100 per beneficiary per
    year less than expected.\1\ These cost reductions have generated $148
    million in net savings for CMS. Participants have generated savings in
    every single year of the model. IAH practices have also reduced
    hospitalizations 20% and increased the time that patients spend at home
    by 13%. Patients of IAH practices have a 40% lower risk of entering a
    nursing home long term.
    ---------------------------------------------------------------------------
        \1\ CMS uses a difference-in-difference methodology to calculate
    savings generated by the model. Under this methodology, the total
    savings over 8 years has been $117 million, or $201 per beneficiary per
    month. However, this approach does not account for the lower costs that
    IAH participants were already generating before they started the model.
    Adjusting CMS's methodology to account for these lower costs pre-model
    produces the $229 million savings estimate.

    Participants also showed signs of improvement throughout the duration
    of the model. In the first year, 12 of the 17 practices delivered care
    at costs less than expected, while by Year 5 all practices were
    delivering care at lower-than-expected costs. Practices that were not
    initially delivering lower costs improved to a point where they were
    saving $330 per beneficiary per month. Practices that were already
    delivering low-cost care at the start of the model increased the
    savings they delivered from $400 per beneficiary per month initially to
    ---------------------------------------------------------------------------
    over $700 per beneficiary per month in Year 8.

    The IAH demonstration successfully enrolled high need patients, who
    cost on average $40-$50,000 per year, throughout its 10 years of
    operation. IAH was initially capped at only 10,000 beneficiaries and
    never allowed new practices to join after the start of the model.
    Despite these limitations, the demonstration retained over 80% of its
    original participating practices through Year 5. Through Year 5, IAH
    participants saved an average of $2,800 per beneficiary per year, for
    an average savings rate of 6%.

    After Year 5, some practices moved from IAH to other value-based models
    that offered better cash flow to maintain operations. In the original
    IAH design, practices would wait 18-24 months to receive any shared
    savings. Despite newer CMMI models that could accommodate home-based
    primary care practices, such as CPC+ and Primary Care First, nearly 60%
    of the IAH practices remained in the demonstration through Year 7
    because the primary care models didn't provide sufficient resources for
    high need patient care. Over the last 2 years of the demonstration, the
    remaining IAH practices have migrated to the High Needs Direct
    Contracting/High Needs ACO REACH model, while still delivering high
    value care. Unfortunately, the High Needs program excludes nearly a
    quarter of IAH qualified beneficiaries, has a minimum size requirement
    that excludes 96% of home-based primary care practices, and requires a
    level of down-side risk that few primary care practices can accept.
    High Needs ACO REACH is only an option for either the largest home-
    based primary care practices or practices that are willing to use a
    third-party aggregator, which typically takes a large portion of any
    savings earned.

    Apply Lessons Learned to Improve, Expand Independence at Home Model

    IAH could benefit nearly two million more Medicare beneficiaries with
    multiple chronic conditions and disability, the fastest growing and
    most costly segment of the Medicare population. IAH pays for itself
    from savings to the Medicare program through a smarter use of
    resources, providing monitoring and maintenance therapy and using
    technologically enhanced urgent care services in the home. IAH also
    eases the overwhelming demand from those living with severe chronic
    illness and disability, who wish to avoid institutionalization.

    The Independence at Home model has benefited from over a decade of
    experience, including lessons learned from other value-based systems.
    See Exhibit 1 at end summarizing the many studies and analyses of the
    Independence at Home model.

    With a revitalization of the model, IAH could address the significant
    disparities in who has access to home-based primary care in their
    community today. The current supply of home-based primary care is
    concentrated in urban metropolitan areas. According to one study, rural
    residents were 78% less likely to receive home-based care than
    residents of the largest metropolitan county.\2\
    ---------------------------------------------------------------------------
        \2\ Yao N, Richie C, Cornwall T and Leff B. Use of Home-Based
    Medical Care and Disparities. Journal of the American Geriatrics
    Society. 07 August 2018.

    We humbly ask the committee to not waste the precious resources devoted
    to this program over the last decade and to capitalize on the promise
    for IAH's future, especially given the growing need for home-based
    primary care in the aging Medicare population. We ask that you work
    with us to extend and revitalize the model in a few modest ways to
    ensure that it can continue to serve our nation's elderly.
    Modifications include better targeting beneficiaries in need, providing
    appropriate financial incentives and supports, bolstering practices
    with additional care management tools, and incorporating a broader set
    of services.

    Provide Caregiver Assessment and Support

          Expand the HBPC model to a new cohort of practices without a
    beneficiary cap.
          Include voluntary and claims-based alignment.
          Align all beneficiaries who receive a plurality of primary care
    from the participating practice; at least 30% of a practice's patients
    must meet High Needs criteria to be eligible for the model.

    Provide Appropriate Financial Incentives and Supports

          Introduce monthly enhanced primary care and health equity
    payments to support care investments.
          Reduce Medicare's guaranteed discount to ACO REACH levels.
          Use a concurrent risk adjustment methodology.

    Bolster Practices with Additional Care Management Tools

          Provide monthly performance data in a user-friendly format.
          Allow benefit enhancements such as the cost sharing waiver, SNF
    3-day waiver, and nurse practitioner provision of service waivers.

    Incorporate a Broader Set of Services

          Unpaid caregiver support.
          Coordination and management of home- and community-based
    services.

    Thank you for your committee's focus on home care for our nation's
    seniors. Providers and allies of the American Academy of Home Care
    stand with you and commit to assisting you in the laudable goal of best
    serving our nation's seniors.

    For further information, contact Peggy Tighe at
    Peggy.Tighe@PowersLaw.com or Emily Johnson at
    ejohnson@bloomhealthcare.com.

      Exhibit 1: The Independence at Home Demonstration, PA Table Review of
                                 the Literature
    ------------------------------------------------------------------------
             Title                Authors          Publication/Link     Year
    ------------------------------------------------------------------------
    Laying the Groundwork for Independence at Home
    ------------------------------------------------------------------------
    Effects of Home-Based    Eric De Jonge et   62 J. Am. Geriatrics    2014
     Primary Care on          al.                Soc'y \1\
     Medicare Costs in High-
     Risk Elders
    ------------------------------------------------------------------------
    Better Access, Quality,  Thomas Edes et     62 J. Am. Geriatrics    2014
     and Cost for             al.                Soc'y \2\
     Clinically Complex
     Veterans with Home-
     Based Primary Care
    ------------------------------------------------------------------------
    Geriatric Care           Steven R.          298 JAMA \3\            2007
     Management for Low-      Counsell,
     PIncome Seniors: A       Christopher M.
     Randomized Controlled    Callahan, Daniel
     Trial                    O. Clark et al.
    ------------------------------------------------------------------------
    Analysis of Independence at Home Results
    ------------------------------------------------------------------------
    Independence at Home:    Konstantinos E.    71 J. Am. Geriatrics    2023
     After 10 Years of        Deligiannidis,     Soc'y \4\
     Evidence, It's Time      Peter Boling,
     for a Permanent          George Taler,
     Medicare Program         Bruce Leff, &
                              Bruce Kinosian
    ------------------------------------------------------------------------
    Evaluation of the        Laura Kimmey,      Mathematica \5\         2023
     Independence at Home     Jason Rotter,
     Demonstration: An        Joseph Lovins, &
     Examination of Year 7,   Rachel Kogan
     the First Year of the
     COVID-19 Pandemic
    ------------------------------------------------------------------------
    Letter to the Editor:    Laura Kimmey &     72 J. Am. Geriatrics    2023
     Independence at Home     Jason Rotter       Soc'y \6\
     Evaluation Findings Do
     Not Support Creating a
     Permanent Medicare
     Program
    ------------------------------------------------------------------------
    Reply to: Independence   Konstantinos E.    72 J. Am. Geriatrics    2023
     at Home Evaluation       Deligiannidis et   Soc'y \7\
     Findings Do Not          al.
     Support Creating a
     Permanent Medicare
     Program--It Does
    ------------------------------------------------------------------------
    The Underappreciated     Katherine          69 J. Am. Geriatrics    2021
     Success of Home-Based    Ornstein, David    Soc'y \8\
     Primary Care: Next       M. Levine, &
     Steps for CMS'           Bruce Leff
     Independence at Home
    ------------------------------------------------------------------------
    Comment on: The          Laura Kimmey &     70 J. Am. Geriatrics    2022
     Underappreciated         Valerie Cheh       Soc'y \9\
     Success of Home-Based
     Primary Care: Next
     Steps for CMS'
     Independence at Home
    ------------------------------------------------------------------------
    Reply to: Comment on:    Katherine          70 J. Am. Geriatrics    2022
     The Underappreciated     Ornstein, David    Soc'y \10\
     Success of Home-Based    M. Levine, &
     Primary Care: Next       Bruce Leff
     Steps for CMS'
     Independence at Home
    ------------------------------------------------------------------------
    Integrated Home- and     Girish Valluru et  67 J. Am. Geriatrics    2019
     Community-Based          al.                Soc'y \11\
     Services Improve
     Community Survival
     Among Independence at
     Home Medicare
     Beneficiaries Without
     Increasing Medicaid
     Costs
    ------------------------------------------------------------------------
    Randomized Controlled Trials
    ------------------------------------------------------------------------
    Outcomes of Home-Based   Alex D. Federman   71 J. Am. Geriatrics    2022
     Primary Care for         et al.             Soc'y \12\
     Homebound Older
     Adults: A Randomized
     Clinical Trial
    ------------------------------------------------------------------------
    Editorial: The           Peter A. Boling &  71 J. Am. Geriatrics    2022
     Challenge of Proving     Bruce Kinosian     Soc'y \13\
     the Value of Medical
     Care in the Home
    ------------------------------------------------------------------------
    Expanding Independence at Home: Model Projection Papers
    ------------------------------------------------------------------------
    Home-Based Primary       James Rotenberg    66 J. Am. Geriatrics    2018
     Care: Beyond Extension   et al.             Soc'y \14\
     of the Independence at
     Home Demonstration
    ------------------------------------------------------------------------

    Projected Savings and    Bruce Kinosian,    64 J. Am. Geriatrics    2016
     Workforce                George Taler, &    Soc'y \15\
     Transformation from      Peter Boling
     Converting
     Independence at Home
     to a Medicare Benefit
    ------------------------------------------------------------------------
    Targeting Frail High     T.E. Edes et al.   1 Innovation in Aging   2017
     Cost Veterans Improves                      \16\
     Impact and Efficiency
     of Home Based Primary
     Care (HBPC)
    ------------------------------------------------------------------------
    To Strengthen the        Bruce Leff, Peter  Health Affairs Blog     2020
     Primary Care First       Boling, George     \17\
     Model for the Most       Taler, & Bruce
     Frail, Look to the       Kinosian
     Independence at Home
     Demonstration
    ------------------------------------------------------------------------
    Home-Based Care Systematic Reviews of Outcomes
    ------------------------------------------------------------------------
    Systematic Review of     Nathan Stall,      62 J. Am. Geriatrics    2014
     Outcomes from Home-      Mark               Soc'y \18\
     Based Primary Care       Nowaczynski, &
     Programs for Homebound   Samir K. Sinha
     Older Adults
    ------------------------------------------------------------------------
    Comparative              Agency for         AHRQ \19\               2016
     Effectiveness Review     Healthcare Rsch.
     No. 164: Home Based      and Quality,
     Primary Care             U.S. Dep't of
     Interventions            HHS.
    ------------------------------------------------------------------------
    Home-Based Primary       Robert M.          69 J. Am. Geriatrics    2021
     Care: A Systematic       Zimbroff,          Soc'y \20\
     Review of the            Katherine A.
     Literature, 2010-2020    Ornstein, & Orla
                              C. Sheehan
    ------------------------------------------------------------------------
    Continuing Need for and Disparities in Access to Home-Based Care
    ------------------------------------------------------------------------
    Primary Care in the      George Taler,      Primary Care for        2018
     Home: The Independence   Peter Boling, &    Older Adults \21\
     at Home Demonstration    Bruce Kinosian
     in Primary Care for
     Older Adults
    ------------------------------------------------------------------------
    Use of Home-Based        Jennifer M.        24 J. Am. Medical       2023
     Clinical Care and Long-  Reckrey et al.     Directors
     Term Services and                           Association \22\
     Supports Among
     Homebound Older Adults
    ------------------------------------------------------------------------
    Geographic               Nengliang Yao et   35 Health Affairs       2016
     Concentration of Home-   al.                \23\
     Based Medical Care
     Providers
    ------------------------------------------------------------------------
    Home-Based Medical Care  Jeffrey Marr et    42 Health Affairs       2023
     Use in Medicare          al.                \24\
     Advantage and
     Traditional Medicare
     in 2018
    ------------------------------------------------------------------------
    County-Level Social      Harriet Mather,    JAMA Open Network       2023
     Vulnerability,           Katherine A.       \25\
     Metropolitan Status,     Ornstein, &
     and Availability of      Catherine
     Home Health Services     McDonough
    ------------------------------------------------------------------------
    The Dynamics of Being    Claire K. Ankuda   69 J. Am. Geriatrics    2021
     Homebound Over Time: A   et al.             Soc'y \26\
     Prospective Study of
     Medicare Beneficiaries
    ------------------------------------------------------------------------
    \1\ https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/
      jgs.12974.
    \2\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.13030.
    \3\ https://jamanetwork.com/journals/jama/fullarticle/209717.
    \4\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18386.
    \5\ https://www.mathematica.org/publications/evaluation-of-the-
      independence-at-home-demonstration-an-examination-of-year-7-the-first-
      year.
    \6\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18656.
    \7\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18659.
    \8\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17426.
    \9\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17640.
    \10\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17641.
    \11\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.15968.
    \12\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17999.
    \13\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18153.
    \14\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.15314.
    \15\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.14176.
    \16\ https://academic.oup.com/innovateage/article/1/suppl_1/1328/
      3902111?login=false.
    \17\ https://www.healthaffairs.org/content/forefront/strengthen-primary-
      care-first-model-most-frail-look-independence-home-demonstration.
    \18\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.13088.
    \19\ https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/home-
      based-care_research.pdf.
    \20\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17365.
    \21\ https://link.springer.com/chapter/10.1007/978-3-319-61329-1_11.
    \22\ https://pubmed.ncbi.nlm.nih.gov/37084771/.
    \23\ https://www.healthaffairs.org/doi/10.1377/
      hlthaff.2015.1437?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.
      org&rfr_dat=cr_pub%20%200pubmed.
    \24\ https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00376.
    \25\ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/
      2810650.
    \26\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17086.

                                     ______

                       American Academy of Ophthalmology

                           20 F Street, NW, Suite 400

                           Washington, DC 20001-6701

                               T: +1 202-737-6662

                              https://www.aao.org/

    Dear Chairman Wyden and Ranking Member Crapo:

    The American Academy of Ophthalmology appreciates the opportunity to
    share our perspectives on bolstering chronic care through Medicare
    physician payment. Ophthalmologists regularly treat numerous chronic
    and potentially blinding eye conditions such as age-related macular
    degeneration, diabetic retinopathy, and glaucoma, among others.
    Ophthalmology practices also treat large numbers of Medicare patients
    and are significantly impacted by Medicare physician payment policies.
    We commend you for holding this timely hearing as the current Medicare
    physician payment system is on an unsustainable path at a time when
    physicians are providing more care with fewer resources to maintain
    their practices as they manage patients in an increasingly complex
    health care environment. Without Congressional action, physicians will
    again be facing Medicare payment cuts in 2025, which could negatively
    impact Medicare beneficiaries' timely access to the health care they
    need.

    The Academy is the largest association of eye physicians and surgeons
    in the United States. A nationwide community of nearly 22,000 medical
    doctors, we protect sight and empower lives by setting the standard for
    ophthalmic education and advocating for our patients and the public. We
    innovate to advance our profession and to ensure the delivery of the
    highest-quality eye care. As such, we stand ready to work with the
    Committee and Congress to develop long-term solutions to the systemic
    problems within the Medicare physician payment system and preserve
    patient access to the highest-quality eye care.

    Our recommendations for long-term reform are listed below. We look
    forward to working with you on the implementation of these needed
    changes.

    Annual Inflation-Based Payment Update:

    When looking at the data, physician payments have fallen far behind
    inflation and increasing practice costs. In the past 22 years, Medicare
    physician payments have only seen a modest increase of 9 percent,
    averaging just 0.4 percent per year. Meanwhile, the expenses associated
    with running a medical practice have surged by 47 percent from 2001 to
    2023. Adjusted for inflation's impact on practice costs, Medicare
    physician pay has declined 26 percent during the same period (2001 to
    2023). This impact is unique to physician payments as nearly all other
    Medicare providers and suppliers receive an annual inflationary payment
    update. With this significant decline in real value of allowed charges,
    financial challenges have disproportionately impacted small,
    independent, and rural physicians, which incentivizes market
    consolidation and practice closures.\1\
    ---------------------------------------------------------------------------
        \1\ Kaiser Family Foundation. What We Know About Provider
    Consolidation. September 2, 2020. https://www.kff.org/health-costs/
    issue-brief/what-we-know-about-provider-consolidation/. Accessed June
    15, 2023.

    As the Senate Committee on Finance continues work to address the broken
    Medicare physician payment system, we urge the Committee to support
    legislation which would provide an annual inflation-based payment
    update based on the full Medicare Economic Index (MEI). A full
    inflation-based update would be a critical step towards resolving the
    problems created by ongoing yearly payment cuts that are plaguing our
    healthcare system and would help provide long fiscal stability for
    physicians.

    Budget Neutrality:

    Another key factor to consider addressing is the mandated budget
    neutrality requirement in the Medicare Physician Fee Schedule. By law,
    Medicare is a budget neutral financing system for physician
    reimbursements. Any positive payment adjustments for those who exceed
    the performance threshold are paid for by those receiving penalties. In
    the early years of the program, it was possible to avoid a penalty
    because the performance threshold was understandably set low as
    eligible providers grew familiar with the new program. As expected, the
    positive payment adjustments were small because most participants were
    not getting a penalty. Fortunately, during these early years Congress
    set aside a pool of money to be split among the exceptional performers
    who exceeded the performance threshold. This provided at least a small
    incentive to adopt meaningful changes to support high-quality care.

    Though the performance threshold has been raised year over year, the
    budget-
    neutral nature of the bonus payment adjustments continues to suppress
    the Congressionally intended meaningful positive payment incentives
    that can be realized. An article in Ophthalmology \2\ reviewed the
    national allowable payments for 13 of the 15 commonly performed
    ophthalmology procedures from 2011 to 2020, documenting a significant
    6.2% decline in reimbursement. The decline is a 17.7% cut when adjusted
    for inflation. While some reductions were due to revaluing misvalued
    codes, this study shows that the statutorily mandated budget neutrality
    requirement is forcing CMS to undervalue ophthalmology and other
    surgical services in the absence of legislation to enlarge the
    physician payment pool. As such, we urge the Committee to address the
    budget neutrality requirement. Therefore, the Academy strongly
    recommends that Congress enact reforms to the budget-
    neutrality policies of the Medicare Physician Fee Schedule to reduce
    inappropriate payment cuts and provide stability for Medicare physician
    payments.
    ---------------------------------------------------------------------------
        \2\ Patel S, Glasser D, Repka M, Berkowitz S, Sternberg P. Changes
    in Medicare Reimbursement for Commonly Performed Ophthalmic Procedures.
    Ophthalmology 2021. doi:10.1016/j.ophtha.2021.02.026. https://
    www.aaojournal.org/article/S0161-6420(21)00194-9/fulltext.
    ---------------------------------------------------------------------------

    Global Surgical Code Payments:

    Medicare currently pays surgeons and other specialists a single fee
    (global payment) when they perform major or minor surgery such as brain
    tumor removal, joint replacement, heart surgery, or cataract surgery.
    CMS established these global payments to cover the costs of a
    procedure, plus the typical pre-operative and follow-up care needed
    within a 10- or 90-day post-operative timeframe. Postop visits require
    the same physician work, medical decision making, and practice expenses
    as office E/M visits. Patient complexity does not disappear during the
    post-operative global period. In contrast, it is not unusual for
    surgery to destabilize comorbid conditions for patients with systemic
    conditions such as diabetes, hypertension, or glaucoma, that were
    stable prior to surgery. Surgeons, therefore, must also consider the
    complexity of problems and complications and/or morbidity or mortality
    of patient management just as they would do for a standalone E/M visit.

    In 2021, CMS increased payment for E/M services. However, the agency
    did not apply these increases to post-operative visits included in
    global surgical codes. The expense and complexity of these visits has
    increased just as those visits outside of the surgical global period.
    Despite engagement efforts by the Academy, the American Medical
    Association, the American College of Surgeons and others, CMS again
    declined to apply the increased E/M values to post-operative visits in
    both the 2023 and 2024 Medicare Physician Fee Schedules.

    Arbitrarily adjusting certain E/M codes in the Fee Schedule conflicts
    with the Omnibus Budget Reconciliation Act (OBRA) of 1989 (Public Law
    101-239), which prohibits Medicare from paying physicians differently
    for the same work. Failing to adjust payment for E/M visits included in
    global codes results in paying surgeons less than other physicians, in
    violation of the law. Every time CMS has increased payment for office
    visits in the past, the agency also adjusted global surgery bundled
    payments to account for the E/M portion of these codes.

    Ophthalmology services, such as the recently revalued retinal
    detachment surgery, demonstrate why the current policy creates
    inequity. Surgeons now receive LESS pay for the work of a retinal
    detachment procedure AND the two post-operative visits, than if the
    surgeon did the procedure for free, and only billed for the two post-
    operative visits at the current rate for E/M office visits. This is
    illogical and emphasizes why CMS' policy must change.

    One reason CMS uses to justify undervaluing surgical E/M visits, is
    that the agency is not convinced surgeons provide all the post-
    operative visits included in global surgical codes. However, a process
    already exists through the American Medical Association's Relative
    Value Scale Update Committee (RUC) to evaluate any global codes
    believed to be ``misvalued'' including the number of postoperative
    visits. The adjustment of cataract surgery fees show how the process
    ensures codes are appropriately valued.

    CMS revalued cataract surgery payment through this medicine-supported
    process in 2019. Since CMS accepted the RUC's recommended revaluation,
    including that ophthalmologists provide three post-operative visits in
    the procedure's 90-day global period, these doctors should be paid
    equally to other physicians for providing the same level of service per
    patient. The Academy continues working with other surgical
    organizations to have CMS revisit its decision and apply the increased
    values to the E/M portion of the global codes. The Academy urges the
    Committee to put additional pressure on the agency to provide proper
    equitable payment for postoperative E/M visits included in global
    surgical packages.

    Payment Challenges and Healthcare Consolidation:

    Historically, ophthalmology practices have been small businesses with
    more than 90% of our members in small practices, defined by Medicare as
    having 15 or fewer physicians. However, medical practice consolidation
    including ophthalmology has increased significantly in recent years.\3\
    While ophthalmology had largely escaped hospital and health system
    practice acquisitions in the past, the specialty is now experiencing a
    trend in private equity consolidation.
    ---------------------------------------------------------------------------
        \3\ Chen E, Cox J, Begaj T, Armstrong G, Khurana R, Parikh R.
    Private Equity in Ophthalmology and Optometry. Ophthalmology.
    2020;127(4):445-455. doi:10.1016/j.ophtha.2020.01.007. https://
    www.aaojournal.org/article/S0161-6420(20)30012-9/fulltext. Published
    2020.

    Looking at consolidation more broadly across medicine, an AMA report
    stated that 2020 was the first year when less than half (49.1%) of
    patient care physicians worked in a private practice. The report also
    noted that the decrease in private practice physicians appears to have
    accelerated in recent years.\4\
    ---------------------------------------------------------------------------
        \4\ Kane C. Policy Research Perspectives: Recent Changes in
    Physician Practice Arrangements: Private Practice Dropped to Less Than
    50 Percent of Physicians in 2020. Ama-assn.org. https://www.ama-
    assn.org/system/files/2021-05/2020-prp-physician-practice-
    arrangements.pdf. Published 2021.

    The Academy is concerned about what greater consolidation within
    medicine could mean for patient care. While private equity has a
    diversity of forms, some of our members are troubled that private
    equity consolidation is prioritizing profit over patient care through
    understaffing and incentivizing unnecessary procedures. Consistent with
    these concerns, the Medicare Payment Advisory Commission's (MedPAC)
    March 2021 report stated that hospitals and physician groups were
    driving up prices as they consolidated.\5\
    ---------------------------------------------------------------------------
        \5\ Medicare Payment Advisory Commission. Report to the Congress:
    Medicare Payment Policy. 2021:xiv. http://www.medpac.gov/docs/default-
    source/reports/mar21_medpac_report_to_the_
    congress_sec.pdf?sfvrsn=0.

    As one of the primary physician specialties caring for Medicare
    beneficiaries, we support the oversight of Medicare spending. The
    Academy strongly believes the lack of fair updates to the Medicare
    Physician Fee Schedule is a major contributing factor to the
    consolidation trend. We believe Congress should review the current
    incentives to consolidate to ensure that Medicare policies are not
    inadvertently contributing to the drive towards greater consolidation
    of medical practices.

    Administrative Burdens on Physician Practices:

    Another aspect impacting the delivery of care is administrative and
    financial burdens dealing with prior authorization, which impose a
    significant strain on physicians and the patients they treat. Obtaining
    pre-approval for medical treatments or tests before administering care
    to their patients is a time-consuming and costly procedure that often
    forces physicians and their staff to spend a significant portion of
    their week engaging in negotiations with insurance companies. In most
    cases the care is ultimately approved. This time would be better
    utilized in caring for patients.

    The practice of prior authorization is rampant, and in 2018, the Office
    of the Inspector General (OIG) conducted a study that revealed an
    alarming trend in Medicare Advantage (MA) plans. It was found that MA
    plans overturned 75% of their own denials, strongly suggesting that the
    prior authorization process significantly delays medically necessary
    care. Furthermore, a more recent analysis conducted by the OIG
    demonstrated that the use of prior authorization by MA plans has led to
    the denial of medically necessary care that would have been covered
    under Medicare Fee-For-Service (FFS) for beneficiaries.

    The Academy has heard from many ophthalmologists, especially retina
    specialists, that some MA plans are requiring prior authorization for
    each visit and each intravitreal injection used to treat age-related
    macular degeneration (AMD), a chronic condition that requires monthly
    treatment in many patients. When asked, these retina specialists report
    that MA plans are approving essentially 100% of their prior
    authorization requests for this service. This continued prior
    authorization requirements are daily care and add additional cost.

    The Academy urges the Committee to support legislation that establishes
    an electronic prior authorization (e-PA) program within Medicare
    Advantage (MA), and also require MA plans to provide real-time decision
    making when responding to requests for items and services. By
    implementing an e-PA program and ensuring timely decisions, Congress
    can help streamline the prior authorization process, reduce
    administrative burdens, decrease pressure for consolidation, and
    improve access to necessary care and services for patients.

    Conclusion:

    The Academy applauds the Committee for conducting this hearing in order
    to develop policies that will improve physician payment and increase
    access to care for patients across the United States. We stand ready to
    work with the Committee and provide feedback as you pursue future
    policy changes.

                                     ______

                 American Academy of Orthopaedic Surgeons and
                  American Association of Orthopaedic Surgeons

                    317 Massachusetts Avenue, NE, Suite 100

                           Washington, DC 20002-5701

                               Phone 202-546-4430

                         https://www.aaos.org/advocacy/

         AAOS Recommendations: A Specialty Care Reimbursement Model to
         Operationalize Value-based Care for Musculoskeletal Conditions

    Prepared and Reviewed by AAOS Healthcare Systems Committee
    Karl M. Koenig, Chair

                              A. Executive Summary

    In response to the Center for Medicare and Medicaid Innovation (CMMI)
    initiatives in the space of value-based payment reform, the American
    Academy of Orthopaedic Surgeons (AAOS) and physician leaders have
    worked closely to develop recommendations toward advancing high value
    orthopaedic payment and practice models. With the end goal of moving
    away from dominant traditional fee-for-service models, the most
    prolific step to date is the sharing of risk on the total cost of care
    with health systems through accountable care organizations (ACOs).
    Building on this foundation, the challenge then remains to develop a
    structure by which ACOs and primary care providers can interact with
    musculoskeletal specialists and teams in a meaningful way. This can be
    achieved by creating opportunities to reward the practice of evidence-
    based, high value, cost-efficient care for patients.

    ACOs have matured at the primary care level, and many are on the road
    to improving quality of care for their populations through enhanced
    coordination and comprehensive chronic and complex disease management
    while sharing savings and lowering costs. However, ACOs still face
    challenges when it comes to organizational transformation around
    specialty care. At the specialty level, procedure-based bundled episode
    payment models, such as those involving total joint replacement surgery
    for osteoarthritis (OA) of the hip or knee, have been met with limited
    success. Cost reductions have been achieved through reductions in
    utilization (e.g., post-acute care), while maintaining but not
    substantially improving, clinical outcomes. Ultimately such models were
    never directly configured to address procedural appropriateness, or the
    provision of timely, equitable, and comprehensive specialized care, nor
    tailored to meet the holistic needs of diverse populations with a view
    to improving their health outcomes more broadly. In essence, the goal
    of true value for patients with specialized conditions has yet to be
    realized.

    Momentum is building among stakeholders in health care to shift the
    status quo toward a whole person approach that considers the patient's
    condition alongside their preferences, values, and needs (characterized
    as ``Comprehensive Condition-Based Care''). This shift promises to
    support and incentivize the reorganization of musculoskeletal care into
    multidisciplinary teams that aim to deliver more coordinated and
    efficient management of conditions across the full cycle of care. Most
    health systems currently perform ``non-operative care'' on the backdrop
    of primary care providers with insufficient support systems and/or
    training in managing musculoskeletal conditions. This often leads to a
    myriad of unnecessary imaging studies, non-value-added interventions,
    and delays to patient care. Once the PCP has exhausted their
    capabilities in caring for a particular condition, they are expected to
    navigate a broad portfolio of specialists and subspecialists who are
    all working under different sets of incentives and payment
    infrastructures. One logical approach to solving this issue is to
    incentivize care through condition-based payments with the aim of
    driving reorganization and model redesign on the specialty front. The
    end goal for ACOs would be early referral of these patients into the
    sphere of efficient, high quality specialty care teams without a
    concern that such patients will immediately become ``high cost,'' but
    instead confidence that they will receive high value care.

    In a comprehensive condition-based payment, a team of providers is paid
    a contracted rate to provide all care for a specified medical condition
    (or set of conditions) while holding themselves accountable to outcome
    measures relevant to that condition. The team is therefore incentivized
    to deliver high-value care throughout the entire cycle of the
    condition, including appropriate decision-making around when to proceed
    with surgical or non-surgical interventions. Such a system offers
    multiple positive effects on the delivery of care for musculoskeletal
    conditions. During our time conceptualizing value-based payment reform
    initiatives, as ``The Consortium for the Next Generation of Alternative
    Payment Models,'' we have identified a comprehensive set of
    considerations for condition-based care that should be addressed by
    stakeholders attempting to collaboratively build such models. These
    considerations have been framed as a design process of discovering the
    nature, scale, and opportunity; defining an analytical approach;
    developing model specifications fit for practice; and delivering the
    transformation.

          B. Discovery: Discovering the Nature, Scale, and Opportunity

    Stakeholders should get a sense of the nature, scale, and opportunity
    (clinical, financial, and experiential) of a new business model
    centered on a high value condition-based payment program. A first step
    is to define who is going to participate in building the most effective
    program before understanding how a new program fits among competing
    priorities within the organization and appreciating the potential
    challenges faced in specifying and building the requirements for such a
    program.

    Who is Going to Participate and How?

    Multiple stakeholders--whether payer, provider, or vendor--can spark
    the transformation toward high value musculoskeletal care and should
    remain steadfast in motivating others to join forces. Orthopaedic
    surgeons must be at the forefront of this change and either lead or be
    heavily involved with these teams because we have the highest level of
    training and often provide the full breadth of evidence-based treatment
    options for a given musculoskeletal condition. Expertise in the full
    spectrum of treatments allows the team to reduce unnecessary diagnostic
    testing that does not change treatment, reduces non-value-added
    interventions for patients, and provides timely evaluation and
    intervention when surgical treatment is the best answer. Having the
    full suite of evidence-based options catalyzes efficiency across the
    system and maximizes value from the patient perspective (which is our
    primary goal).

    A team delivering condition-based care must have ``all the tools in
    their toolbox'' to avoid unnecessary delays in access and treatment.
    Depending on the condition, the clinical team structure may vary and
    includes a multitude of musculoskeletal providers such as Orthopaedic
    surgeons, rheumatologists, primary care sports medicine specialists,
    physical therapists, physiatrists, associate providers, podiatrists,
    chiropractors, prosthetist/orthotists, dieticians and mental health
    providers.

    Should our team participate? Gaining a broader understanding of
    participating entities across the stakeholder groups and the base
    configuration of the contracting arrangement will enable the design of
    a program that is fit for purpose. Are we confident we will
    collectively have the people, resources, creativity, and capabilities
    to successfully implement condition-based care and most importantly the
    belief that this is ultimately better care? If not, then working with
    another entity to convene and manage comprehensive, condition-based
    payments on a larger scale may be the best entry point.

    Scoping Exercise

    We recommend an initial scoping exercise to concretely identify the
    affected patient population, geographical distribution, key
    stakeholders/service providers, affected membership count (including
    identified payer segments), and estimate of medical expenses for
    affected members. The most obvious candidates for a Medicare population
    would be ``Knee Pain/Knee Osteoarthritis'' or ``Low Back Pain/
    Degeneration.'' Given the previous experience with procedure bundles in
    these conditions, prior experience can facilitate the genesis of a
    pilot program.

    Clear gaps and opportunities for improvement should be articulated,
    such as suboptimal utilization, deficiencies in existing care pathways,
    outcomes assessed, issues of access and health equity, and
    affordability of care.

         C. Definition: Defining an Analytical Approach and Assumptions

    It is important to define an analytical approach and set expectations
    on analytical outputs early as part of the cycle of evidence generation
    that will fuel program configuration, implementation, and scaling. From
    this point onward, we illustrate recommendations and a framework with
    the management of knee pain/knee osteoarthritis in general (secondary
    to degenerative joint disease). Ideally, this phase should also
    accompany an actuarial model of the targeted population to identify
    reasonable financial constructs and targets.

    _______________________________________________________________________

        1. Condition Scope
    ------------------------------------------------------------------------
    Knee pain, degeneration, and derangement
        - Osteoarthritis
        - Meniscal tear
    ------------------------------------------------------------------------
        2. Condition Scope--Exclusions
    ------------------------------------------------------------------------
    Exclude
        - Malignancy (primary or metastatic)
        - Post-traumatic Arthritis (Motor vehicle accidents, trauma, intra-
         articular fracture)
        - Autoimmune arthrosis (e.g., Rheumatoid arthritis, lupus) or other
         inflammation
    ------------------------------------------------------------------------
        3. Diagnostic Coding
    ------------------------------------------------------------------------
    Global MSK codes (ICD-10)--the partnership intent is to effectively
     capture all relevant MSK diagnoses together (e.g., Knee Osteoarthritis
     (side specific), Mensical Tear, Sprain/Strain, etc). (See Appendix)

    A separate consideration is to include pain diagnoses that are later
     confirmed with an Eligible MSK Diagnosis. (e.g., member diagnosed with
     knee OA, but presented with knee pain 2 months prior--therefore,
     include all related Knee Pain services during that 2-month interim
     period). Such relevant services for pain episodes that lead to a
     diagnosed clinical condition (e.g., E&M, imaging, rehabilitation) could
     reasonably be included for maintaining accountability.
    ------------------------------------------------------------------------
        4. Service Scope
    ------------------------------------------------------------------------
    Type of service (some or all)
        1. All related E&M codes for musculoskeletal providers
        2. Specific CPT codes (e.g., surgery, physical therapy, anesthesia)
        3. Capture but "bucket" lower value interventions (e.g., MRI,
         hyaluronic acid, arthroscopy)

    Geographic
        1. ZIP code/county level
        2. State level
        3. MSA level
        4. Other strategic level

    Place of service (some or all)
        1. Inpatient
        2. Outpatient
        3. Office
        4. Ambulatory Surgical Center (ASC)
        5. ED

    Illustration
    Include all CPT codes that evidence an eligible diagnosis (defined
     earlier by Scope considerations) within a prespecified claim level
     (e.g., first four positions), at any Place of Service, in as wide a
     geography as feasible. More is better to create critical mass for
     clinicians, patients, and finances (practice revenue potential, medical
     expense savings potential; spread out fixed costs for everyone for this
     transformation). (See Appendix H).
    ------------------------------------------------------------------------
        5. Performance Evaluation
    ------------------------------------------------------------------------
    Performance Start-Stop
        1. Performance Year--predefined 12-month period wherein APM
         eligibility, attribution, and accountability are adjudicated. Most
         obvious is calendar year (January 1-December 31).
        2. Episode basis--member-specific starting date when initial
         eligible diagnosis/Trigger starts. Unique for each member (e.g.,
         one member on March 13th, another on April 3rd, etc)

    Duration of Performance
        1. 90 days
        2. 6 months
        3. 12 months

    Illustration
    12-month performance year on a calendar year basis with 90 day and 6-
     month evaluations

    Outcomes Reporting:
        1. Patient-reported Pain/Function: participation requires the
         incorporation of knee specific PRO scores and aggregate reporting
         at 6 months and 12 months (for accountability rather than
         comparison across participants). KOOS JR is currently used most
         broadly.
        2. Clinical: Utilize current clinical outcome metrics reporting for
         surgical patients (readmissions, reoperations)
    ------------------------------------------------------------------------

    Define and Communicate Savings Assumptions

    Based upon the analytical approach and analytical outputs, the
    participating service provider(s) should be able to use the data to
    specify a) where they identify the opportunity, b) how they approach
    that identified opportunity in their service delivery configuration,
    and c) the projected magnitude of impact on outcomes related to
    quality, finances, and/or experience.

    For example, illustrative opportunities in musculoskeletal care are
    shown in the table below where impact can be generated around
    utilization (increase high value and decrease low value strategies),
    intensity (reduce the intensity of utilization of specific strategies),
    locus of services (shift the location of services to enable more
    convenience, quality, experience while reducing cost).

    ------------------------------------------------------------------------
                                                          Projected area/
        Opportunity Area             Approach           magnitude of Impact
    ------------------------------------------------------------------------
    Injections               Reduce utilization       Financial
                              (e.g., hyaluronic
                              acid) and reduce
                              intensity (e.g.,
                              steroid)
    ------------------------------------------------------------------------
    Advanced Imaging         Reduce utilization       Financial
                              (e.g., MRI) and reduce
                              intensity (e.g.,
                              Frequency of x-rays)
    ------------------------------------------------------------------------
    Rehabilitation           Shift locus of services  Financial/Quality/
                              to self-management at    Experience
                              home; Reduce
                              utilization of post-
                              acute care; Increase
                              utilization of
                              exercise therapy,
                              education, and self-
                              management
    ------------------------------------------------------------------------
    Pain education and       Increase assessments of  Financial/Quality/
     behavioral health        mental/behavioral        Experience
     management               health, train in
                              coping strategies,
                              health coaching,
                              psychological
                              interventions
    ------------------------------------------------------------------------
    Overall visits           Reduce number of         Financial/Experience
                              outpatient visits
    ------------------------------------------------------------------------
    Surgery                  Reduce inappropriate     Financial/Quality/
                              surgical utilization     Experience
                              and increase
                              appropriate surgical
                              selection through
                              shared decision-
                              Pmaking
    ------------------------------------------------------------------------

    Broad statements of savings assumptions e.g., ``15% savings on
    musculoskeletal-
    related costs'' should be validated and articulated lever-by-lever by
    both payer and provider, including actuarial associates from each.
    These assumptions should be founded upon the payer's actual membership
    population and the provider's current or desired-future membership
    reach, as well as incorporate program engagement assumptions, e.g., 15%
    savings on 10% engaged members in a given year over 100,000 lives by
    specific geographies.

    C. Develop

    _______________________________________________________________________

        Program Pricing
    ------------------------------------------------------------------------
    Key Q. What should the episode price be inclusive of and what are
     withholding criteria?

    Key Points. The price is inclusive of:
        - Historical per-patient annual spend on relevant services
         (according to the program specifications regarding included ICD-
         10s, CPTs, sites, types, provider, geographies, lines of business,
         etc.)
    ------------------------------------------------------------------------
    MSK Illustration
    Include surgical professional fee distributed across all patients as
     fraction of utilization rate (e.g., $1,000 fee, 15% utilization rate =
     $150 added to each per-member per-period payment)
        - For the related-but-separate surgical bundle, there will exist a
         separate target price (less the surgical professional fee)

    Apply withholds for 1) episode completion/attribution and 2) quality
     measurement
    Balance provider-specific and multi-provider/regional utilization
     history
    Also need to include correction for under-utilization of relevant
     services (e.g., nutrition, mental health)
    ------------------------------------------------------------------------
        Type and Level of Risk
    ------------------------------------------------------------------------
    Key Q. What are the key considerations around type and level of risk?

    Key Points. Likely begin with initial upside for 1-2 years, introduce
     downside years 2-3 and beyond, moving eventually toward risk-adjusted
     capitated payment. Scope of risk to be defined by Program Parameters
     (diagnosis, service, site, type, provider, geography, etc.,).
    ------------------------------------------------------------------------

                   D. Delivery: Delivering the Transformation

    With the incentive of appropriate condition-based payments as an
    organizing principle, a variety of different structures will be viable.
    Time and experience will yield the most efficient structures and the
    system will adjust appropriately.

    Multidisciplinary MSK Practices: Many such practices currently exist
    who could take on a condition-based payment structure with minimal
    investment and adjustment. Often created by the expansion of
    Orthopaedic surgery groups, there are many examples of teams that
    already include Rheumatology, PMNR, Primary Care Sports, Physical
    Therapy, Podiatry, and Prosthetists/Orthotists. Such groups will be
    poised to take on pilot programs and prove the concept in conjunction
    with CMS. Internal reorganization will be required for many, but new
    capital investment and hiring could be minimized.

    Fully integrated health systems: Broad Solutions engage with both
    providers and members to improve care delivery and assume deep global/
    total accountability for cost and quality. For members they may offer
    care management, navigation, education, and other virtual or in-person
    services. For providers they may offer service line management, care
    pathways, incentive structures, ancillary services.

    Role of Market-based and digital health solutions:

    Utilization management solutions can be denial or education-based to
    enable provider (and member) adherence to clinical practice guidelines.
    These entities can provide immediate value but may also trigger some
    friction with the provider community. Such solutions could be used to
    stimulate accountable entities to perform and/or accept substantial
    risk to dial down the utilization management, or even turn it off.

    Point Solutions have rapidly expanded with a laser-focus on member
    experience and the delivery of coordinated, continuous, and convenient
    care for patients both in-person and through virtual care. Such
    solutions can provide relatively immediate value for health plans and
    accountable entities, with return on investment (ROI) guarantees.
    However, point solution coordination and integration with traditional
    provider networks is generally lacking at this time. In order to
    provide the full spectrum of care and take on a condition-based
    payment, these entities will need to partner with existing providers.
    This is another method of organization that will ``naturally'' create
    new entities and enable participation by smaller independent providers
    and practice groups.

     Appendix: Included ICD-10 Codes for ``Knee Pain/Knee Osteoarthritis''
                             for Medicare Patients

    _______________________________________________________________________

    M13861          Lower Extremity         Other specified arthritis, right
                                             knee
    ------------------------------------------------------------------------
    M13862          Lower Extremity         Other specified arthritis, left
                                             knee
    ------------------------------------------------------------------------
    M170            Lower Extremity         Bilateral primary osteoarthritis
                                             of knee
    ------------------------------------------------------------------------
    M1711           Lower Extremity         Unilateral primary
                                             osteoarthritis, right knee
    ------------------------------------------------------------------------
    M1712           Lower Extremity         Unilateral primary
                                             osteoarthritis, left knee
    ------------------------------------------------------------------------
    M1712           Lower Extremity         Unilateral primary
                                             osteoarthritis, left knee
    ------------------------------------------------------------------------
    M1712           Lower Extremity         Unilateral primary
                                             osteoarthritis, left knee
    ------------------------------------------------------------------------
    M174            Lower Extremity         Other bilateral secondary
                                             osteoarthritis of knee
    ------------------------------------------------------------------------
    M222X1          Lower Extremity         Patellofemoral disorders, right
                                             knee
    ------------------------------------------------------------------------
    M2241           Lower Extremity         Chondromalacia patellae, right
                                             knee
    ------------------------------------------------------------------------
    M23051          Lower Extremity         Cystic meniscus, posterior horn
                                             of lat mensc, right knee
    ------------------------------------------------------------------------
    M2341           Lower Extremity         Loose body in knee, right knee
    ------------------------------------------------------------------------
    M2341           Lower Extremity         Loose body in knee, right knee
    ------------------------------------------------------------------------
    M2341           Lower Extremity         Loose body in knee, right knee
    ------------------------------------------------------------------------
    M238X9          Lower Extremity         Other internal derangements of
                                             unspecified knee
    ------------------------------------------------------------------------
    M2392           Lower Extremity         Unspecified internal derangement
                                             of left knee
    ------------------------------------------------------------------------
    M24661          Lower Extremity         Ankylosis, right knee
    ------------------------------------------------------------------------
    M25462          Lower Extremity         Effusion, left knee
    ------------------------------------------------------------------------
    M25561          Lower Extremity         Pain in right knee
    ------------------------------------------------------------------------
    M25562          Lower Extremity         Pain in left knee
    ------------------------------------------------------------------------
    M67461          Lower Extremity         Ganglion, right knee
    ------------------------------------------------------------------------
    M7041           Lower Extremity         Prepatellar bursitis, right knee
    ------------------------------------------------------------------------
    M7121           Lower Extremity         Synovial cyst of popliteal space
                                             [Baker], right knee
    ------------------------------------------------------------------------
    M7122           Lower Extremity         Synovial cyst of popliteal space
                                             [Baker], left knee
    ------------------------------------------------------------------------
    M7122           Lower Extremity         Synovial cyst of popliteal space
                                             [Baker], left knee
    ------------------------------------------------------------------------
    M7651           Lower Extremity         Patellar tendinitis, right knee
    ------------------------------------------------------------------------
    M93261          Lower Extremity         Osteochondritis dissecans, right
                                             knee
    ------------------------------------------------------------------------
    M9689           Lower Extremity         Oth intraop and postproc comp
                                             and disorders of the ms sys
    ------------------------------------------------------------------------
    Q686            Lower Extremity         Discoid meniscus
    ------------------------------------------------------------------------
    S8001XD         Lower Extremity         Contusion of right knee,
                                             subsequent encounter
    ------------------------------------------------------------------------
    S83004A         Lower Extremity         Unspecified dislocation of right
                                             patella, initial encounter
    ------------------------------------------------------------------------
    S83004D         Lower Extremity         Unspecified dislocation of right
                                             patella, subs encntr
    ------------------------------------------------------------------------
    S83200D         Lower Extremity         Bucket-hndl tear of unsp mensc,
                                             current injury, r knee, subs
    ------------------------------------------------------------------------
    S83206A         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, right knee,
                                             init
    ------------------------------------------------------------------------
    S83206D         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, right knee,
                                             subs
    ------------------------------------------------------------------------
    S83207A         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, left knee, init
    ------------------------------------------------------------------------
    S83207D         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, left knee, subs
    ------------------------------------------------------------------------
    S83207S         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, l knee, sequela
    ------------------------------------------------------------------------
    S83209A         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, unsp knee, init
    ------------------------------------------------------------------------
    S83209D         Lower Extremity         Unsp tear of unsp meniscus,
                                             current injury, unsp knee, subs
    ------------------------------------------------------------------------
    S83221D         Lower Extremity         Prph tear of medial meniscus,
                                             current injury, r knee, subs
    ------------------------------------------------------------------------
    S83222D         Lower Extremity         Prph tear of medial meniscus,
                                             current injury, l knee, subs
    ------------------------------------------------------------------------
    S83231A         Lower Extremity         Complex tear of medial mensc,
                                             current injury, r knee, init
    ------------------------------------------------------------------------
    S83231D         Lower Extremity         Complex tear of medial mensc,
                                             current injury, r knee, subs
    ------------------------------------------------------------------------
    S83232D         Lower Extremity         Complex tear of medial mensc,
                                             current injury, l knee, subs
    ------------------------------------------------------------------------
    S83241D         Lower Extremity         Oth tear of medial meniscus,
                                             current injury, r knee, subs
    ------------------------------------------------------------------------
    S83242D         Lower Extremity         Oth tear of medial meniscus,
                                             current injury, left knee, subs
    ------------------------------------------------------------------------
    S83251A         Lower Extremity         Bucket-hndl tear of lat mensc,
                                             current injury, r knee, init
    ------------------------------------------------------------------------
    S83251D         Lower Extremity         Bucket-hndl tear of lat mensc,
                                             current injury, r knee, subs
    ------------------------------------------------------------------------
    S83261A         Lower Extremity         Prph tear of lat mensc, current
                                             injury, right knee, init
    ------------------------------------------------------------------------
    S83261D         Lower Extremity         Prph tear of lat mensc, current
                                             injury, right knee, subs
    ------------------------------------------------------------------------
    S83271A         Lower Extremity         Complex tear of lat mensc,
                                             current injury, right knee,
                                             init
    ------------------------------------------------------------------------
    S83281D         Lower Extremity         Oth tear of lat mensc, current
                                             injury, right knee, subs
    ------------------------------------------------------------------------
    S83411A         Lower Extremity         Sprain of medial collateral
                                             ligament of right knee, init
    ------------------------------------------------------------------------
    S83412A         Lower Extremity         Sprain of medial collateral
                                             ligament of left knee, init
    ------------------------------------------------------------------------
    S83422A         Lower Extremity         Sprain of lateral collateral
                                             ligament of left knee, init
    ------------------------------------------------------------------------
    S83521A         Lower Extremity         Sprain of posterior cruciate
                                             ligament of right knee, init
    ------------------------------------------------------------------------
    S838X2A         Lower Extremity         Sprain of other specified parts
                                             of left knee, init encntr
    ------------------------------------------------------------------------
    S8391XA         Lower Extremity         Sprain of unspecified site of
                                             right knee, initial encounter
    ------------------------------------------------------------------------
    S8392XA         Lower Extremity         Sprain of unspecified site of
                                             left knee, initial encounter
    ------------------------------------------------------------------------
    Z96651          Lower Extremity         Presence of right artificial
                                             knee joint
    ------------------------------------------------------------------------
    Z96652          Lower Extremity         Presence of left artificial knee
                                             joint
    ------------------------------------------------------------------------
    Z96653          Lower Extremity         Presence of artificial knee
                                             joint, bilateral
    ------------------------------------------------------------------------
    Z96659          Lower Extremity         Presence of unspecified
                                             artificial knee joint
    ------------------------------------------------------------------------
    M1710           Lower Extremity         Unilateral primary
                                             osteoarthritis, unspecified
                                             knee
    ------------------------------------------------------------------------
    M175            Lower Extremity         Other unilateral secondary
                                             osteoarthritis of knee
    ------------------------------------------------------------------------
    M179            Lower Extremity         Osteoarthritis of knee,
                                             unspecified
    ------------------------------------------------------------------------
    M179            Lower Extremity         Osteoarthritis of knee,
                                             unspecified
    ------------------------------------------------------------------------
    M179            Lower Extremity         Osteoarthritis of knee,
                                             unspecified
    ------------------------------------------------------------------------
    M25569          Lower Extremity         Pain in unspecified knee
    ------------------------------------------------------------------------
    M25569          Lower Extremity         Pain in unspecified knee
    ------------------------------------------------------------------------
    M11269          Lower Extremity         Other chondrocalcinosis,
                                             unspecified knee
    ------------------------------------------------------------------------
    M13169          Lower Extremity         Monoarthritis, not elsewhere
                                             classified, unspecified knee
    ------------------------------------------------------------------------
    M25469          Lower Extremity         Effusion, unspecified knee
    ------------------------------------------------------------------------
    M25669          Lower Extremity         Stiffness of unspecified knee,
                                             not elsewhere classified
    ------------------------------------------------------------------------
    M67469          Lower Extremity         Ganglion, unspecified knee
    ------------------------------------------------------------------------
    M2212           Lower Extremity         Recurrent subluxation of
                                             patella, left knee
    ------------------------------------------------------------------------
    M222X2          Lower Extremity         Patellofemoral disorders, left
                                             knee
    ------------------------------------------------------------------------
    M222X9          Lower Extremity         Patellofemoral disorders,
                                             unspecified knee
    ------------------------------------------------------------------------
    M2240           Lower Extremity         Chondromalacia patellae,
                                             unspecified knee
    ------------------------------------------------------------------------
    M2242           Lower Extremity         Chondromalacia patellae, left
                                             knee
    ------------------------------------------------------------------------
    M23222          Lower Extremity         Derang of post horn of medial
                                             mensc d/t old tear/inj, l knee
    ------------------------------------------------------------------------
    M23322          Lower Extremity         Oth meniscus derang, post horn
                                             of medial meniscus, l knee
    ------------------------------------------------------------------------
    M2342           Lower Extremity         Loose body in knee, left knee
    ------------------------------------------------------------------------
    M2351           Lower Extremity         Chronic instability of knee,
                                             right knee
    ------------------------------------------------------------------------
    M23612          Lower Extremity         Oth spon disrupt of anterior
                                             cruciate ligament of left knee
    ------------------------------------------------------------------------
    M25369          Lower Extremity         Other instability, unspecified
                                             knee
    ------------------------------------------------------------------------
    M6751           Lower Extremity         Plica syndrome, right knee
    ------------------------------------------------------------------------
    M6752           Lower Extremity         Plica syndrome, left knee
    ------------------------------------------------------------------------
    M71569          Lower Extremity         Other bursitis, not elsewhere
                                             classified, unspecified knee
    ------------------------------------------------------------------------
    S76111A         Lower Extremity         Strain of right quadriceps
                                             muscle, fascia and tendon, init
    ------------------------------------------------------------------------
    S83005A         Lower Extremity         Unspecified dislocation of left
                                             patella, initial encounter
    ------------------------------------------------------------------------
    S83005S         Lower Extremity         Unspecified dislocation of left
                                             patella, sequela
    ------------------------------------------------------------------------
    S83015D         Lower Extremity         Lateral dislocation of left
                                             patella, subsequent encounter
    ------------------------------------------------------------------------
    S83203D         Lower Extremity         Oth tear of unsp meniscus,
                                             current injury, right knee,
                                             subs
    ------------------------------------------------------------------------
    S83204D         Lower Extremity         Oth tear of unsp meniscus,
                                             current injury, left knee, subs
    ------------------------------------------------------------------------
    S83221A         Lower Extremity         Prph tear of medial meniscus,
                                             current injury, r knee, init
    ------------------------------------------------------------------------
    S83222A         Lower Extremity         Prph tear of medial meniscus,
                                             current injury, l knee, init
    ------------------------------------------------------------------------
    S83222S         Lower Extremity         Prph tear of medial mensc,
                                             current injury, l knee, sequela
    ------------------------------------------------------------------------
    S83241A         Lower Extremity         Oth tear of medial meniscus,
                                             current injury, r knee, init
    ------------------------------------------------------------------------
    S83242A         Lower Extremity         Oth tear of medial meniscus,
                                             current injury, left knee, init
    ------------------------------------------------------------------------
    S83262D         Lower Extremity         Prph tear of lat mensc, current
                                             injury, left knee, subs
    ------------------------------------------------------------------------
    S83281A         Lower Extremity         Oth tear of lat mensc, current
                                             injury, right knee, init
    ------------------------------------------------------------------------
    S83412D         Lower Extremity         Sprain of medial collateral
                                             ligament of left knee, subs
    ------------------------------------------------------------------------
    S83412S         Lower Extremity         Sprain of medial collateral
                                             ligament of left knee, sequela
    ------------------------------------------------------------------------
    S83511A         Lower Extremity         Sprain of anterior cruciate
                                             ligament of right knee, init
    ------------------------------------------------------------------------
    S83511D         Lower Extremity         Sprain of anterior cruciate
                                             ligament of right knee, subs
    ------------------------------------------------------------------------
    S83511S         Lower Extremity         Sprain of anterior cruciate
                                             ligament of right knee, sequela
    ------------------------------------------------------------------------
    S83512A         Lower Extremity         Sprain of anterior cruciate
                                             ligament of left knee, init
    ------------------------------------------------------------------------
    S83512D         Lower Extremity         Sprain of anterior cruciate
                                             ligament of left knee, subs
    ------------------------------------------------------------------------
    S83521D         Lower Extremity         Sprain of posterior cruciate
                                             ligament of right knee, subs
    ------------------------------------------------------------------------

                   Appendix: Included E&M, CPT, and Services

    _______________________________________________________________________

    20610             Arthrocentesis, Aspiration and/or Injection; Major
                       Joint or Bursa (e.g., Shoulder, Hip, Knee Joint,
                       Subacromial Bursa);
    ------------------------------------------------------------------------
    20611             Arthrocentesis, Aspiration and/or Injection, Major
                       Joint Or Bursa (e.g., Shoulder, Hip, Knee,
                       Subacromial Bursa); With Ultrasound Guidance, With
                       Permanent Recording and Reporting
    ------------------------------------------------------------------------
    20680             Removal of Implant; Deep (e.g., Buried Wire, Pin,
                       Screw, Metal Band, Nail, Rod or Plate)
    ------------------------------------------------------------------------
    27327             Excision, Tumor, Soft Tissue of Thigh or Knee Area,
                       Subcutaneous; Less Than 3 Cm
    ------------------------------------------------------------------------
    27347             Excision of Lesion of Meniscus or Capsule (e.g., Cyst,
                       Ganglion), Knee
    ------------------------------------------------------------------------
    27438             Arthroplasty, patella; with prosthesis
    ------------------------------------------------------------------------
    27446             Arthroplasty, knee, condyle and plateau; medial OR
                       lateral compartment
    ------------------------------------------------------------------------
    27447             Arthroplasty, Knee, Condyle And Plateau; Medial and
                       Lateral Compartments With or Without Patella
                       Resurfacing (Total Knee Arthroplasty)
    ------------------------------------------------------------------------
    29505             Application Of Long Leg Splint (Thigh To Ankle Or
                       Toes)
    ------------------------------------------------------------------------
    29874             Arthroscopy, Knee, Surgical; For Removal Of Loose Body
                       Or Foreign Body (e.g., Osteochondritis Dissecans
                       Fragmentation, Chondral Fragmentation)
    ------------------------------------------------------------------------
    29875             Arthroscopy, Knee, Surgical; Synovectomy, Limited
                       (e.g., Plica Or Shelf Resection) (Separate Procedure)
    ------------------------------------------------------------------------
    29876             Arthroscopy, Knee, Surgical; Synovectomy, Major, 2 Or
                       More Compartments (e.g., Medial Or Lateral)
    ------------------------------------------------------------------------
    29877             Arthroscopy, Knee, Surgical; Debridement/Shaving of
                       Articular Cartilage (Chondroplasty)
    ------------------------------------------------------------------------
    29879             Arthroscopy, Knee, Surgical; Abrasion Arthroplasty
                       (Includes Chondroplasty Where Necessary) Or Multiple
                       Drilling Or Microfracture
    ------------------------------------------------------------------------
    29880             Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
                       And Lateral, Including Any Meniscal Shaving)
                       Including Debridement/Shaving of Articular Cartilage
                       (Chondroplasty), Same or Separate Compartment(S),
                       When Performed
    ------------------------------------------------------------------------
    29881             Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
                       or Lateral, Including Any Meniscal Shaving) Including
                       Debridement/Shaving of Articular Cartilage
                       (Chondroplasty), Same or Separate Compartment(s),
                       When Performed
    ------------------------------------------------------------------------
    73552             Radiologic Examination, Femur; Minimum 2 Views
    ------------------------------------------------------------------------
    73560,TC          Radiologic Examination, Knee; 1 or 2 Views
    ------------------------------------------------------------------------
    73560             Radiologic Examination, Knee; 1 or 2 Views
    ------------------------------------------------------------------------
    73562,TC          Radiologic Examination, Knee; 3 Views
    ------------------------------------------------------------------------
    73562             Radiologic Examination, Knee; 3 Views
    ------------------------------------------------------------------------
    73564             Radiologic Examination, Knee; Complete, 4 Or More
                       Views
    ------------------------------------------------------------------------
    73565,TC          Radiologic Examination, Knee; Both Knees, Standing,
                       Anteroposterior
    ------------------------------------------------------------------------
    73565             Radiologic Examination, Knee; Both Knees, Standing,
                       Anteroposterior
    ------------------------------------------------------------------------
    73590             Radiologic Examination; Tibia And Fibula, 2 Views
    ------------------------------------------------------------------------
    73721             MRI Knee Lt or Rt W/O Contrast
    ------------------------------------------------------------------------
    73718             MRI Lower Leg Lt or Rt W/O Contrast
    ------------------------------------------------------------------------
    73720             MRI Lower Leg Lt or Rt W/O & W/Contrast
    ------------------------------------------------------------------------
    73723             MRI Knee Lt or Rt W/O & W/Contrast
    ------------------------------------------------------------------------
    73700             CT Knee w/o IV contrast
    ------------------------------------------------------------------------
    73701             CT knee w/ IV contrast
    ------------------------------------------------------------------------
    73702             CT knee w/ and w/o IV contrast
    ------------------------------------------------------------------------
    76377             CT knee 3D postprocessing
    ------------------------------------------------------------------------
    76000,TC          Fluoroscopy (Separate Procedure), up to 1 Hour
                       Physician or Other Qualified Health Care Professional
                       Time, Other Than 71023 or 71034 (e.g., Cardiac
                       Fluoroscopy)
    ------------------------------------------------------------------------
    76000             Fluoroscopy (Separate Procedure), up to 1 Hour
                       Physician or Other Qualified Health Care Professional
                       Time, Other Than 71023 or 71034 (e.g., Cardiac
                       Fluoroscopy)
    ------------------------------------------------------------------------
    76882             Ultrasound, Extremity, Nonvascular, Real-Time With
                       Image Documentation; Limited, Anatomic Specific
    ------------------------------------------------------------------------
    90832             Psychotherapy, 30 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    90834             Psychotherapy, 45 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    90837             Psychotherapy, 60 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    93971             Duplex Scan of Extremity Veins Including Responses to
                       Compression and Other Maneuvers; Unilateral Or
                       Limited Study
    ------------------------------------------------------------------------
    97110             Therapeutic Procedure, 1 or More Areas, Each 15
                       Minutes; Therapeutic Exercises to Develop Strength
                       and Endurance, Range of Motion and Flexibility
    ------------------------------------------------------------------------
    97140             Manual Therapy Techniques (e.g., Mobilization/
                       Manipulation, Manual Lymphatic Drainage, Manual
                       Traction), 1 or More Regions, Each 15 Minutes
    ------------------------------------------------------------------------
    97161             Physical Therapy Eval Low Complex 20 Min
    ------------------------------------------------------------------------
    97162             Physical Therapy Eval Mod Complex 30 Min
    ------------------------------------------------------------------------
    99024             Postoperative Follow-Up Visit, Normally Included in
                       the Surgical Package, to Indicate That an Evaluation
                       and Management Service was Performed During a
                       Postoperative Period for a Reason(s) Related To the
                       Original Procedure
    ------------------------------------------------------------------------
    99201             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Low Severity. Level
                       1
    ------------------------------------------------------------------------
    99202             Office Or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Low to Moderate
                       Severity. Level 2
    ------------------------------------------------------------------------
    99203             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Moderate Severity.
                       Level 3
    ------------------------------------------------------------------------
    99204             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient, Moderate to High
                       Severity. Level 4
    ------------------------------------------------------------------------
    99205             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Moderate to High
                       Severity. Level 5
    ------------------------------------------------------------------------
    99211             Office Or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low
                       Severity. Level 1
    ------------------------------------------------------------------------
    99212             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low to
                       Moderate Severity. Level 2
    ------------------------------------------------------------------------
    99213             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low to
                       Moderate Severity. Level 3
    ------------------------------------------------------------------------
    99214             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Moderate to
                       High Severity. Level 4
    ------------------------------------------------------------------------
    99215             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Moderate to
                       High Severity. Level 5
    ------------------------------------------------------------------------
    99492             First 70 Minutes in the First Calendar Month for
                       Behavioral Health Care Manager Activities, in
                       Consultation With a Psychiatric Consultation and
                       Directed by the Treating Provider
    ------------------------------------------------------------------------
    99493             First 60 Minutes in a Subsequent Month for Behavioral
                       Health Care Manager Activities
    ------------------------------------------------------------------------
    99494             Each Additional 30 Minutes in a Calendar Month of
                       Behavioral Health Care Manager Activities
    ------------------------------------------------------------------------
    J3301             Injection, Triamcinolone Acetonide, Not Otherwise
                       Specified, 10 mg
    ------------------------------------------------------------------------
    L1810             Knee Orthosis, Elastic With Joints, Prefabricated Item
                       That Has Been Trimmed, Bent, Molded, Assembled, or
                       Otherwise Customized to fit a Specific Patient by an
                       Individual With Expertise
    ------------------------------------------------------------------------
    L1812             Knee Orthosis, Elastic With Joints, Prefabricated, Off-
                       The-Shelf
    ------------------------------------------------------------------------
    L1820             Knee Orthosis, Elastic With Condylar Pads and Joints,
                       With or Without Patellar Control, Prefabricated,
                       Includes Fitting and Adjustment
    ------------------------------------------------------------------------
    L1845             Knee Orthosis, Double Upright, Thigh and Calf, With
                       Adjustable Flexion and Extension Trimmed, Bent,
                       Molded, Assembled
    ------------------------------------------------------------------------
    MISCLMSW30        Lmsw Visit 30 min.
    ------------------------------------------------------------------------
    MISCLMSW45        Lmsw Visit 45 min.
    ------------------------------------------------------------------------
    MISCLMSW60        Lmsw Visit 60 min.
    ------------------------------------------------------------------------
    MISCMG30          Social Worker Meet And Greet/Cp Visit 30 min.
    ------------------------------------------------------------------------
    MISCMG45          Social Worker Meet And Greet/Cp Visit 45 min.
    ------------------------------------------------------------------------
    MISCMG60          Social Worker Meet And Greet/Cp Visit 60 min.
    ------------------------------------------------------------------------
    MISCRD30          Registered Dietitian Visit 30 min.
    ------------------------------------------------------------------------
    MISCRD45          Registered Dietitian Visit 45 min.
    ------------------------------------------------------------------------
    MISCRD60          Registered Dietitian Visit 60 min.
    ------------------------------------------------------------------------
    MISCSW            Collab Care Social Worker Non-Billable Visit
    ------------------------------------------------------------------------
    80053             Pathology & Labs
    ------------------------------------------------------------------------
    85027             Pathology & Labs
    ------------------------------------------------------------------------
    85652             Pathology & Labs
    ------------------------------------------------------------------------
    86140             Pathology & Labs
    ------------------------------------------------------------------------
    87641             Pathology & Labs
    ------------------------------------------------------------------------
    97163             Physical Therapy
    ------------------------------------------------------------------------
    G0502             Risk Modification
    ------------------------------------------------------------------------
    G0503             Risk Modification
    ------------------------------------------------------------------------
    20610             Arthrocentesis, Aspiration and/or Injection; Major
                       Joint or Bursa
    ------------------------------------------------------------------------
    20611             Arthrocentesis, Aspiration and/or Injection, Major
                       Joint or Bursa (e.g., Shoulder, Hip, Knee,
                       Subacromial Bursa); With Ultrasound Guidance, With
                       Permanent Recording and Reporting
    ------------------------------------------------------------------------
    20680             Removal of Implant; Deep (e.g., Buried Wire, Pin,
                       Screw, Metal Band, Nail, Rod or Plate)
    ------------------------------------------------------------------------
    27327             Excision, Tumor, Soft Tissue of Thigh or Knee Area,
                       Subcutaneous; Less Than 3 cm
    ------------------------------------------------------------------------
    27347             Excision of Lesion of Meniscus or Capsule (e.g., Cyst,
                       Ganglion), Knee
    ------------------------------------------------------------------------
    27438             Arthroplasty, patella; with prosthesis
    ------------------------------------------------------------------------
    27446             Arthroplasty, knee, condyle and plateau; medial OR
                       lateral compartment
    ------------------------------------------------------------------------
    27447             Arthroplasty, Knee, Condyle and Plateau; Medial and
                       Lateral Compartments With or Without Patella
                       Resurfacing (Total Knee Arthroplasty)
    ------------------------------------------------------------------------
    29505             Application of Long Leg Splint (Thigh to Ankle or
                       Toes)
    ------------------------------------------------------------------------
    29874             Arthroscopy, Knee, Surgical; for Removal of Loose Body
                       or Foreign Body (e.g., Osteochondritis Dissecans
                       Fragmentation, Chondral Fragmentation)
    ------------------------------------------------------------------------
    29875             Arthroscopy, Knee, Surgical; Synovectomy, Limited
                       (e.g., Plica Or Shelf Resection) (Separate Procedure)
    ------------------------------------------------------------------------
    29876             Arthroscopy, Knee, Surgical; Synovectomy, Major, 2 or
                       More Compartments (e.g., Medial or Lateral)
    ------------------------------------------------------------------------
    29877             Arthroscopy, Knee, Surgical; Debridement/Shaving Of
                       Articular Cartilage (Chondroplasty)
    ------------------------------------------------------------------------
    29879             Arthroscopy, Knee, Surgical; Abrasion Arthroplasty
                       (Includes Chondroplasty Where Necessary) or Multiple
                       Drilling or Microfracture
    ------------------------------------------------------------------------
    29880             Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
                       And Lateral, Including Any Meniscal Shaving)
                       Including Debridement/Shaving Of Articular Cartilage
                       (Chondroplasty), Same Or Separate Compartment(S),
                       When Performed
    ------------------------------------------------------------------------
    29881             Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
                       or Lateral, Including Any Meniscal Shaving) Including
                       Debridement/Shaving of Articular Cartilage
                       (Chondroplasty), Same Or Separate Compartment(S),
                       When Performed
    ------------------------------------------------------------------------
    73552             Radiologic Examination, Femur; Minimum 2 Views
    ------------------------------------------------------------------------
    73560, TC         Radiologic Examination, Knee; 1 or 2 Views
    ------------------------------------------------------------------------
    73560             Radiologic Examination, Knee; 1 or 2 Views
    ------------------------------------------------------------------------
    73562, TC         Radiologic Examination, Knee; 3 Views
    ------------------------------------------------------------------------
    73562             Radiologic Examination, Knee; 3 Views
    ------------------------------------------------------------------------
    73564             Radiologic Examination, Knee; Complete, 4 or More
                       Views
    ------------------------------------------------------------------------
    73565, TC         Radiologic Examination, Knee; Both Knees, Standing,
                       Anteroposterior
    ------------------------------------------------------------------------
    73565             Radiologic Examination, Knee; Both Knees, Standing,
                       Anteroposterior
    ------------------------------------------------------------------------
    73590             Radiologic Examination; Tibia And Fibula, 2 Views
    ------------------------------------------------------------------------
    73721             MRI Knee Lt or Rt W/O Contrast
    ------------------------------------------------------------------------
    73718             MRI Lower Leg Lt or Rt W/O Contrast
    ------------------------------------------------------------------------
    73720             MRI Lower Leg Lt or Rt W/O & W/Contrast
    ------------------------------------------------------------------------
    73723             MRI Knee Lt or Rt W/O & W/Contrast
    ------------------------------------------------------------------------
    73700             CT Knee w/o IV contrast
    ------------------------------------------------------------------------
    73701             CT knee w/ IV contrast
    ------------------------------------------------------------------------
    73702             CT knee w/ and w/o IV contrast
    ------------------------------------------------------------------------
    76377             CT knee 3D postprocessing
    ------------------------------------------------------------------------
    76000,TC          Fluoroscopy (Separate Procedure), up to 1 Hour
                       Physician or Other Qualified Health Care Professional
                       Time, Other Than 71023 or 71034 (e.g., Cardiac
                       Fluoroscopy)
    ------------------------------------------------------------------------
    76000             Fluoroscopy (Separate Procedure), up to 1 Hour
                       Physician or Other Qualified Health Care Professional
                       Time, Other Than 71023 or 71034 (e.g., Cardiac
                       Fluoroscopy)
    ------------------------------------------------------------------------
    76882             Ultrasound, Extremity, Nonvascular, Real-Time With
                       Image Documentation; Limited, Anatomic Specific
    ------------------------------------------------------------------------
    90832             Psychotherapy, 30 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    90834             Psychotherapy, 45 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    90837             Psychotherapy, 60 Minutes With Patient and/or Family
                       Member
    ------------------------------------------------------------------------
    93971             Duplex Scan of Extremity Veins Including Responses to
                       Compression and Other Maneuvers; Unilateral or
                       Limited Study
    ------------------------------------------------------------------------
    97110             Therapeutic Procedure, 1 or More Areas, Each 15
                       Minutes; Therapeutic Exercises to Develop Strength
                       and Endurance, Range of Motion and Flexibility
    ------------------------------------------------------------------------
    97140             Manual Therapy Techniques (e.g., Mobilization/
                       Manipulation, Manual Lymphatic Drainage, Manual
                       Traction), 1 Or More Regions, Each 15 Minutes
    ------------------------------------------------------------------------
    97161             Physical Therapy Eval Low Complex 20 Min.
    ------------------------------------------------------------------------
    97162             Physical Therapy Eval Mod Complex 30 Min.
    ------------------------------------------------------------------------
    99024             Postoperative Follow-Up Visit, Normally Included in
                       the Surgical Package, to Indicate That an Evaluation
                       and Management Service was Performed During a
                       Postoperative Period for a Reason(s) Related to the
                       Original Procedure
    ------------------------------------------------------------------------
    99201             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Low Severity. Level
                       1
    ------------------------------------------------------------------------
    99202             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Low to Moderate
                       Severity. Level 2
    ------------------------------------------------------------------------
    99203             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Moderate Severity.
                       Level 3
    ------------------------------------------------------------------------
    99204             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient, Moderate to High
                       Severity. Level 4
    ------------------------------------------------------------------------
    99205             Office or Other Outpatient Visit for the Evaluation
                       and Management of a New Patient; Moderate to High
                       Severity. Level 5
    ------------------------------------------------------------------------
    99211             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low
                       Severity. Level 1
    ------------------------------------------------------------------------
    99212             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low to
                       Moderate Severity. Level 2
    ------------------------------------------------------------------------
    99213             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Low to
                       Moderate Severity. Level 3
    ------------------------------------------------------------------------
    99214             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Moderate to
                       High Severity. Level 4
    ------------------------------------------------------------------------
    99215             Office or Other Outpatient Visit for the Evaluation
                       and Management of an Established Patient; Moderate To
                       High Severity. Level 5
    ------------------------------------------------------------------------
    99492             First 70 Minutes in the First Calendar Month for
                       Behavioral Health Care Manager Activities, in
                       Consultation With a Psychiatric Consultation and
                       Directed by the Treating Provider
    ------------------------------------------------------------------------
    99493             First 60 Minutes in a Subsequent Month for Behavioral
                       Health Care Manager Activities
    ------------------------------------------------------------------------
    99494             Each Additional 30 Minutes in a Calendar Month of
                       Behavioral Health Care Manager Activities
    ------------------------------------------------------------------------
    J3301             Injection, Triamcinolone Acetonide, Not Otherwise
                       Specified, 10 mg
    ------------------------------------------------------------------------
    L1810             Knee Orthosis, Elastic With Joints, Prefabricated Item
                       That Has Been Trimmed, Bent, Molded, Assembled, or
                       Otherwise Customized to fit a Specific Patient by an
                       Individual With Expertise
    ------------------------------------------------------------------------
    L1812             Knee Orthosis, Elastic With Joints, Prefabricated, Off-
                       the-Shelf
    ------------------------------------------------------------------------
    L1820             Knee Orthosis, Elastic With Condylar Pads and Joints,
                       With or Without Patellar Control, Prefabricated,
                       Includes Fitting and Adjustment
    ------------------------------------------------------------------------
    L1845             Knee Orthosis, Double Upright, Thigh and Calf, With
                       Adjustable Flexion And Extension Trimmed, Bent,
                       Molded, Assembled
    ------------------------------------------------------------------------
    MISCLMSW30        Lmsw Visit 30 Min.
    ------------------------------------------------------------------------
    MISCLMSW45        Lmsw Visit 45 Min.
    ------------------------------------------------------------------------
    MISCLMSW60        Lmsw Visit 60 Min.
    ------------------------------------------------------------------------
    MISCMG30          Social Worker Meet and Greet/Cp Visit 30 Min.
    ------------------------------------------------------------------------
    MISCMG45          Social Worker Meet and Greet/Cp Visit 45 Min.
    ------------------------------------------------------------------------
    MISCMG60          Social Worker Meet And Greet/Cp Visit 60 Min.
    ------------------------------------------------------------------------
    MISCRD30          Registered Dietitian Visit 30 Min.
    ------------------------------------------------------------------------
    MISCRD45          Registered Dietitian Visit 45 Min.
    ------------------------------------------------------------------------
    MISCRD60          Registered Dietitian Visit 60 Min.
    ------------------------------------------------------------------------
    MISCSW            Collab Care Social Worker Non-Billable Visit
    ------------------------------------------------------------------------
    80053             Pathology & Labs
    ------------------------------------------------------------------------
    85027             Pathology & Labs
    ------------------------------------------------------------------------
    85652             Pathology & Labs
    ------------------------------------------------------------------------
    86140             Pathology & Labs
    ------------------------------------------------------------------------
    87641             Pathology & Labs
    ------------------------------------------------------------------------
    97163             Physical Therapy
    ------------------------------------------------------------------------
    G0502             Risk Modification
    ------------------------------------------------------------------------
    G0503             Risk Modification
    ------------------------------------------------------------------------

                                     ______

           American Academy of Otolaryngology--Head and Neck Surgery

                               1650 Diagonal Road

                              Alexandria, VA 22314

                               T: 1-703-836-4444

                               F: 1-703-683-5100

                           W: https://www.entnet.org/

    On behalf of the American Academy of Otolaryngology--Head and Neck
    Surgery (AAO--HNS), I am pleased to submit the following comments in
    response to the Senate Finance Committee's hearing to examine how
    changes to Medicare physician payment can bolster chronic care.

    The AAO--HNS is the national medical association of physicians
    dedicated to the care of patients with disorders of the ears, nose, and
    throat, as well as related structures of the head and neck. The Academy
    has approximately 13,000 members who provide clinical, surgical, and
    hospital care in rural, urban, and suburban communities. Our membership
    spans academic, private independent practices, and employed physicians
    across all practice sizes from solo to large single-specialty and
    multi-specialty groups, reaching into the hundreds.

    Otolaryngologist--head and neck surgeons--diagnose and treat patients
    from conception to end of life, providing complete diagnostic, medical
    and surgical treatment for a wide range of medical conditions,
    including allergic and sinus disease, hearing and balance disorders,
    head and neck cancer, sleep disorders, speech and swallowing problems,
    cosmetic reconstructive surgery of the face and neck, acute trauma to
    the head and neck, and pediatric and geriatric care.

    Reforming our nation's healthcare system is a complex endeavor, and
    there is no one-size-fits-all solution. The AAO--HNS shares the
    Committee's desire to work toward a more affordable, sustainable, and
    patient-centered healthcare system--particularly on ways to reduce the
    burden of chronic disease management in the Medicare program.

    Our statement addresses the major issues affecting our members under
    the current Medicare physician payment system and quality improvement
    program. We urge the Committee to consider our recommendations (in
    bold), and we look forward to working together to advance policies that
    ensure access to comprehensive care for our patients and provide much-
    needed stability for physicians.

    Reforming the Medicare Physician Fee Schedule

    The AAO--HNS continues to be deeply alarmed about the growing financial
    instability of the Medicare physician payment system due to a
    confluence of fiscal uncertainties. For the past 4 years, physicians
    participating in Medicare have faced annual statutory payment cuts
    which come in the absence of inflationary updates. The payment system
    remains on an unsustainable path threatening beneficiaries' access to
    physicians. When adjusted for inflation, Medicare physician payment has
    effectively declined 29% from 2001 to 2024 (see chart below).

    [GRAPHIC] [TIFF OMITTED] T1124.006

    .epsThe Medicare physician payment system lacks an adequate annual
    physician payment update, unlike those that apply to other Medicare
    provider payments. A continuing statutory freeze in annual Medicare
    physician payments is scheduled to last until 2026, when updates resume
    at a rate of 0.25% per year indefinitely, well below current rates of
    inflation.

    Physician practices cannot continue to absorb increasing costs while
    their payment rates dwindle. Several Medicare Trustees reports \1\ have
    underscored that they ``expect access to Medicare participating
    physicians to become a significant issue in the long term'' unless
    Congress takes steps to bolster the system. The current Medicare
    physician payment system--with its lack of an inflationary update--is
    particularly destabilizing. We therefore urge the passage of the
    Strengthening Medicare for Patients and Providers Act (H.R. 2474),\2\
    which provides a permanent annual update equal to the increase in the
    Medical Economic Index. Such an update would provide much needed
    financial stability for physicians and strengthen Medicare patients'
    access to care.
    ---------------------------------------------------------------------------
        \1\ https://home.treasury.gov/news/press-releases/jy1381.
        \2\ https://www.congress.gov/bill/118th-congress/house-bill/2474/
    text?s=1&r=1&q=%7B%22
    search%22%3A%22hr+2474%22%7D.

    Physician payments are further eroded by the budget neutrality
    requirement within the Medicare Physician Fee Schedule. Budget
    neutrality requires spending on Medicare to have no budgetary impact--
    which means increases in payment for a subset of physician services in
    a given year require across-the-board decreases in payment for all
    physicians. This does not take into consideration the varying costs
    associated with performing these services. CMS actuaries have on
    occasion overestimated the impact of Relative Value Units (RVUs)
    changes in the fee schedule. When these misestimates are not adjusted
    in a timely way, it results in permanent removal of billions of dollars
    from the payment pool. Increasing the budget neutrality threshold and
    allowing for corrections is one critically necessary step towards
    getting physicians out of the cycle of annual pay cuts. As such, the
    AAO--HNS supports the Provider Reimbursement Stability Act (H.R.
    6371),\3\ which would increase the budget neutrality threshold, allow
    for corrections of overestimates and underestimates of budget
    neutrality adjustments, and require timely updates to practice expense
    RVUs.
    ---------------------------------------------------------------------------
        \3\ https://www.congress.gov/bill/118th-congress/house-bill/6371/
    text?s=2&r=1&q=%7B%22
    search%22%3A%22hr+6371%22%7D.

    In summary, we urge action to improve the physician payment system by
    providing an inflationary payment update and revisiting budget-
    neutrality requirements.

     Improving Alternative Payment Models (APMs) and Merit-based Incentive
                        Payment System (MIPS)

    Our specialty is actively involved in the transition of care, when safe
    and effective, from the inpatient setting to the hospital outpatient
    and Ambulatory Surgery Centers (ASC) settings and ultimately, the
    office setting, to increase flexibility and access to care while saving
    the overall healthcare system significant expense. Our specialty is
    engaged in defining quality for diagnosis and treatment of
    otolaryngologic disease using Clinical Practice Guidelines \4\ and a
    Clinical Data Registry \5\ that also works to improve outcomes,
    eliminate unnecessary care, and decrease costs.
    ---------------------------------------------------------------------------
        \4\ https://www.entnet.org/quality-practice/quality-products/
    clinical-practice-guidelines/.
        \5\ https://www.entnet.org/quality-practice/reg-ent-clinical-data-
    registry/.

    Otolaryngologist--head and neck surgeons around the country are
    participating in various types of value-based care networks, including
    specialty-run clinically integrated networks and other shared savings
    ---------------------------------------------------------------------------
    models.

    MACRA's Merit-based Incentive Payment System (MIPS) program was felt to
    have great promise when introduced, but the program has failed in most
    ways to deliver either savings or improved care. The majority of
    quality measures used in MIPS do not follow standard practice patterns
    of specialist physicians and have not shown any tracking toward
    improved patient outcomes, the final measuring stick. The only
    consistent quality of the MIPS program is that it gets more difficult
    and expensive by the year for physicians, especially those in
    independent practice, to comply with the cadre of rules promulgated
    annually.

    The AAO--HNS recognizes that alternative payment models (APMs) may
    provide value-based care by providing incentive payments to deliver
    high-quality and cost-efficient care for a clinical condition, a care
    episode or a patient population. However, due to a lack of approved
    APMs that apply to specialty physicians, high initial costs of
    transitioning to an APM, and the looming end of the incentive payment,
    far fewer physicians participate in APMs than had been forecast. Given
    the program's current shortcomings, the AAO--HNS supports the
    continuation of an extension of the 5% APM bonus payment to help
    physicians make the transition towards these evolving payment models.

    We offer the following recommendations for the Committee's
    consideration:

          A true value-based, quality program under Medicare should relate
    to the day-to-day practice of medicine and measure outcomes that are
    important to both physicians and their patients by measuring outcomes
    they are trying to achieve, not administrative markers. To increase
    participation in MACRA or a successor program, one must also consider
    economic principles. Physicians must be compensated appropriately, and
    the administrative costs and complexity must not dissuade
    participation. In terms of appropriate compensation, physicians must be
    treated equally to other Medicare providers and, at a minimum, receive
    annual payment updates based on an inflation proxy such as the Consumer
    Price Index (CPI).

          In developing new measures of value-based care, CMS should work
    with each medical specialty society to develop best-care paradigms for
    the most common diseases/problems seen by each specialty. These
    paradigms will serve as the underlying foundation for value-based care
    and allow for well-defined cost and quality alignment modeling.
    Performance feedback based on these best care paradigms will enable
    physicians to compare themselves to their peer group and help
    facilitate care improvement solutions. In addition, value-based care
    measures should not be limited to claims data but should incorporate
    patient-reported outcomes. The data is there, and it should be
    incorporated.

          It is important to maintain Qualified Clinical Data Registries
    (QCDRs) as an anchor to the current MIPS and any forthcoming Medicare
    quality improvement program. These registries, such as the AAO--HNS'
    Reg-ent registry,\6\ can adequately recognize and incentivize high-
    quality care as well as identify areas for clinical improvement and
    cost savings.
    ---------------------------------------------------------------------------
        \6\ https://www.entnet.org/quality-practice/reg-ent-clinical-data-
    registry/.

          When having discussions around more equitable, value-based
    systems, it is essential to allow flexibility through pilot studies to
    gather data on the value of each of these pilots before committing to
    one particular solution. As we have learned through MACRA, there may
    ---------------------------------------------------------------------------
    not be one system that equitably fits all.

          A reliable cost-reduction strategy available to CMS is to
    transition care from high to low-cost facilities when clinically
    appropriate. As mentioned, our specialty can shift specific care away
    from hospital outpatient departments and into lower-cost Ambulatory
    Surgical Centers (or other non-facility settings). To enable care in
    lower-cost facilities, Congress can urge CMS to provide appropriate
    reimbursement on both the physician work and practice expense portion
    for these services. While this initially increases rates to the
    provider, it creates much greater savings to Medicare by avoiding the
    higher hospital outpatient fees. Accomplishing this will require
    Medicare Part B to have a similar funding mechanism as Medicare Part A
    that allows CMS flexibility to move away from the budget-neutral
    requirement that has created the current situation.

    Supporting the healthcare team to transform chronic disease care

    Physicians, including otolaryngologist--head and neck surgeons, and
    health systems across the country continue to face the growing
    challenge of preventing and managing chronic diseases. The Centers for
    Disease Control and Prevention estimates that 90% of all healthcare
    costs in the U.S. go toward treating chronic disease and mental
    health--about $3.7 trillion a year. This highlights the need to support
    and create innovative approaches, such as team-base care, to ensure
    patients with chronic disease have access to both medical and surgical
    care--particularly in rural and underserved areas.

    As the Committee considers changes to the current Medicare payment
    system, flexibility in supporting the comprehensive physician-led
    healthcare team is essential to effectively managing the growing burden
    of chronic disease on the overall health system.

    Accounting for economic benefits of healthcare legislation

    Allowing Congress the ability to look at the financial impact of
    preventive health legislation beyond the 10-year Congressional Budget
    Office (CBO) scoring window is another important tool that is critical
    for addressing chronic conditions. That is why the AAO-HNS has endorsed
    the Dr. Michael C. Burgess Preventive Health Savings Act (H.R. 766/S.
    114), which would allow Congress to consider the long-term economic
    benefits of legislation that promotes wellness and reduces the
    incidence of chronic conditions. It is widely recognized that
    preventing a chronic condition will improve health outcomes, reduce
    costs to our healthcare system, and provide patients with a better
    quality of life. It is time for the CBO to have an updated scoring
    methodology that accounts for these long-term economic benefits, and
    therefore, we urge Congress to pass the Dr. Michael C. Burgess
    Preventive Health Savings Act.

    Again, we thank the Senate Finance Committee for furthering the
    discussion to improve Medicare physician payment and increase patient
    access. The AAO--HNS stands ready to offer ourselves as a resource for
    further discussions. If you have any questions or require further
    information, please contact govtaffairs@entnet.org.

    Sincerely,

    James C. Denneny III, M.D.
    Executive Vice President and CEO

                                     ______

                  American Association of Clinical Urologists

                        1061 East Main Street, Suite 300

                          East Dundee, Illinois 60118

                                 (847) 752-5355

                            email: info@aacuweb.org

                         website: https://aacuweb.org/

    U.S. Senate
    Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510-6200

    April 11, 2024

    Dear Chairman Wyden, Ranking Member Crapo and Members of the Committee,

    On behalf of the American Association of Clinical Urologists (AACU) we
    wanted to send in our comments on the April 11, 2024 hearing titled
    ``Bolstering Chronic Care through Medicare Physician Payment.''

    Founded in 1968 by urologists concerned by the government's increasing
    role in the practice of medicine, the AACU is a professional
    organization representing the interests of more than 3,700+ member
    urologists, and urologic societies engaged as advocacy affiliates
    across the United States. We are dedicated to developing and advancing
    health policy education as it affects urologic practice in order to
    preserve and promote the professional autonomy of our members and
    support the highest quality of care for Patients.

    On behalf of our urology members, we remain cautiously optimistic that
    Congress will finally come to the correct policy decision in order to
    protect physicians by awarding an adequate and sustainable
    reimbursement metric for our members. This is especially true for
    urologists whose patients are dealing with chronic conditions. If these
    conditions aren't managed appropriately, these conditions will
    undoubtedly be another cause of significantly contributing to the
    alarmingly increasing higher drug spend in our country.

    Urologists care deeply about patient access and adherence and improved
    outcomes but have found the last several years difficult to achieve
    this due to Medicare's constantly shrinking reimbursement metrics.
    Physicians have been pleading for Congress to solve this issue for
    years since this problem is now being compounded with others that
    threaten our healthcare system. From physician shortages due to
    retirements and low reimbursements, to increased wages and operational
    expenses as a direct result of the physician shortages, our industry is
    in trouble. All the while we are expected to continue business and
    usual when our patients need us the most. Something has to give.

    Notwithstanding, we have been grateful for Congress' effort to pass a
    skinny package of health extenders for fiscal 2024 in early March that
    included a 1.68% partial fix for the 3.37% cut to Medicare physician
    payments. We are also hopeful that conversations between the Medicare
    payment reform working group, MedPAC and this Committee will hear our
    concerns and put a permanent solution in place such as directing the
    Centers for Medicare and Medicaid Services (CMS) to include an
    inflationary index to the conversion factor so that the income of
    providers is not eroded over time due to the effects of inflation.

    We look forward to serving as a resource to you and this Committee.

    Please reach out to Ron Lanton, AACU Director of Government Affairs at
    rlanton@aacuweb.org with any questions or concerns.

    Sincerely,

    Harbhajan S. Ajrawat, M.D., FACS    Ian M Thompson III, M.D.
    President                           Health Policy Chair

                                     ______

                 American Association of Hip and Knee Surgeons

                         9400 W Higgins Road, Suite 230

                            Rosemont, IL 60018-4976

                              OFFICE: 847-698-1200

                               FAX: 847-698-0704

                             https://www.aahks.org/

    Chairman Wyden and Ranking Member Crapo, thank you for holding this
    hearing on critical patient care improvements and Medicare Physician
    Fee Schedule (``MPFS'') reforms that are necessary to provide stability
    and appropriate levels of support for the care that hip and knee
    surgeons provide to beneficiaries across the country.

    AAHKS is the foremost national specialty organization of more than
    4,900 physicians with expertise in total joint arthroplasty (``TJA'')
    procedures. Many of our Members conduct research in this area and are
    experts on the evidence-based medicine issues associated with the risks
    and benefits of treatments for patients suffering from lower extremity
    joint conditions. AAHKS is guided by four principles:

          Patient access, especially for high-risk patients, and physician
    incentives must remain a focus;
          Reductions in physician reimbursement by public and private
    payers drives provider consolidation;
          Payment reform is most effective when physician-led; and
          The burden of excessive physician reporting on metrics detracts
    from care.

    Continued Medicare cuts to physician reimbursement for total hip and
    knee arthroplasty, which have drastically outpaced overall cuts to the
    Physician Fee Schedule over the past 30 years, is one of the primary
    factors driving health care consolidation and the growing inability of
    physicians to maintain an independent practice. AAHKS appreciates the
    hearing statements from Committee Members and witnesses regarding the
    unsustainable MPFS annual updates, and the harm that the MPFS budget
    neutrality function inflicts when reimbursement for some services are
    increased causing completely unrelated services to be cut.

    [GRAPHIC] [TIFF OMITTED] T1124.007

        .eps  The cuts to total hip and knee arthroplasty are not grounded
    in the value to our patients, advancements in patient care, or the
    effort that our members invest in improving outcomes and reducing
    overall spend for the procedure. The cuts have also come from multiple
    aspects of the Medicare program, each of which has major policy
    implications for this Committee's priorities for the Medicare program.
    We urge the Committee to consider the cumulative impact of the
    following cuts on our Members and the Medicare beneficiaries they
    serve: Devaluing total hip and knee arthroplasty's primary surgical
    code (i.e., unjustified reduction in relative value units (RVUs) as
    advocated by a private insurer).
          Not recognizing surgeons' increasing role in value-based driven
    work managing patient health through primary care-like pre-surgical
    optimization and coordination services.
          Unilaterally regrouping the procedures used to value different
    TJA procedures (i.e., shifting Ambulatory Payment Classification
    (``APC'') code groupings without public notice or the opportunity to
    comment or any input from physicians on clinical matters).
          Reductions in the Alternative Payment Model (``APM'')
    participation payment.
          Cuts caused by unrelated MPFS services being increased (budget
    neutrality function of MPFS).
          The lack of an inflationary update to the MPFS despite
    escalating costs.

    All of these cuts are exacerbated by the growth and capriciousness of
    prior authorization programs that ignore patient clinical needs, and
    rising complexity and administrative burdens from all payers.

    There is no doubt that TJA reimbursement has been a disproportionate
    target of physician cuts because it is Medicare's largest procedural
    code. Americans are living longer, as your Committee well knows, are
    increasingly burdened with comorbidities that accelerate the end-stage
    osteoarthritis and necessitates a total hip and knee replacements. As
    such, there is urgent demand for our Members' surgical interventions
    but cuts to TJA physician reimbursement undermine the goal of improving
    care and reducing costs. Advancements in patient care, pioneered by
    many of our Members, have drastically reduced hospital patient days,
    improved recovery times, reduced use of opioids and saved the Medicare
    program billions. We urge the Committee support our physicians in their
    continued efforts to bring value to the Medicare beneficiary and the
    Medicare Trust Funds.

    Beyond undermining physician work that benefits Medicare beneficiaries
    and reduces total Medicare expenditures, there is a basic math problem
    in the strategy of cutting surgeon reimbursement year-over-year to
    achieve savings: Surgeons represent less than 6% of the overall cost of
    hip and knee replacement, but their services are essential to
    controlling costs in the other 94%.

    [GRAPHIC] [TIFF OMITTED] T1124.008

    .epsThere are deeply concerning policy implications for patient care
    associated with chronic reductions in physician reimbursement in
    response to growing demand, improved outcomes, increased physician
    labor, rising practice costs and complex administrative burdens. If the
    goal is purely savings, it's not in the best interest of the program or
    Medicare beneficiaries to undermine the lowest-cost/highest-value
    clinical partner the Centers for Medicare and Medicaid Services (CMS)
    has to improve care and control costs.

                     HIP & KNEE SURGEONS HAVE THE HIGHEST
                         LEVEL OF PARTICIPATION IN APMS

    Hip and knee surgeons have been at the forefront of the transition to
    value-based models of care. Our members have worked with CMS to develop
    existing alternative payment models (``APMs''), improve risk-adjustment
    models to ensure all patients have equitable access to care, and
    develop new global payment models for osteoarthritis which will result
    in even more hip and knee surgeons joining innovative models of care.
    They were early voluntary adopters of the Bundled Payments for Care
    Improvement (BPCI) model, where physician-led bundles have improved
    care and reduced costs. Their procedures were also the first to be
    subjected to a mandatory Centers for Medicare and Medicaid Innovation
    (CMMI) APM: the Comprehensive Care for Joint Replacement Model (CJR).
    There is no other subspecialty with a greater level of participation in
    APMs, as our members approach 50% participation.

    Members of AAHKS have worked for several years on developing a
    longitudinal osteoarthritis disease state model that leverages our
    surgeons' unrecognized work as the primary care provider for Medicare
    beneficiaries with osteoarthritis. This model represents a paradigm
    shift that aligns risk-sharing with effective management of the
    underlying condition that can lead to TJA and removing barriers to care
    when TJA is necessary; improving patient outcomes, safeguarding the
    Medicare trust fund, and reducing administrative burdens.

    AAHKS agrees with the comments by hearing witnesses regarding the need
    for enhanced clinical stakeholder input in APM development. While AAHKS
    has been grateful for some of the changes that the CMMI has made as a
    result of AAHKS engagement, improving clinical stakeholders' ability to
    effectively improve APM design is critical for their success. We share
    witness concerns that the Physician-
    Focused Payment Model Technical Advisory Committee (PTAC) has
    recommended 14 models for implementation, and none of them has been
    implemented; including the longitudinal osteoarthritis model AAHKS
    members have proposed.

                 APM PATIENT CARE IMPROVEMENTS & SAVINGS HAVE
                 BEEN USED TO JUSTIFY ADDITIONAL PHYSICIAN CUTS

    While our surgeons are proud to be APM pioneers, they have also been
    the first to hit the policy speed-bumps on the onramp to value-based
    care. One of the most problematic cuts to TJA reimbursement stemmed
    directly from AAHKS-members success in APMs. This was the result of the
    disconnect between fee-for-service Medicare rate-setting policies and
    the work our physicians do in APMs.

    One of the main drivers of savings for TJA within the CJR and BPCI has
    been our surgeon's work with patients to optimize their health prior to
    surgery. Similar to primary care and care-coordination services, this
    ``pre-surgical optimization'' requires our surgeons to work with
    patients in the weeks and months prior to surgery to address health
    conditions that could complicate their surgical outcomes (e.g., reduce
    their body mass index (BMI), treat hypertension, manage diabetes
    management, etc). The results of this work are that patients are
    healthier, have better surgical outcomes, and shorter recovery times.
    This not only lays the groundwork for improved patient experience, but
    results in significant Medicare savings by reducing hospital stays.

    This is an example of the <6% of overall TJA reimbursement to surgeons
    being leveraged to reduce costs for the other 94% of the total
    procedure reimbursement. This is only possible through the tremendous
    amount of work our surgeons do outside of the operating room. However,
    in 2018 an American Medical Association (AMA) RVS Update Committee
    (RUC) review of THA and TKA was initiated anonymously by a national
    for-profit insurance company \1\ used the physician reimbursement
    review process to allege that Medicare THA/TKA reimbursement, along
    with many other procedures are overvalued. For hip and knee
    replacement, the insurance company based this allegation mainly on one
    study of only two facilities.
    ---------------------------------------------------------------------------
        \1\ Private insurance companies stand to gain from a proposed
    reduction by the AMA RUC by reducing their own payments to surgeons
    under commercial insurance arrangements that are pegged to a percentage
    of the national Medicare rate.

    Due to the limitations of the current RUC process, only work done 24
    hours prior to a surgical procedure and 90 days afterwards was
    considered. Subsequently, it did not recognize all the pre-service work
    incentivized over the weeks/months in APMs, but did recognize the
    resulting shorter hospitalizations and fewer post-operative doctor
    visits. This was despite being presented with a study that accounted
    for the time commitment needed for delivery of value-based patient care
    and an independent national survey of AAHKS members, it was found that
    more than 98% of respondents are providing preoptimization services.
    The RUC ultimately recommended a cut in TKA and THA reimbursement,
    despite acknowledging that the pre-optimization work was occurring. CMS
    ---------------------------------------------------------------------------
    finalized the recommended cut in 2021.

    These cuts fundamentally undermine the investments AAHKS members have
    made to improve patient care and take on substantial risk in APMs to
    reduce overall Medicare spending. The real work that thousands of our
    surgeons do, backed up by studies and a national survey, was discounted
    by an anonymously submitted two-site survey that was never intended to
    capture the value of the services our surgeons provide to their
    patients and the Medicare program. It sends a chilling message to all
    physicians that high levels of participation and success in APMs will
    result in punitive compensation cuts for their services.

    AAHKS was encouraged to hear Committee Members support for coordinated
    care. During the hearing, a Member of the Committee asked the panel how
    to create payments to incentivize physicians to provide the ``right
    care''. We strongly urge the Committee to address the disconnect
    between fee-for-service rate-setting process and the valuable work that
    occurs within APMs and reverse the cuts that hip and knee surgeons
    received for providing the right care.

                     EXTENSION OF APM PARTICIPATION PAYMENT

    AAHKS strongly supports the extension of the full 5% APM participation
    payment. We appreciate that Congress extended the participation at
    1.88% on March 8th, and that the payment could have lapsed entirely
    without allocating limited federal funds to this priority. However,
    AAHKS is concerned that the reduced reauthorized payment is not
    sufficient to speed physician adoption of value-based care and support
    continued participation in APMs.

    AAHKS supports the Committee Member and witness statements highlighting
    the importance of the payment for APM uptake, and we urge the Committee
    to consider the importance of ongoing support while CMS is still
    developing, testing and changing APMs. While many of our members
    already participate in APMs, they are frequently updated with new
    target benchmarks, risk adjustment methodology and other program
    elements. Supporting current APM participants through these changes is
    also an important function of the participation payment. AAHKS is
    concerned by some policy proposals that have introduced the concept of
    phasing-out of the APM participation fee based on how long a
    participant has been in an APM. We urge the Committee to recognize the
    changing nature of CMMI APMs and reject phase-out proposals, especially
    amid increasing practice expenses and reimbursement pressures outlined
    in this statement.

               PRIOR AUTHORIZATION: A BARRIER FOR PATIENT CARE,
                            A BURDEN FOR PHYSICIANS

    AAHKS appreciates the Committee's attention to prior authorization
    reform, and the hearing comments of Members and witnesses regarding
    ongoing challenges to patient access to care and physician
    administrative burdens.

    Delays for our patients translate into more days wrestling with the
    pain of osteoarthritis; more days away from their jobs and basic
    activities they enjoy. Our surgeons have dedicated their careers to
    restoring our patients to a pain free, productive and mobile life. It
    is a daily occurrence to have their medically necessary care delayed by
    prior authorization decisions made by reviewers without expertise in
    TJA that deeply conflict with the health care needs of the Medicare
    beneficiary.

    Within a declining reimbursement environment, hip and knee surgeons
    have been diverting more time and resources ensuring their patients are
    covered for their medically necessary TJA. It is commonplace, even in
    small independent practices, to have full-time staff handling prior
    authorization documentation. There is no separate revenue stream to
    support those staff; it all comes out of the dwindling 6% of
    reimbursement surgeons receive for the total TJA episode of care.

    We support the finalized regulations that modernize prior authorization
    programs within Medicare Advantage.\2\ We look forward to sharing with
    the Committee additional suggested reforms to ensure that patient
    access to care is not delayed.
    ---------------------------------------------------------------------------
        \2\ 89 FR 8758.

    AAHKS is interested in providing stakeholder feedback on the draft
    ``prior authorization for prior authorization'' legislation mentioned
    during the hearing. We support the need for stricter parameters, and
    strong justification for the implementation of any prior authorization
    program or new requirements within existing prior authorization
    programs.

                    APPROPRIATE SETTING FOR APPROPRIATE CARE

    It is essential that the most appropriate setting of care for a major
    surgery is a decision made by the physician and their informed patient.
    Prior authorization programs can interfere with when a patient can
    receive care, but other recent Medicare policy changes have made
    substantial changes to where a patient can receive TJA.

    Until 2018, all lower-joint TJAs were performed in the inpatient
    setting, and CMS maintained the procedures on the ``inpatient-only
    list'' (``IPO''). CMS began removing the procedures from the IPO list
    in 2018, when they made total knee replacement surgery available in the
    outpatient setting for the first time. In 2019 they allowed for the
    procedure in Ambulatory Surgery Centers (``ASCs'') in 2019, and total
    hip replacement surgery followed in 2020.

    AAHKS supports the ability for the physician to choose the most
    clinically appropriate setting for their patients' treatment. However,
    procedures coming off the Medicare inpatient-only list do not have
    established clinical criteria within Medicare's ``Two-Midnight Rule''
    to ensure the availability of inpatient care for medically complex
    patients. That creates ambiguity unique to procedures coming off the
    IPO list that has caused many hospitals to push patients into the
    outpatient setting, regardless of clinical considerations, for fear of
    audits and penalties.

    AAHKS recommends that any legislative action on the Medicare IPO list
    include a requirement for clear Two-Midnight Rule guidance for
    procedures coming off the IPO list to ensure that patients are treated
    in the most clinically appropriate setting of care.

                 CHOICE IS THE KEY TO ADDRESSING CONSOLIDATION

    Continued cuts to Medicare reimbursement makes it more difficult for
    surgeons to sustain independent practices or have a realistic range of
    options for practice models. This leads to mergers and consolidation.
    Consolidation leads to fewer choices for consumers across the care
    continuum, higher prices, and decreased access to care--particularly in
    rural and underserved areas. Reduced reimbursement for Total Hip
    Arthroplasty (THA)/Total Knee Arthroplasty (TKA) can also lead to
    surgeons shifting their focus to other procedures and conditions for
    which they have trained, despite the accelerating need for joint
    replacement in the Medicare age eligible population.

    AAHKS supports surgeons that work across all employment arrangements,
    from small independent practices to academic medical centers.
    Physicians should have a choice of the setting in which they work;
    however, their ability to choose is diminishing as a result of the
    dwindling 6% of the total reimbursement for TJA they receive to keep
    their practices afloat. The financial strain imposed on small practices
    drives consolidation and, in turn, increases the cost of care for the
    Medicare program and beyond.

    In light of President Biden's Executive Order on Promoting Competition
    in the American Economy, CMS should evaluate whether its proposed
    reductions in Medicare physician rates promote competition in health
    care or facilitate consolidation. AAHKS is optimistic for the future
    passage of H.R. 3284, the Providers and Payers COMPETE Act of 2023,
    which recently was reported out of the House Committee on Energy and
    Commerce by a vote of 49-0. HR 3284 would require the Secretary of the
    Department of Health and Human Services (HHS) to assess and report to
    Congress on the impact of any Medicare reimbursement or regulatory
    changes on consolidation of healthcare providers and payers. Such
    reporting is an important step to better inform Congress and CMS on how
    not to exacerbate health industry consolidation through Medicare
    payment rates reductions.

    Conclusion

    AAHKS appreciates the Committee's attention to the urgent need to
    address beneficiaries' chronic care needs through Medicare physician
    payment reform and looks forward to partnering with the Committee in
    its work. As Americans live longer and increasingly struggle with
    comorbidities that can exacerbate osteoarthritis, our surgeons provide
    a lifeline to return them to a pain-free, productive, and healthier
    life. With the right supports, our Members are ready and able to meet
    the growing demand for TJA to continue bringing value to beneficiaries
    and their families.

    AAHKS appreciates the Committees consideration of the perspectives
    shared in this Statement for the Record. If you have any questions, you
    can reach Mike Zarski at mzarski@aahks.org or Joshua Kerr at
    jkerr@aahks.org.

                                     ______

                  American Association of Nurse Practitioners

                         1400 Crystal Drive, Suite 540

                              Arlington, VA 22202

                         Website: https://www.aanp.org/

    The American Association of Nurse Practitioners (AANP), representing
    the 385,000 Nurse Practitioners (NPs) in the United States, appreciates
    the opportunity to provide a statement for the record for the Senate
    Committee on Finance hearing entitled ``Bolstering Chronic Care through
    Medicare Physician Payment.'' AANP is committed to empowering all NPs
    to advance high-quality, equitable care, while addressing health care
    disparities through practice, education, advocacy, research, and
    leadership (PEARL).\1\ We appreciate the Committee's attention to
    Medicare reimbursement policies and their impact on patient access to
    care. We thank Chairman Wyden and Ranking Member Crapo for holding this
    hearing. Members and expert witnesses identified the need to address
    the structural inequities within the Medicare reimbursement model which
    inhibit beneficiary access to coordinated, whole-person, patient-
    centered care. We look forward to working with the Committee on a
    Medicare reimbursement model which equitably reimburses NPs for the
    care they provide to patients.
    ---------------------------------------------------------------------------
        \1\ https://www.aanp.org/advocacy/advocacy-resource/position-
    statements/commitment-to-addressing-health-care-disparities-during-
    covid-19, https://www.aanp.org/about/about-the-american-association-of-
    nurse-practitioners-aanp/strategic-focus.

    This issue is of particular importance to our members, as NPs provide a
    substantial portion of the high-quality,\2\ cost-effective \3\ care
    that our communities require. As of 2021, there were over 193,000 NPs
    billing for Medicare services, making NPs the largest and fastest
    growing Medicare designated provider specialty.\4\ Approximately 42% of
    Medicare patients receive billable services from a nurse
    practitioner,\5\ and approximately 80% of NPs are seeing Medicare and
    Medicaid patients.\6\
    ---------------------------------------------------------------------------
        \2\ https://www.aanp.org/images/documents/publications/
    qualityofpractice.pdf.
        \3\ https://www.aanp.org/images/documents/publications/
    costeffectiveness.pdf.
        \4\ https://data.cms.gov/ MDCR Providers 6 Calendar Years 2017-
    2021.
        \5\ Ibid.
        \6\ NP Fact Sheet (aanp.org).

    NPs also provide a significant portion of health care in rural areas
    and areas of lower socioeconomic and health status. As such, they
    understand the barriers to care that face vulnerable populations on a
    daily basis.\7\, \8\, \9\ They are also
    ``significantly more likely than primary care physicians to care for
    vulnerable populations. Nonwhites, women, American Indians, the poor
    and uninsured, people on Medicaid, those living in rural areas,
    Americans who qualify for Medicare because of a disability, and dual-
    eligibles are all more likely to receive primary care from NPs than
    from physicians.''\10\
    ---------------------------------------------------------------------------
        \7\ Davis, M. A., Anthopolos, R., Tootoo, J., Titler, M., Bynum, J.
    P. W., & Shipman, S. A. (2018). Supply of Healthcare Providers in
    Relation to County Socioeconomic and Health Status. Journal of General
    Internal Medicine, 4-6. https://doi.org/10.1007/s11606-017-4287-4.
        \8\ Xue, Y., Smith, J. A., & Spetz, J. (2019). Primary Care Nurse
    Practitioners and Physicians in Low-Income and Rural Areas, 2010-2016.
    Journal of the American Medical Association, 321(1), 102-105.
        \9\ Andrilla, C. H. A., Patterson, D. G., Moore, T. E., Coulthard,
    C., & Larson, E. H. (2018). Projected Contributions of Nurse
    Practitioners and Physicians Assistants to Buprenorphine Treatment
    Services for Opioid Use Disorder in Rural Areas. Medical Care Research
    and Review, Epub ahead. https://doi.org/10.1177/1077558718793070.
        \10\ https://www.aei.org/research-products/report/nurse-
    practitioners-a-solution-to-americas-primary-care-crisis/.

    As has been highlighted by MedPAC and data from the Centers for
    Medicare and Medicaid Services, NPs provide a growing amount of care to
    Medicare beneficiaries. As noted above, in the June 2022 report to the
    Congress, the Medicare Provider Advisory Commission (MedPAC) found that
    NPs and PAs comprise approximately one-third of the primary care
    workforce, and up to half in rural areas.\11\ Along with primary care,
    MedPAC has also published data on the importance of NPs providing
    mental and behavioral health care.\12\ NPs are also the second largest
    provider group in the National Health Services Corps \13\ and the
    number of NPs practicing in community health centers has grown
    significantly over the past decade.\14\
    ---------------------------------------------------------------------------
        \11\ https://www.medpac.gov/wp-content/uploads/2022/06/
    Jun22_MedPAC_Report_to_
    Congress_SEC.pdf (see Chapter 2).
        \12\ https://www.medpac.gov/wp-content/uploads/2023/06/
    Jun23_MedPAC_Report_To_
    Congress_SEC.pdf.
        \13\ https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
    budget-justification-fy2024.pdf.
        \14\ https://www.nachc.org/wp-content/uploads/2023/07/Community-
    Health-Center-Chartbook-2023-2021UDS.pdf.

    We strongly support the opening statement by Chairman Wyden which notes
    the importance of empowering health care providers who are managing and
    coordinating patient care. We further agree that Medicare's ``out-of-
    whack payment rules''\15\ do not reflect the modern delivery of health
    care, and that all providers ``need to be valued and compensated more
    fully by Medicare.''\16\ As Ranking Member Crapo stated in his
    testimony, ``Medicare's coverage and payment policies play a dominant
    role in setting benchmarks and baseline rules of the road not just for
    the program itself, but also for countless other payers''\17\ which
    impacts patients across the spectrum of care. Therefore, we concur that
    ``structural fee schedule reforms should shift away from the status
    quo, which forces clinicians to vie for ever-
    dwindling resources and move toward models that promote and reward
    team-based, patient-centered approaches.''\18\
    ---------------------------------------------------------------------------
        \15\ https://www.finance.senate.gov/imo/media/doc/
    0411_wyden_statement.pdf (senate.gov).
        \16\ Ibid.
        \17\ https://www.finance.senate.gov/imo/media/doc/
    0411_crapo_statement.pdf (senate.gov).
        \18\ Ibid.

    It is critical that Medicare's payment policies are updated to reflect
    the modern delivery of health care. When the Medicare fee schedule was
    initially introduced, nurse practitioners were authorized to bill
    Medicare on a limited basis. However, there has been a significant
    evolution in providers who bill the Medicare program, and the fee
    schedule is no longer limited to physicians. It sets the rates and
    policies for a broad spectrum of providers who bill Medicare, including
    NPs. As Congress has taken action to expand which clinicians are
    authorized to bill the Medicare program, many Medicare statutes and
    ---------------------------------------------------------------------------
    payment policies do not reflect these changes.

    Included below are our suggested proactive policy solutions which would
    work towards the important goals identified by the Committee members,
    including increasing access to care, and equitably reimbursing
    providers. These policies include addressing the 15 percent payment
    reduction NPs receive in the Medicare program, including NPs within the
    Health Professional Shortage Area (HPSA) Medicare bonus, including NPs
    within the Medicare fee schedule valuation process, and removing
    longstanding barriers within the Medicare program. We greatly
    appreciate your consideration of this statement and look forward to
    working with the Committee on these issues.

                Equitable Reimbursement for Nurse Practitioners

    As NPs continue to provide increasing amounts of care for Medicare
    patients, it is important to understand the significant evolution of
    the role of NPs in Medicare. In 1977, Congress first formally
    recognized care delivered by nurse practitioners in the Medicare
    program in rural health clinics.\19\ In 1989, Congress authorized
    direct reimbursement under the Medicare program for services rendered
    by nurse practitioners in rural areas, and indirect reimbursement for
    NPs rendering services in skilled nursing facilities.\20\ Since 1997,
    Congress has authorized reimbursement under the Medicare program to NPs
    regardless of setting or geographic area, for any services that would
    be covered when provided by a physician, in accordance with State law,
    at 85% of the fee schedule rates.\21\
    ---------------------------------------------------------------------------
        \19\ https://www.govinfo.gov/content/pkg/STATUTE-91/pdf/STATUTE-91-
    Pg1485.pdf (govinfo.gov).
        \20\ https://www.govinfo.gov/app/details/STATUTE-103/STATUTE-103-
    Pg2106 (govinfo.gov).
        \21\ 63 FR 30862, https://www.govinfo.gov/content/pkg/FR-1998-06-
    05/pdf/98-14650.pdf.

    Since this policy was implemented in 1997, despite the increasing
    importance of NPs in Medicare, the reimbursement structure has not
    changed in over 26 years. NPs are still reimbursed at 85% of the fee
    schedule for the services they provide. This means that if an NP
    provides a patient with the exact same service, with the exact same
    components and time requirements as their physician colleagues, they
    are paid 15% less. This 15% differential is significant and is in
    addition to other factors which impact reimbursement rates, including
    statutory reductions and corresponding adjustments to the conversion
    factor.\22\ It is important to note that inflation and other financial
    pressures identified by the Committee members are exacerbated for NPs
    due to this decreased reimbursement rate. This inequitable
    reimbursement structure is an anachronism and does not reflect the
    modern health care system.
    ---------------------------------------------------------------------------
        \22\ CY 2024 Medicare Physician Fee Schedule Final Rule, https://
    www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-
    rule-advances-health-equity.

    Therefore, we respectfully request that the Committee address the
    inequitable reimbursement structure for NPs within the Medicare
    program, and ensure any legislation includes equitable reimbursement
    for nurse practitioners. This is directly aligned with NAM Future of
    Nursing report which stated, ``Payment reform can help improve
    population health, address social needs and [social determinants of
    health], reduce health disparities, supporting the provision of
    effective, efficient, equitable, and accessible care for all across the
    care continuum instead of incentivizing the volume of care or low value
    procedures and practices.''\23\
    ---------------------------------------------------------------------------
        \23\  The Future of Nursing 2020-2030--National Academy of
    Medicine, https://nam.edu/publications/the-future-of-nursing-2020-2030/
    (nam.edu).
    ---------------------------------------------------------------------------

             Medicare Payment in Rural and Underserved Communities

    Nurse practitioners are a critical, and growing, part of the health
    care workforce. While reimbursement equity is an important principal
    regardless of geographic location, we recognize the unique challenge of
    rural and underserved communities in addressing clinician shortages. As
    noted above, in the June 2022 report to the Congress, MedPAC found that
    NPs and PAs comprise approximately one-third of the primary care
    workforce, and up to half in rural areas.\24\ When rural communities
    experience hospital closures, it is often NPs who are filling the gaps
    and providing critical care to these communities. According to the
    Government Accountability Office (GAO), an exception to the pattern of
    clinicians leaving rural areas after rural hospital closures were
    APRNs, finding that ``[c]ounties with rural hospital closures
    experienced a greater increase in the availability of advanced practice
    registered nurses (61.3 percent), compared to counties without closures
    (56.3 percent).''\25\
    ---------------------------------------------------------------------------
        \24\ https://www.medpac.gov/wp-content/uploads/2022/06/
    Jun22_MedPAC_Report_to_
    Congress_SEC.pdf (see Chapter 2).
        \25\ https://www.gao.gov/assets/gao-21-93.pdf.

    However, despite the importance of NPs to the health care workforce in
    rural and underserved communities, NPs are not eligible for the 10%
    Medicare bonus available to their physician colleagues in health
    professional shortage areas (HPSAs).\26\ For NPs in HPSAs, this means
    there can be up to a 25% difference in reimbursement rates between NPs
    and their physician colleagues.\27\ This differential is substantial,
    and impacts both primary care and mental health HPSAs. According to the
    Health Resources and Services Administration (HRSA), there are
    currently 101 million patients living in 8,504 Primary Care HPSAs which
    require 17,463 practitioners. There are 166 million patients living in
    6,767 Behavioral Health HPSAs which require 8,358 practitioners.\28\
    ---------------------------------------------------------------------------
        \26\ Physician Bonuses, CMS, https://www.cms.gov/medicare/payment/
    fee-for-service-providers/physician-bonuses-health-professional-
    shortage-areas-hpsas.
        \27\ Health Professional Shortage Area Physician Bonus Program,
    https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-
    documents/HPSAfctshtTextOnly.pdf (hhs.gov).
        \28\ Shortage Areas, https://data.hrsa.gov/topics/health-workforce/
    shortage-areas (hrsa.gov).

    As the Committee considers policy options to better support rural and
    underserved providers, ensuring NPs practicing in rural and underserved
    communities have equitable access to the HPSA Medicare Bonus Program is
    critical. Therefore, we respectfully request the Committee update the
    Medicare HPSA incentive bonus program to include NPs. This is aligned
    with the FY 2025 Department of Health and Human Services (HHS) Budget
    in Brief \29\ which included a legislative proposal to broaden the HPSA
    incentive program to include NPs. In the request, HHS notes that ``This
    proposal responds to the evolving delivery of healthcare in the United
    States. Academic research found that the share of medical visits
    delivered by nurse practitioners or physician assistants increased from
    14 percent to 26 percent among Medicare beneficiaries between 2013 and
    2019. Research also found that nurse practitioners make up a larger
    share of the primary care workforce in lower income and rural areas.''
    ---------------------------------------------------------------------------
        \29\ Ibid.

    The confluence of the COVID-19 PHE, opioid epidemic and behavioral
    health workforce shortages have led to an ongoing behavioral health
    crisis in the United States. According to HRSA, more than one-third of
    Americans live within mental health professional shortage areas.\30\
    Data demonstrates that nurse practitioners have been critical in
    filling access gaps and providing mental and behavioral health care to
    Medicare beneficiaries. A recent study published in Health Affairs
    found that from 2011-2019 the number of psychiatric-mental health NPs
    (PMHNPs) treating Medicare beneficiaries grew by 162%, compared to a 6%
    drop in psychiatrists during that same period.\31\ The study also found
    that the proportion of all mental health prescriber visits provided by
    PMHNPs to Medicare beneficiaries increased from 12.5% to 29.8% during
    that same period, exceeding 50% in rural, full practice authority
    regions.\32\
    ---------------------------------------------------------------------------
        \30\ 88 FR 52366.
        \31\ Trends in Mental Health Care Delivery By Psychiatrists and
    Nurse Practitioners in Medicare, 2011-19, Health Affairs, https://
    www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.00
    289?journalCode=hlthaff.
        \32\ Ibid.

    In addition, MedPAC found ``large shifts in the behavioral health
    workforce over time: Between 2016 and 2021, substantial growth in
    behavioral health services provided by nurse practitioners occurred,
    while volume by psychiatrists declined.''\33\ The report also states
    that ``we found shifts over time in the specialty of the clinicians who
    provide Part B behavioral health services. Most notably, between 2016
    and 2021, the volume of these services provided by psychiatrists
    declined (5 percent average annual decrease) and rose for nurse
    practitioners (12 percent average annual increase).''\34\ Accordingly,
    we also support section 101 of the Better Mental Health Care, Lower-
    Cost Drugs, and Extenders Act which would expand the HPSA bonuses to
    15% for mental health and substance use disorder services provided in
    mental health HPSAs by a broader group of clinicians, including NPs.
    ---------------------------------------------------------------------------
        \33\ https://www.medpac.gov/wp-content/uploads/2023/06/
    Jun23_MedPAC_Report_To_
    Congress_SEC.pdf.
        \34\ Ibid.
    ---------------------------------------------------------------------------

             Increase Access by Removing Federal Medicare Barriers

    In the hearing, Senator Grassley highlighted the need to remove federal
    barriers that prevent clinicians from practicing to the full extent of
    their state scope of practice, to strengthen access to care and improve
    outcomes. We strongly agree with updating outdated federal statutes
    which do not reflect the modern provision of health care and prevent
    NPs from fully meeting the health care needs of their communities.
    Reports issued by the National Academies of Medicine,\35\ American
    Enterprise Institute,\36\ the Brookings Institution,\37\ the Federal
    Trade Commission,\38\ the Bipartisan Policy Center \39\ and the U.S.
    Department of Health and Human Services under multiple administrations
    \40\, \41\, \42\ have all highlighted the
    positive impact of removing barriers confronted by NPs and their
    patients. The World Health Organization's State of the World's Nursing
    2020 report also recommends modernizing regulations to authorize APRNs
    to practice to the full extent of their education and clinical
    training, and noted the positive impact this would have on addressing
    health care disparities and improving health care access within
    vulnerable communities.\43\ As noted by MedPAC data, the number of
    encounters per FFS beneficiary with APRNs and PAs increased by 10.4
    percent from 2021-2022.\44\ This increase underscores the urgent need
    for Congressional action to remove these barriers to care.
    ---------------------------------------------------------------------------
        \35\ The Future of Nursing 2020-2030--National Academy of Medicine,
    https://nam.edu/publications/the-future-of-nursing-2020-2030/
    (nam.edu).
        \36\ https://www.aei.org/wp-content/uploads/2018/09/Nurse-
    practitioners.pdf.
        \37\ https://www.brookings.edu/wp-content/uploads/2018/06/
    AM_Web_20190122.pdf.
        \38\ https://www.aanp.org/advocacy/advocacy-resource/ftc-advocacy.
        \39\ Strengthening the Health Professional Workforce, Bipartisan
    Policy Center, https://bipartisanpolicy.org/blog/strengthening-health-
    professional-workforce/.
        \40\ https://www.hhs.gov/sites/default/files/Reforming-Americas-
    Healthcare-System-Through-Choice-and-Competition.pdf.
        \41\ https://aspe.hhs.gov/pdf-report/impact-state-scope-practice-
    laws-and-other-factors-practice-and-supply-primary-care-nurse-
    practitioners.
        \42\ https://www.cms.gov/About-CMS/Agency-Information/OMH/
    Downloads/Rural-Strategy-2018.pdf.
        \43\ https://apps.who.int/iris/bitstream/handle/10665/331673/
    9789240003293-eng.pdf.
        \44\ medpac.gov/wp-content/uploads/2024/03/
    Mar24_MedPAC_Report_To_Congress_SEC.pdf.

    As the Committee works on legislation to enhance access to care, we
    strongly encourage inclusion of the following bipartisan legislation;
    the Promoting Access to Diabetic Shoes Act (S. 260), the Improving Care
    and Access to Nurses Act (S. 2418), and the Increasing Access to
    Quality Cardiac Rehabilitation Care Act of 2023 (S. 3481). These
    bipartisan bills will reduce the administrative burden for NPs and
    increase needed access to care for patients. This is especially true in
    rural and underserved communities, where requiring unnecessary visits,
    referrals or certifications presents immense challenges for patients.
                Promoting Access to Diabetic Shoes Act (S. 260)
    S. 260 would authorize NPs to satisfy the documentation requirement for
    coverage of therapeutic shoes for individuals with diabetes. NPs
    provide the full range of care to patients with diabetes, but federal
    law requires that an NP must send a patient who needs therapeutic shoes
    to a physician to certify that need. Additionally, according to current
    statute, the certifying physician must take over the treatment of the
    patient's diabetic condition going forward. These barriers often lead
    to delays in accessing needed items and undermine care continuity. The
    estimated total annual cost of an individual patient with diabetes is
    $17,000.\45\ However, if left untreated, patients with diabetes may
    face serious complications including foot ulcers or amputations,
    driving up the estimated annual individual costs to $52,000.\46\ By
    removing this outdated and unnecessary barrier, NPs would be authorized
    to certify the need for therapeutic shoes for patients with diabetes,
    and ensure they get the care they need in a timely fashion.
    ---------------------------------------------------------------------------
        \45\ American Diabetes Association. (2018). Economic Costs of
    Diabetes in the U.S. in 2017. Diabetes Care, 41, 917-928. http://
    care.diabetesjournals.org/content/diacare/early/2018/03/20/dci18-
    0007.full.pdf.
        \46\ Agency for Healthcare Research and Quality (2011). Data points
    #3: Economic burden of diabetic foot ulcers and amputations. https://
    effectivehealthcare.ahrq.gov/topics/diabetes-foot-ulcer-amputation-
    economics/research.

    Passage of this legislation will also reduce Medicare spending by
    eliminating duplicative services. Removing the unnecessary additional
    certifying visit requirements could save the Medicare program $12.1
    million annually.\47\ Data also demonstrates that NPs manage the care
    for patients with diabetes in a cost-effective manner that results in
    health care savings. A recent study utilizing Veterans Affairs (VA)
    data from FY 2013 found significant savings, 6-7% lower costs, for
    highly complex diabetic patients who had an NP as their primary
    provider compared to those with a physician.\48\ Other researchers
    found even greater savings, 12-13% lower costs when examining patients
    with diabetes with varying degrees of complexity served by the VA. For
    a single VA medical center, this equated to an annual savings of just
    over $14 million, exemplifying the efficiency and effectiveness of NP
    delivered care in the VA.\49\ Patients who choose nurse practitioners
    as their health care providers deserve equitable access to care from
    their chosen health care provider.
    ---------------------------------------------------------------------------
        \47\ Analysis based on author calculations. Approximately 134,000
    Medicare patient visits billed using an established patient level 3 E/M
    code (CPT 99213).
        \48\ Morgan, et al. (2019). Impact of Physicians, Nurse
    Practitioners, and Physician Assistants on Utilization and Costs for
    Complex Patients. Health Affairs, 38(6), 1028-1036. https://
    www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014.
        \49\ Rajan, et. al (2021) ``Health care costs associated with
    primary care physicians versus nurse practitioners and physician
    assistants.'' https://pubmed.ncbi.nlm.nih.gov/34074952/.
    ---------------------------------------------------------------------------
                Improving Care and Access to Nurses (ICAN) Act (S. 2418)
    S. 2418 would update the Medicare and Medicaid programs to ensure that
    NPs and other APRNs are authorized to provide care as effectively and
    efficiently as possible, consistent with state law. This includes
    updating Medicare and Medicaid to remove barriers to evidence-based
    preventive services such as authorizing NPs to order cardiac and
    pulmonary rehabilitation, refer patients for medical nutrition therapy,
    certify patients' needs for diabetic shoes, establish home infusion
    plans of care, and perform mandatory visits in skilled nursing
    facilities. This bill does not supersede any state laws, it simply
    modernizes these provisions within Medicare and Medicaid to make them
    consistent with state law to ensure that beneficiaries have access to
    these health care services, from their provider of choice, without
    undue burden. This legislation is supported by over 235 national,
    state, and local organizations \50\ including the National Rural Health
    Association, National Association of Rural Health Clinics, American
    Health Care Association, LeadingAge, Americans for Prosperity, and
    AARP.\51\ Patients who choose NPs as their health care providers should
    not face increased burdens and decreased access to medically necessary
    treatment that are covered by Medicare and Medicaid.
    ---------------------------------------------------------------------------
        \50\ https://www.aanp.org/news-feed/more-than-235-organizations-
    show-their-support-for-the-ican-act.
        \51\ https://www.aana.com/comment-letter/aarp-endorsement-of-i-can-
    act-hr-2713.
    ---------------------------------------------------------------------------
                Increasing Access to Quality Cardiac Rehabilitation Care
                        Act (S. 3481)
    S. 3481 would authorize NPs to order cardiac and pulmonary
    rehabilitation for Medicare patients. In 2018, Congress passed
    legislation which authorized NPs, clinical nurse specialists (CNSs) and
    physician assistants (PAs) to supervise cardiac and pulmonary
    rehabilitation starting in 2024. However, these clinicians are still
    not authorized to order cardiac and pulmonary rehabilitation for
    Medicare patients.

    Cardiac rehabilitation and pulmonary rehabilitation are programs
    designed to improve a patient's physical, psychological, and social
    functioning after a qualifying diagnosis or procedure, such as a heart
    attack or coronary artery bypass surgery or after a diagnosis of
    chronic obstructive pulmonary disease (COPD). Heart disease remains the
    leading cause of death in the United States with nearly 700,000 deaths
    per year.\52\ Not only does heart disease have a tremendous impact on
    the lives of patients and their families, but managing and treating
    heart disease and related risk factors is estimated to cost the United
    States over $320 billion annually.\53\ Chronic obstructive pulmonary
    disease (COPD) is the sixth leading cause of death in the United
    States, with nearly 150,000 deaths per year.\54\ COPD is estimated to
    cost the United States nearly $50 billion annually in related health
    care expenditures and indirect mortality and morbidity costs.\55\
    ---------------------------------------------------------------------------
        \52\ https://www.cdc.gov/heartdisease/about.htm.
        \53\ Birger M, Kaldjian AS, Roth GA, Moran AE, Dieleman JL, Bellows
    BK. Spending on Cardiovascular Disease and Cardiovascular Risk Factors
    in the United States: 1996 to 2016. Circulation. 2021 Jul
    27;144(4):271-282. doi: 10.1161/CIRCULATIONAHA.120.053216. Epub 2021
    Apr 30. PMID: 33926203; PMCID: PMC8316421.
        \54\ https://www.lung.org/research/trends-in-lung-disease/copd-
    trends-brief/copd-mortality.
        \55\ https://www.lung.org/research/trends-in-lung-disease/copd-
    trends-brief/copd-burden.

    Yet, while studies show that these programs can reduce
    hospitalizations, decrease heart attack recurrence, increase adherence
    to preventive medication, improve overall health and reduce the need
    for costly care, less than 25 percent of qualifying patients receive
    cardiac rehabilitation and only three percent of Medicare patients with
    COPD receive pulmonary rehabilitation.\56\, \57\,
    \58\ Participation rates are even lower for female and minority
    patients and those who live outside metropolitan areas or in lower
    income urban areas.\59\, \60\ Research also indicates that
    cardiac rehabilitation is associated with lower all-cause mortality
    rates in patients with diabetes, however patients with diabetes have
    lower participation rates than the non-
    diabetes population.\61\ For these reasons, it is essential that
    Congress increase access to these vital services.
    ---------------------------------------------------------------------------
        \56\ https://millionhearts.hhs.gov/data-reports/factsheets/
    cardiac.html.
        \57\ https://www.ahajournals.org/doi/10.1161/
    CIRCOUTCOMES.119.005902
        \58\ https://www.atsjournals.org/doi/10.1513/AnnalsATS.201805-
    332OC.
        \59\ Li S, Fonarow GC, Mukamal K, Xu H, Matsouaka RA, Devore AD,
    Bhatt DL. Sex and Racial Disparities in Cardiac Rehabilitation Referral
    at Hospital Discharge and Gaps in Long-Term Mortality. J Am Heart
    Assoc. 2018 Apr 6;7(8):e008088. doi: 10.1161/JAHA.117.008088. PMID:
    29626153; PMCID: PMC6015394.
        \60\ Castellanos LR, Viramontes O, Bains NK, Zepeda IA. Disparities
    in Cardiac Rehabilitation Among Individuals from Racial and Ethnic
    Groups and Rural Communities--A Systematic Review. J Racial Ethn Health
    Disparities. 2019 Feb;6(1):1-11. doi: 10.1007/s40615-018-0478-x. Epub
    2018 Mar 13. PMID: 29536369.
        \61\ https://www.ahajournals.org/doi/10.1161/JAHA.117.006404.
    ---------------------------------------------------------------------------

                    Improving Accountable Care Organizations

    The Medicare Shared Savings Program (MSSP) is an important component of
    Medicare, which saved more than 1.8 billion dollars in 2022.\62\ Over
    140,000 NPs are participating in MSSP ACOs, providing critical services
    to millions of Medicare beneficiaries within the program.\63\ However,
    statutory requirements \64\ still exist which require a beneficiary to
    receive a primary care service from a physician as a pre-step before
    they can be assigned to a MSSP accountable care organization (ACO).
    This requirement inhibits the ability of Medicare to equitably provide
    accountable care, and limits the participation of patients who see NPs
    as their primary care providers. Therefore, we strongly support the
    passage of the ACO Assignment Improvement Act of 2024 (S. 3939) which
    would address this barrier and fully include NPs and their patients in
    the MSSP.
    ---------------------------------------------------------------------------
        \62\ Medicare Shared Savings Program Saves Medicare More Than $1.8
    Billion in 2022 and Continues to Deliver High-quality Care. CMS.
    https://www.cms.gov/newsroom/press-releases/medicare-shared-savings-
    program-saves-medicare-more-18-billion-2022-and-continues-deliver-high.
        \63\ https://data.cms.gov/medicare-shared-savings-program/
    performance-year-financial-and-quality-results/data. (January 2022
    Performance Year Financial and Quality Results).
        \64\ Social Security Act Section 1899(c)(1).

    We appreciate that in the 2024 Medicare Physician Fee Schedule final
    rule, CMS updated the MSSP to better include patients seen by NPs, and
    better align beneficiaries with the clinician who is providing their
    care.\65\ The CMS analysis of this expansion of the assignment
    methodology to better account for NPs' patients notes that the changes
    would add a population of patients who have been historically
    underrepresented in the MSSP.\66\ This includes those with a disabled
    Medicare enrollment type, those residing in areas with a slightly
    higher average ADI national percentile rank, and a larger share of
    Medicare Part D LIS enrollment. This is consistent with the June 2022
    MedPAC report which found that, among all clinician types, NPs on
    average had the highest share of allowed charges associated with low-
    income subsidy (LIS) beneficiaries. ``In 2019, 41 percent of the
    allowed charges billed by NPs who practiced in primary care were for
    LIS beneficiaries, as were 36 percent for NPs who practiced in
    specialty care compared with 28 percent for primary care physicians and
    PAs and 25 percent for specialty care physicians and PAs.''\67\
    ---------------------------------------------------------------------------
        \65\ P. 961 2024 PFS Final Rule. https://public-
    inspection.federalregister.gov/2023-24184.pdf.
        \66\ 88 FR 52440. https://www.federalregister.gov/documents/2023/
    08/07/2023-14624/medicare-and-medicaid-programs-cy-2024-payment-
    policies-under-the-physician-fee-schedule-and-other.
        \67\ medpac.gov/wp-content/uploads/2023/03/
    Mar23_MedPAC_Report_To_Congress_SEC.pdf (Page 135).

    In its FY 2021 Budget in Brief, HHS stated that basing ACO-assignment
    on a broader set of primary care providers, including NPs, better
    reflects our current primary care workforce and would lead to $80
    million in savings for the Medicare program over 10 years.\68\ However,
    statutory barriers still need to be fixed in order to fully include NPs
    and their patients in the program. Therefore, we respectfully request
    the Committee include S. 3939 in any legislative efforts pursuant to
    this hearing in order to fully include NPs and their patients in the
    MSSP.
    ---------------------------------------------------------------------------
        \68\ HHS. https://www.hhs.gov/sites/default/files/fy-2021-budget-
    in-brief.pdf (hhs.gov) (page 84).
    ---------------------------------------------------------------------------

          Creation of a Medicare Payment Technical Advisory Committee

    During the hearing, Senator Whitehouse and witness Dr. Amol Navathe
    discussed the importance of establishing a technical advisory committee
    to help CMS more accurately determine fee schedule rates. We appreciate
    the Committee's attention to this matter, and firmly believe that
    reform is needed for the current valuation process. The historic issues
    with undervaluation of primary care services are directly aligned with
    the issues within the overall valuation process. Therefore, the process
    must be reformed to improve accuracy and ensure the updates are regular
    and comprehensive. These reforms must include a CMS technical advisory
    committee which is inclusive of all health care providers billing the
    Medicare program.

    Multiple official reports from government agencies and MedPAC have
    identified serious flaws with the current process, and CMS' valuation
    of services. In May 2015, the United States Government Accountability
    Office (GAO) issued a report to Congressional Committees on Medicare
    Physician Payment: Better Data and Greater Transparency Could Improve
    Accuracy.\69\ In this report, GAO states that ``CMS's process for
    establishing relative values embodies several elements that cast doubt
    on whether it can ensure accurate Medicare payment rates and a
    transparent process.''\70\ The report identifies numerous flaws within
    the process and concludes that ``CMS's process for establishing
    relative values embodies several elements that cast doubt on whether it
    can ensure accurate Medicare payment rates and a transparent
    process.''\71\ GAO also noted that ``in the majority of cases, CMS
    accepts the RUC's recommendations and participation by other
    stakeholders is limited''\72\ and that ``Given the process and data
    related weaknesses associated with the RUC's recommendations, such
    heavy reliance on the RUC could result in inaccurate Medicare payment
    rates.''\73\ As noted in the GAO report, ``the reliability of work
    relative value recommendations may be undermined by survey respondents'
    potential conflicts of interest.''\74\
    ---------------------------------------------------------------------------
        \69\ GAO-15-434, Medicare Physician Payment Rates: Better Data and
    Greater Transparency Could Improve Accuracy. https://www.gao.gov/
    assets/gao-15-434.pdf.
        \70\ Ibid.
        \71\ Ibid.
        \72\ Ibid.
        \73\ Ibid.
        \74\ Ibid.

    These inherent conflicts in the valuation process led to a historic
    undervaluation of E&M services, which are a foundational aspect of the
    primary care system. The resulting negative impact on Medicare
    beneficiaries was identified in MedPAC's 2018 Report to the Congress
    Medicare and the Health Care Delivery System. Chapter 3 of this report,
    stated that ``this mispricing may lead to problems with beneficiary
    access to these services'' which are ``essential for a high-quality,
    coordinated health care delivery system.''\75\ The report states that
    ``to estimate clinician work time for specific services, CMS relies on
    data from surveys conducted by specialty societies that are reviewed by
    the RUC. We have concerns about these data; for example, the surveys
    have low response rates and low total number of responses, which raises
    questions about the representativeness of the results.''\76\ The
    Commission stated that the systemic undervaluation of E&M services was
    partially ``because the fee schedule is budget neutral, ambulatory E&M
    services become underpriced through a process of passive
    devaluation.''\77\
    ---------------------------------------------------------------------------
        \75\ jun18_medpacreporttocongress_rev_nov2019_note_sec.pdf.
        \76\ Ibid.
        \77\ jun18_ch3_medpacreport_sec.pdf.

    From 2011 to 2015, CMS agreed 69% of the time with the valuations set
    by the RUC.\78\ GAO highlighted the inherent conflict in their report,
    noting that ``stakeholder participation in CMS's process is limited
    because of incomplete information regarding which services are
    undergoing RUC--and eventually CMS--review.''\79\ In its 2015 report,
    GAO recommended ``to help improve CMS's process for establishing
    relative values for Medicare physicians' services, the Administrator of
    CMS should incorporate data and expertise from physicians and other
    relevant stakeholders into the process as well as develop a timeline
    and plan for using the funds appropriated by the Protecting Access to
    Medicare Act of 2014.''\80\
    ---------------------------------------------------------------------------
        \78\ GAO-15-434, Medicare Physician Payment Rates: Better Data and
    Greater Transparency Could Improve Accuracy. https://www.gao.gov/
    assets/gao-15-434.pdf.
        \79\ Ibid.
        \80\ Medicare Physician Payment Rates: Better Data and Greater
    Transparency Could Improve Accuracy, U.S. GAO. https://www.gao.gov/
    products/gao-15-434.

    In a 2022 update, GAO noted that ``to close this recommendation, we
    need documentation that CMS has started to incorporate data more
    broadly into its process for establishing relative values and that it
    has a documented timeline and plan for how it will use the funds
    appropriated by the Protecting Access to Medicare Act of 2014. As of
    December 2022, we had not received this documentation.''\81\ Therefore,
    as the Committee considers action on reimbursement, we support the
    establishment of a technical advisory panel, which is aligned with the
    recommendation from GAO.
    ---------------------------------------------------------------------------
        \81\ Ibid.
    ---------------------------------------------------------------------------

                                   Conclusion

    We appreciate the Committee's recognition of the need to address the
    structural inequities within the Medicare program which inhibit
    beneficiary access to coordinated, whole-person, patient-centered care.
    NPs are inequitably reimbursed for the care they provide to Medicare
    patients and still face barriers to participation in the program,
    despite the essential value that they provide in maintaining access to
    high-quality care for Medicare beneficiaries. We look forward to
    working with the Committee on improving and modernizing the Medicare
    program to reflect the current health care workforce and to meet the
    needs of Medicare beneficiaries.

                                     ______

                  American Association of Orthopaedic Surgeons

                    317 Massachusetts Avenue, NE, Suite 100

                           Washington, DC 20002-5701

                               Phone 202-546-4430

                         https://www.aaos.org/advocacy/

    On behalf of its 39,000 orthopaedic surgeon members, the American
    Association of Orthopaedic Surgeons (AAOS) is pleased to submit this
    statement for the record of the April 11, 2024 hearing, ``Bolstering
    Chronic Care through Medicare Physician Payment,'' before U.S. Senate
    Committee on Finance. We share the committee's goal of preserving
    patient access to care by reimbursing physicians appropriately under
    Medicare. Given ongoing concerns about increased consolidation and
    vertical integration in healthcare that the committee highlighted in a
    separate hearing last summer, it is critical that Congress take this
    opportunity to get Medicare payment reform right.

    Consolidation Trends in the U.S. Health Care System

    Consolidation is inextricably linked to Medicare payment policy, as
    declining physician reimbursements often fail to cover the skyrocketing
    cost of practicing medicine. As a result, small independent physician
    practices are being pushed to their financial brink and forced to merge
    with massive healthcare conglomerates and larger hospital systems.
    Ultimately, it is our patients who are most negatively impacted by this
    trend, as it has been well established that consolidation has not led
    to improved health of patients and often leads to higher costs and
    decreased patient choice.\1\ The stress of running a medical practice,
    including amplified financial pressures and administrative burdens, is
    causing one in five physicians to consider leaving private practice
    within 2 years.\2\ Unfortunately, the negative impact of the rising
    costs of running a medical practice disproportionately impacts small,
    independent practices, rural physicians, and those serving low-income
    and marginalized communities increasing the risk of access to care
    issues for some of our country's most vulnerable patients who are most
    in need of chronic care.
    ---------------------------------------------------------------------------
        \1\ https://www.kff.org/health-costs/issue-brief/what-we-know-
    about-provider-consolidation/.
        \2\ https://www.mcpiqojournal.org/article/S2542-4548(21)00126-0/
    fulltext.

    Despite promises of increased productivity and reducing redundancies,
    consolidation has not resulted in the lower costs and better care
    promised by the massive U.S. health care systems. Rather, research
    shows that increased consolidation has led to higher health care prices
    across the board. The consolidation of practices and integration with
    hospital systems can lead to increased prices for common orthopaedic
    procedures and decrease competition and opportunities among independent
    practices in the same market. For example, the cost for knee
    replacement and lumbar spine fusion were approximately 30 percent
    higher in concentrated markets versus competitive markets.\3\ This data
    amplifies the concerning trend that consolidation has consistently led
    to higher costs for patients and payers, undermining affordability and
    access to care.
    ---------------------------------------------------------------------------
        \3\ JC Robinson. Hospital Market Concentration, Pricing, and
    Profitability in Orthopedic Surgery and Interventional Cardiology. Am J
    Managed Care 2011; 17(6):e241-e248.
    ---------------------------------------------------------------------------

    Stabilizing Medicare Reimbursement for Physicians

    Our nation's physicians are currently grappling with yet another cut to
    the Medicare Physician Fee Schedule (MPFS). Coupled with medical
    practice costs which are projected to increase by 4.6% this year, even
    the reduced cut of 1.69% that Congress implemented in its recent
    appropriations package is financially straining physician practices
    past their breaking point.

    While the gap between rising physician costs and stagnant or declining
    reimbursement has grown more volatile in recent years, the economic
    uncertainty it creates for physicians has been slowly building for
    decades. The projected 4.6% increase clinicians' input costs for CY
    2024--as measured by the Medicare Economic Index (MEI)--is the highest
    it's been this century, beating last year's record of 3.8%. In fact,
    since 2001, the cost of running a medical practice has increased 39%,
    but the Centers for Medicare & Medicaid Services (CMS) has only
    increased reimbursement for physicians by 11%.\4\ Unlike hospitals and
    nursing homes--physicians and other health care professionals do not
    receive an automatic increase to help keep up with the rate of
    inflation. As a result, when adjusting for inflation in practice cost,
    Medicare physician pay dropped by 20% over the past 2 decades.\5\
    ---------------------------------------------------------------------------
        \4\ https://www.ama-assn.org/system/files/medicare-pay-chart-
    2021.pdf.
        \5\ https://www.ama-assn.org/sites/ama-assn.org/files/2022-09/
    medicare-updates-inflation-chart.jpg.

    Given this economic climate, it should come as no surprise that many
    practices are forced to choose between closing their doors or
    consolidating with larger healthcare institutions that can provide the
    kind of economic stability needed to continue treating patients.
    Increasing physician reimbursement to keep pace with hospital
    reimbursement is one very tangible way that Congress can alleviate the
    economic conditions that lead to consolidation and ultimately higher
    costs for health care. Providing physicians with a full inflationary
    update tied to MEI is a necessary first step to further stabilize the
    MPFS. For this reason, we urge Congress to pass H.R. 2474, the
    Strengthening Medicare for Patients and Providers Act, which would
    accomplish this goal.

    Budget Neutrality

    Physicians are not only struggling to keep up with inflation, but they
    also face Medicare reimbursement cuts year-after-year due to budget
    neutrality constraints. The Omnibus Budget Reconciliation Act of 1989
    contained a provision which mandated that any upward payment
    adjustments or the addition of new procedures that will increase
    spending by $20 million or more must be offset by cuts elsewhere in the
    MPFS. As a result, the various medical specialties are pitted against
    each other in competition over the size of their respective pieces of
    the MPFS pie, creating even more uncertainty for physicians. It is not
    uncommon for a physician in one specialty to see their payments reduced
    because of policy decisions aimed at a completely different specialty
    that have little to do with their day-to-day practice of medicine. In
    fact, roughly 60% of the original 3.37% cut that CMS proposed in this
    year's MPFS can be attributed to one such policy decision--the
    implementation of the G2211 add on code that is primarily directed
    towards primary care and other office/outpatient evaluation and
    management (E/M) intensive specialties.

    The idea that physicians must compete against each other for fewer and
    fewer resources is completely antithetical to the team-based, patient
    centered approach that is so vital to chronic care. Rather than
    promoting the kind of collaborative, cooperative environment necessary
    to coordinate care for patients with chronic conditions across multiple
    specialties, the current payment reimbursement reinforces a zero-sum
    view of delivering healthcare, where one specialty's reimbursement bump
    is another specialty's loss. A good first step would be to raise the
    MPFS budget neutrality threshold and index it to inflation going
    forward, as well as providing statutory guard rails to limit the year-
    over-year changes to the conversion factor (CF).

    Unless we make long-term, structural changes to how Medicare--and by
    extension, how the rest of the private market, which often adjusts its
    rates based on changes to Medicare--values the services physicians
    provide, the idea of the independent, private practice physician will
    continue to fade from our health care system. For that model of health
    care delivery to be a financially viable option for physicians, they
    must have some sense of long-term financial security that the current
    patchwork of yearly payment fixes fails to provide to those who aren't
    salaried employees of a larger institution. While we appreciate
    Congress' efforts to mitigate the annual cuts, short-term legislative
    fixes only kick the can down the road without addressing the underlying
    stability. Next year, when both the 1.25% statutory adjustment from the
    Consolidated Appropriations Act, 2023 and the additional 1.68% relief
    from this year's appropriations package are set to expire, physicians
    are set to face yet another cut of 2.93% for 2025.

    AAOS is supportive of legislation led by Reps. Greg Murphy (R-NC), Brad
    Wenstrup (R-OH) and Michael Burgess (R-TX), ``The Provider
    Reimbursement Stability Act of 2023,'' which would reform budget
    neutrality and provide much needed stability within the MPFS for
    orthopaedic surgeons and the larger physician community. As written,
    the legislation would provide a full inflationary update to the MPFS
    and limit positive or negative adjustments to Medicare reimbursements
    to 2.5 percent. AAOS believes this legislation is another great step
    that Congress can take towards more comprehensive payment reform.

    Specialists' Role in the Transition to Value-Based Care

    The original intent of Medicare Access and CHIP Reauthorization Act of
    2015 (MACRA)--to incentivize the shift of U.S. healthcare spending and
    delivery from a fee-for-service model to a value-based care model--has
    been successfully implemented in some respects. However, it has failed
    to create the abundance of opportunities for physicians to participate
    in alternative payment models (APMs) that are necessary to make the
    program successful.

    As it relates to orthopaedic surgery, a shift to value-based models has
    proven to be complicated and costly with limited return on investment.
    Physicians are overloaded with administrative burden to comply with the
    numerous value-based payment models and patients are often unaware that
    they are participating in such arrangements, thus limiting the
    effectiveness of such programs.

    When considering the goals of MACRA, it is important to return to the
    intent of the law and explore options for providing are in a way that
    is of high value while remaining accessible to all patients. This may
    look like a single system for designing and operating all value-based
    payment models, with one platform for measure testing, approval, and
    use, as well as the same single platform for submission. Such a
    platform would be compatible with both government-operated and
    privately-
    operated value-based care programs.

    AAOS is supportive of advancing value-based care and developed a value-
    based care continuum (VBCC) to help orthopaedic practices better
    understand and navigate various alternative payment models created to
    achieve value-based care. AAOS also supports the creation of voluntary,
    physician-led alternative payment models that expand access to quality
    specialty care through wraparound approaches to musculoskeletal
    disorders. This includes care teams that assess the clinical and social
    factors that make surgical and nonsurgical interventions safe,
    effective, and long-lasting. Orthopaedic surgeons should remain the
    foremost leaders of these care teams which may include mid-level
    practitioners, nurse navigators, and physical therapists. Essential to
    improved access is reduced administrative burden which detracts from
    time spent with the patient and slows the treatment process.

    AAOS members are eager and willing participants in the transition to
    value-based care and were early adopters of value-based payment models,
    participating in the now partially mandatory Comprehensive Care for
    Joint Replacement (CJR) and voluntary Bundled Payments for Care
    Improvement-Advanced (BPCI-A) programs. Our members' work to optimize
    patient care, increase value, and decreased costs resulted in an
    estimated $61.6 million estimated net savings in the first three
    performance years of the CJR program.\6\
    ---------------------------------------------------------------------------
        \6\ https://innovation.cms.gov/data-and-reports/2022/cjr-fg-
    thirdannrpt.

    Any legislation passed by Congress must support surgeon-led models,
    which are highly effective at achieving participation from physicians,
    ---------------------------------------------------------------------------
    savings to the Medicare program, and patient engagement in their care.

    Congress clearly demonstrated its commitment to surgeon-led models when
    it created the Physician-focused Payment Model Technical Advisory
    Committee (PTAC) to review and recommend stakeholder-designed APM
    proposals. However, the committee has been plagued by years of turmoil
    and resignations in protest of HHS' failure to adopt any of its
    recommended models.\7\ In fact, PTAC has evaluated more than three
    dozen models and recommended several to HHS and CMS, but none have been
    adopted.
    ---------------------------------------------------------------------------
        \7\ https://www.politico.com/newsletters/politico-pulse/2019/11/25/
    a-closer-look-at-medicare-for-all-783041.

    The problems with PTAC point to a broader issue with how CMS has been
    exploring and evaluating options for alternative payment models and
    cost savings in health care. Just last month, the Congressional Budget
    Office issued a report estimating that the Center for Medicare &
    Medicaid Innovation (CMMI)--the agency tasked with testing new APMs and
    identifying potential cost savings--actually increased federal spending
    by $5.4 billion between 2011 and 2020, and will continue to increase
    net spending by $1.3 billion over the next decade. The spending
    increase is a result of CMMI's failure to identify and expand models
    that produce cost savings. The agency spent $7.9 billion to operate
    models between 2011 and 2020. Of the 49 models it initiated, only 6
    ``generated statistically significant savings'' and only 4 have been
    ---------------------------------------------------------------------------
    ``certified for expansion'' by CMS and HHS.

    As Congress considers ways to improve the pipeline of viable APMs,
    particularly for specialty care, it should explore ways to bolster the
    role of PTAC and give surgeons real input in developing and
    implementing models that best suit the needs of their patients.

    CMS has taken the initiative to create and support Accountable Care
    Organization (ACO) models, which is a significant step in moving the
    United States toward a population health approach to care. Ultimately,
    we all want to create and participate in a model that helps patients
    achieve good health outcomes and enable us to sustainably care for our
    rapidly growing Medicare population. However, the current models are
    designed to place the risk and cost management aspects of value-based
    payments solely in the realm of primary care practitioners while
    keeping the specialists and their teams in the fee-for-service world.
    This is based on the premise that ACOs will be able to identify and
    refer patients to high value specialists while providing most of the
    care themselves.

    Given the proportion of Medicare dollars spent on specialty care and
    the prevalence of conditions that are treated by specialists, this is a
    recipe for failure. The AAOS strongly recommends an approach that
    allows risk sharing downstream with the specialists who provide care
    for these conditions. Providing efficient, evidence-based treatments
    for musculoskeletal conditions with an eye toward preventive care and
    improving overall health can only be accomplished with deep and
    expansive expertise in the most prevalent health conditions. To achieve
    the shared savings that CMS aims for, it mandates that the experts who
    work directly with patients on key decision making are incentivized
    toward value. The most promising model to facilitate ACO/Specialist
    collaboration is a condition-based payment mechanism as described in
    the attached white paper developed by AAOS volunteers and staff. Thus,
    AAOS urges the Center for Medicare and Medicaid Innovation (CMMI) to
    explore and immediately pilot a program for the management of chronic,
    prevalent conditions such as osteoarthritis of the knee, as delineated,
    with plans to expand into other conditions as the reconciliation,
    monitoring, and payment mechanisms are refined from this initial
    experience.

    Key factors that drive improvements in cost, quality and outcomes are
    communication, collaboration, and the use of high-quality data to
    inform clinical decision making. Successful population health
    organizations maintain services to patients aimed at providing as much
    on site and well-rounded care as possible. This may cost more upfront
    for organizations but eventually help to avoid costly acute and post-
    acute care. Such interventions will inevitably result in more value-
    based revenue and more importantly, better outcomes and happier
    patients. By utilizing high quality data and metrics, primary care
    practitioners and their teams can adopt referral patterns that
    correspond to population health and value-based care goals. They will
    be able to identify and work with high quality, high performing
    specialists. This will decrease stress and time for referral
    appointments for the primary care while enhancing the patient's
    experience and trust in the population-based organization.

    Engaging specialists in episodic care management also reduces the
    stress and strain on primary care. No single physician can know and
    understand best practices for the management of every disease. By
    engaging specialists who are familiar with best practices for any given
    disease process, time and costly interventions can often be avoided. To
    share an example, it is quite common for a patient to have waited a
    lengthy period to be seen in an orthopaedic practice. They usually
    present in pain and frustrated with an MRI that is positive for
    meniscal tearing amid extensive osteoarthritis and their expectation is
    that arthroscopic surgery will heal their meniscal tear. In such a
    scenario, by engaging orthopaedic surgeons and other musculoskeletal
    specialists earlier in the process the patient would be more satisfied
    that their needs and fears were being addressed, the unnecessary MRI
    would be avoided, the patient would be reassured that arthroscopy is
    not indicated for meniscal tears in the setting of osteoarthritis and
    that by undergoing physical therapy and other non-operative measures
    they could potentially postpone or obviate the need for total knee
    arthroplasty. Thus, saving the system money and further enhancing the
    patient's experience with improved health outcomes.

    We urge you to consider the profound impact that interoperability,
    multi-payer alignment of measures, and administrative burden have on
    the ability for physicians to successfully participate in alternative
    payment models. It is incumbent upon Congress and CMS to ensure that
    these perennial barriers are resolved in any future model. Likewise,
    AAOS strongly encourages the agency to only consider voluntary models
    that have incentives for participation. Mandatory models have
    historically been unsuccessful in engaging physicians who are otherwise
    eager to lead in the shift to value-based care. As in our earlier
    comments on the Comprehensive Care for Joint Replacement (CJR) Model
    and subsequent extension, a mandate to include all episodes,
    physicians, and facilities in a designated Metropolitan Statistical
    Area severely disadvantaged those surgeons, non-physician providers,
    and facilities that either did not have the proper infrastructure to
    optimize patient care under
    episodes-of-care payment models and/or lacked adequate patient volumes
    to create sufficient economies of scale. A voluntary program that
    allows surgeons, facilities, and non-surgical providers to tailor their
    episode-of-care models to their unique patient population would lead to
    far better patient outcomes as well as more accurate and efficient
    payments.

    In conclusion, the American Association of Orthopaedic Surgeons urges
    Congress to take immediate action to address the growing challenges
    facing physicians and their patients in the U.S. healthcare system. By
    stabilizing Medicare reimbursement, reforming budget neutrality, and
    supporting the development of physician-led alternative payment models,
    Congress can help to reverse the trend of consolidation, preserve
    patient access to care, and promote the transition to value-based care.
    We stand ready to work with the Committee and other stakeholders to
    advance these critical priorities and ensure that our nation's
    healthcare system remains robust, innovative, and patient-centered for
    years to come. Thank you for the opportunity to submit this statement
    for the record, and we look forward to continuing to engage with the
    Committee on these important issues.

                                     ______

                   American Clinical Neurophysiology Society

                         555 East Wells St., Suite 1100

                            Milwaukee, WI 53202-3823

                             Phone: (414) 918-9803

                              Fax: (414) 276-3349

                             https://www.acns.org/

    April 25, 2024

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    Washington, DC                      Washington, DC

    Dear Chair Wyden and Ranking Member Crapo:

    On behalf of the American Clinical Neurophysiology Society (ACNS), we
    appreciate the opportunity to provide input on the Senate Finance
    Committee's April 11th hearing on ``Bolstering Chronic Care through
    Medicare Physician Payment.'' We appreciate that Senators raised issues
    related to the Medicare conversion factor, prior authorization, and
    quality programs and we look forward to working with the Committee and
    the bipartisan working group on legislative solutions to these issues.

    Founded in 1946, ACNS is a professional society with more than 1,500
    members comprised of physicians, researchers and allied health
    professionals devoted to the establishment and maintenance of standards
    of professional excellence in clinical neurophysiology under the
    practice of neurology, neurosurgery, and psychiatry. ACNS members
    utilize neurophysiology techniques in the diagnosis and management of
    patients with disorders of the nervous system and in research examining
    the function of the nervous system in health and disease.

    Clinical neurophysiology is a neurology subspecialty. ACNS members
    focus attention not just on electroencephalography (EEG), but also on
    evoked potentials, electromyography, nerve conduction studies,
    neurophysiologic intraoperative monitoring, polysomnography and other
    sleep technology, quantitative neurophysiological methods,
    magnetoencephalography, sleep disorders, epilepsy, neuromuscular
    disorders, brain stimulation, brain-computer interfacing, and related
    areas. Many of the patients we treat are Medicare beneficiaries;
    consequently, an effective Medicare payment system is of particular
    importance to our members.

    While we appreciate the challenges of primary care, we want to note
    that the patients with chronic conditions that our members treat
    require long-term specialized care; indeed, ACNS members are the
    medical home for patients with epilepsy a very common chronic
    neurological condition, amongst others such as chronic neuromuscular
    diseases. The solutions that the Committee develops should not be
    limited to primary care but should support those physicians who manage
    patients' complex, and often chronic, conditions, and we offer the
    following recommendations as the Committee continues its work.

    Recommendations to Improve the Medicare Payment System

    Creating reimbursement stability must be a high priority for Congress
    as you develop legislation to revise the payment system. We believe
    that the current system is broken and unsustainable for Medicare
    beneficiaries and providers. Each year the threat of cuts to physician
    payments creates uncertainty and anxiety for physicians, who already
    feel overwhelmed and undervalued. We already see workforce shortages
    across specialties, including neurology where increasingly a dwindling
    workforce takes care of an ever-expanding demographic of elderly
    patients. Neurologists develop longitudinal relationships with their
    patients to manage their complex health conditions.

    As you know, the Medicare Access and CHIP Reauthorization Act (MACRA)
    of 2015 eliminated the SGR's volume-based targets, which resulted in
    annual decreases to the conversion factor; often Congress stepped in to
    avert those required cuts. However, due to the retention of the
    Physician Fee Schedule's statutory budget neutrality requirement and
    lack of conversion factor updates, the last of 0.5 percent update was
    applied in 2020, physicians again face significant payment cuts
    requiring Congress to intervene. Under the SGR and MACRA, Medicare
    physician payment has stagnated for the last 2 decades. Physicians have
    struggled to keep pace as practice costs, the consumer price index, and
    other factors have kept physician payments flat. Meanwhile, hospital
    inpatient and outpatient reimbursement, which include a mechanism for
    regular updates, have increased at a steady pace.

    ACNS would support the development of a stable Medicare payment system
    that eliminated the threat of yearly payment cuts, while also keeping
    payments on pace with inflation and creating increases that were on par
    with other payment systems under Medicare. Barriers to care will worsen
    if the stability of maintaining a livelihood as a physician remains
    threatened.

    We believe that MACRA cannot be fixed without eliminating or adjusting
    the budget neutrality requirement. While Congress and CMS would like to
    transition to value-based payment models, it likely cannot be done
    without increases to physician payments, given that the costs of
    practicing medicine are increasing. Costs such as investment in
    electronic health records, staff training, staff compensation, supplies
    and other items needed to operate a practice are increasing with
    inflation, yet physician payment remains flat.

    The payment system cannot be updated or fixed unless the system
    provides for regular updates to the underlying practice expense inputs.
    Specifically, the indirect practice expense inputs of operating a
    medical practice used in the calculation of physician payments for
    Medicare services indirect are derived from survey data that is 16
    years old. We believe that regularly updating the direct and indirect
    practice expense is a key component of a stable Medicare payment system
    that will include increases that are proportionate to economic changes.

    CMS is aware that the Medicare Economic Index (MEI) weights need to be
    updated. CMS had proposed to update the MEI using 2017 data from the
    United States Census Bureau's Service Annual Survey but ultimately
    decided not to make this change in CY 2023 due to the significant
    redistributive effect of the policy. We implore Congress to work with
    CMS to update the MEI and develop a mechanism to keep it current.

    In addition to revising the budget neutrality adjustment, we believe
    that the compliance and reporting requirements of the Quality Payment
    Program (QPP) are extremely complex despite Congress' intention to
    simplify quality reporting requirements under MACRA. The QPP includes
    two separate, but equally complex payment systems--MIPS and advanced
    APMs; however, MIPS is not significantly more streamlined than the
    programs it was intended to replace. Congress must strive to revise the
    QPP such that its requirements support the delivery of truly value-
    based care and improved quality and do not create new check the box
    exercises or administrative burden. Even though the program was created
    to streamline quality reporting and to simplify it, many practices hire
    staff simply to assist with meeting the reporting requirements.

    Additionally, MACRA's statutory requirements have impeded Congress'
    goals for the program. For instance, MACRA legislation dictated the
    weights of the different MIPS categories--quality, cost, promoting
    interoperability, and improvement activities. While the cost category
    now comprises 30 percent of the physician's MIPS score, we believe it
    does not accurately reflect a physician's performance. Measuring the
    cost of physician care must be attributed appropriately, and account
    for factors that are under the control of the physician. We encourage
    Congress to take this into account when considering revisions to the
    quality payment program.

     Recommendations to Increase Provider Participation in Value-based
                        Payment Models

    As you know, value-based care models were created to tie payment for
    healthcare services to the quality of the care provided and not simply
    the volume of care delivered, while rewarding physicians for efficiency
    and effectiveness. However, the programs created under CMS have created
    challenges for physicians and physician practices that do not translate
    into value.

    There is an increased administrative burden and financial risk involved
    with participation in value-based payment models. There is a
    significant investment in training staff at a time when there are
    staffing shortages and high turnover rates. This training often takes
    away time and resources that should be devoted to patient care. In
    addition, with so many variations in practices, including practice
    size, specialty type, practice location, and population demographics, a
    one-size fits all model simply does not work. Flexibility is key to
    provider participation as a model that is not adaptable will not take
    hold. We also believe that payment models should decrease the risk to
    the provider by limiting the penalty for those items out of control of
    the provider (such as when a patient cannot afford a medication or does
    not have access to transportation to attend appointments).

    In summary, value-based payment models need to be tailored to
    specialties and subspecialties, with associated meaningful quality
    measures, and those payment models need to be easy for the provider to
    enroll and navigate.

    Recommendations to Improve MIPS and APM Programs

    To improve the MIPS program, CMS needs to have the authority and
    resources to create programs that are meaningful to all providers and
    patients regardless of specialty type, while lowering the burden to
    participate in these programs. We understand the constraints under the
    current payment system. We believe that collaboration with stakeholders
    will assist in creating more meaningful programs.

    ACNS also believes there needs to be more meaningful quality measures
    created for specialties. Often our members report on measures that have
    little impact on the care provided, and providers may simply be
    fulfilling administrative requirements. We would welcome the
    opportunity to work with CMS and other stakeholders to create
    meaningful, actionable measures for our specialty.

    We also would like to see a quality program that produces measured
    feedback that is timely and actionable. At present, we do not believe
    that some of the information found in performance reports is relatable
    to our practice patterns. Finally, many of the quality measures do not
    focus on patient care and outcomes, therefore we again encourage CMS
    and other stakeholders to consider creating more meaningful measures.

    We would also recommend simplifying the reporting requirements and
    reporting tools used in quality programs, while aligning rules and
    administrative tasks across programs. In addition, we believe that
    providers need more meaningful and useful educational resources so that
    we are better equipped to meet the demands of quality payment programs.

     Recommendations on Reducing the Burden of Prior Authorization

    Prior authorization is a major barrier to the delivery of timely care
    and treatments to patients and resulting in additional administrative
    burdens for providers. People with chronic illnesses such as epilepsy
    often experience prior authorization issues when accessing care. For
    example, prior authorization requirements make it difficult to schedule
    appointments for the Epilepsy Monitoring Unit (EMU). Our providers are
    not able to receive prior authorization until the day of the scheduled
    procedure, leaving no time to adequately counsel the patient on the
    procedure or the cost of the service. If the prior authorization is
    denied, the patient faces the difficult choice of going forward with
    the procedure or rescheduling, which may not be medically advisable.
    This also may strain the patient-provider relationship, which hinders
    the practice of medicine.

    Those staff responsible for approving prior authorizations often lack
    the expertise on the areas of medicine that our members practice, which
    can cause additional barriers to care. For example, a children's
    hospital treating a pediatric patient with potential catastrophic
    epilepsy may seek prior authorization for a procedure called a
    hemispherectomy, the removal of half of a patient's brain. After
    significant delay, the insurer approves the prior authorization for the
    hemispherectomy but states that a separate authorization would have to
    be given for performing the procedure on the other half of the brain.
    The decision makers did not have the expertise to understand that you
    would not perform two hemispherectomies on the same patient, which took
    additional provider time to explain to the insurer. It would reduce the
    burden on providers if there were subject matter experts reviewing the
    prior authorization request to ensure timely and appropriate
    authorization.

    Thank you again for the opportunity to provide our feedback as the
    Finance Committee develops legislation to address physician payment and
    improve care for patients with chronic conditions, such as epilepsy. We
    look forward to working with the Committee and the bipartisan working
    group led by Senators Stabenow and Thune as this process moves forward.
    Please reach out to Stefanie Rinehart at srinehart@dc-crd.com with any
    questions.

    Sincerely,

    Meriem Bensalem-Owen, M.D., FACNS
    President

                                     ______

      American College of Allergy, Asthma, and Immunology Advocacy Council

                              85 W. Algonquin Road

                          Arlington Heights, IL 60005

                                  847-427-1200

                           https://college.acaai.org/

    April 16, 2024

    Hon. Ron Wyden                      Hon. Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         Senate
    Committee on Finance                Committee on Finance
    221 Dirksen Senate Office Building  239 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    RE: ACAAI Statement for the Record in Response to U.S. Senate Committee
    on Finance Committee Hearing: Bolstering Care through Medicare
    Physician Payment--Thursday, April 11, 2024

    The American College of Allergy, Asthma, and Immunology's (ACAAI's)
    Advocacy Council appreciates the Senate Committee on Finance holding a
    hearing on improving chronic care through Medicare physician payment.
    We hope this hearing highlighted the insufficiency of Medicare
    reimbursement for physicians who care for patients with chronic
    conditions.

    ACAAI represents more than 6,000 board-certified allergists and
    healthcare professionals. Allergists specialize in treating both adult
    and pediatric patients with chronic conditions such as asthma, food
    allergies, hives or urticaria, stinging insect hypersensitivity, sinus
    problems, allergic rhinitis, anaphylaxis, immune deficiencies, and
    atopic dermatitis or eczema, among other things.

    Chronic conditions generally cannot be cured. They require ongoing care
    from a trusted and skilled clinician to effectively manage the
    patient's condition. Chronic care for a condition such as asthma
    requires regular office visits and medication adherence and management.
    Modern technology makes it possible to track symptoms outside of the
    exam room and allows patients to communicate with clinicians more
    regularly through portal messages. The current reimbursement model does
    not adequately account for these advances. Improvements are needed so
    that clinicians are reimbursed in a way that incentivizes care
    management and supports modern clinical approaches to chronic care
    management.

    Recent policy changes such as revised evaluation and management (E/M)
    code values and documentation requirements have helped allergy
    practices receive more adequate reimbursements. However, more is
    needed.

    Overall, we agree with many of the key issues brought up in the
    hearing, including low physician payments, the fragmented system of
    services produced by the Physician Fee Schedule, and the lack of
    meaningful value or clinical relevance in the metrics used in value-
    based payment programs such as the Medicare's Merit-Based Incentive
    System (MIPS).

    The ACAAI agrees with the Finance Committee that physician payment
    reform is necessary to improve treatment for patients with chronic
    conditions. To achieve this goal, ACAAI recommends:

          Permanently preventing various Medicare reimbursement reductions
    from taking effect at the start of each calendar year. ACAAI is
    appreciative of Congress' efforts to avert reductions to Medicare
    reimbursement rates, but the annual cycle of physicians advocating
    against cuts to the Conversion Factor to prevent Medicare reimbursement
    reductions highlights the need for a sustainable solution. We encourage
    the Senate to introduce and pass a companion version of Pass H.R. 2474,
    the Strengthening Medicare for Patients and Providers Act, and H.R.
    6371, the Provider Reimbursement Stability Act of 2023.

         Congress must permanently waive the 4% PAYGO reduction put into
    place when passing the American Rescue Plan of 2021. Moreover, the
    continuous extension of the 2% Medicare sequestration reduction,
    initially intended to be only for 10 years when it was implemented in
    2011, has created an enduring challenge for healthcare providers. This
    reduction, in combination with the expiration of the MIPS exceptional
    performance bonus and other policies, has made it difficult for many
    allergists to receive meaningful Medicare reimbursement adjustments.
    Creating greater financial certainty for allergy practices is not just
    a solution but a lifeline for the healthcare workforce serving patients
    facing chronic conditions, ultimately ensuring access to quality care
    for those who need it most.

          Congress should pass S. 3805, No Fees for EFTs Act, which would
    close the EFT fee loophole by specifying that fees are prohibited for
    transactions occurring directly between health plans and providers,
    including EFT transactions facilitated on behalf of health plans by
    covered entities or third parties. Additionally, Congress should
    prohibit automatic Virtual Credit Card (VCC) payments unless providers
    give advanced consent, effectively changing VCCs from opt-out to opt-in
    payment options. HIPAA has established a standard electronic
    transaction for Electronic Funds Transfer (EFT) payments to healthcare
    providers, promoting the transition away from paper checks. These EFT
    payments are akin to an employer directly depositing an employee's
    paycheck into their bank account and have been increasingly adopted,
    with 75% of claims payments utilizing the standard EFT transaction as
    of 2022. However, certain commercial payers exploit a loophole that
    allows them to charge healthcare providers additional fees for EFT
    transactions.

         In addition, some commercial health plans attempt to reimburse
    physicians using Virtual Credit Cards (VCCs). These are electronic
    numbers provided to physicians for payment, similar to credit card
    transactions, but they often entail payment fees. Physicians should
    have the option to opt out of VCC payments and receive a standard EFT
    transaction, which is free of additional charges. However, the opt-out
    process can be administratively burdensome for healthcare practices,
    and the alternative EFT payment may also carry fees when facilitated by
    third-party payment vendors. While CMS can regulate HIPAA transaction
    standards, it lacks the authority to address VCC-related issues.
    Congress therefore needs to act to protect practices from VCC payment
    fees.

          Simplifying Merit-Based Incentive Payments (MIPS) and Advanced
    Payment Models. Value-based payments, while well-intentioned, can be
    burdensome for allergists treating chronic conditions. As currently
    constructed, programs such as MIPS require significant investment of
    resources to effectively participate but have limited opportunities for
    physicians to receive significant payment increases as a reward for
    this investment. Allergists would benefit from less burdensome and more
    meaningful requirements to succeed in these programs, with a reformed
    payment incentive system to increase the benefits of succeeding in
    value-based payment programs.

         Additionally, physicians would have more success in value-based
    payment models if they were specifically tailored to the conditions
    they treat. We are disappointed that CMS has not tested any of the
    physician-focused payment models (PFPM) recommended by the PFPM
    Technical Advisory Committee (PTAC). In the MACRA legislation that
    created MIPS, Congress intended for PFPMs to serve as a physician-led
    alternative pathway to value-based care for chronic conditions to
    supplement MIPS and Advanced APMs. ACAAI's model, the
    Patient-Centered Asthma Care Payment Model,\1\ was among the dozens of
    models that the PTAC recommended to CMS. Our model is an example of an
    innovative reimbursement model to reward effective chronic care
    management for asthma. Congress should direct CMS to dedicate a portion
    of CMMI's budget to implement PFPM recommended by PTAC.
    ---------------------------------------------------------------------------
        \1\ https://college.acaai.org/sites/default/files/Resources/
    Advocacy/apm_exec_summary-complete_model.pdf.

          Continuing bipartisan efforts to reform prior authorization,
    particularly in the Medicare Advantage program by reintroducing the
    Improving Seniors Timely Access to Care Act originally considered in
    the 117th Congress. Requiring health plans to streamline their prior
    authorization processes will benefit physicians treating chronic care.
    Prior authorization, often used excessively by health plans, creates
    immense administrative challenges for physicians. It is essential that
    providers treating advanced chronic conditions, particularly amid
    widespread physician shortages, care for as many patients as possible.
    The barriers put in place due to prior authorization exacerbate
    ---------------------------------------------------------------------------
    challenges for patients with chronic conditions when accessing care.

         While a recent CMS final rule implements much of this policy, gaps
    continue to exist. For example, the final rule for prior authorization
    does not apply to drugs. Medications are an essential component of a
    patient's chronic care management. Delaying a patient's access to their
    medication can disrupt their care.

         Congress should move to pass the Improving Seniors Timely Access
    to Care Act to help close these gaps. Congress should also further
    limit health plans' use of prior authorization and penalize plans for
    improperly denying claims. ACAAI also recommends that Congress explore
    a program that requires health plans to adopt a ``fast-track'' for
    physicians who have a high amount of their prior authorization claims
    approved.

          Curtailing the influence of Pharmacy Benefit Managers (PBM) in
    dictating which medications treating chronic conditions (such as
    inhalers for treating asthma) are included in formularies. To address
    and improve how physicians treat chronic care, they should be able to
    prescribe medications that, according to their expert opinion, would
    best improve the quality of life for someone living with a chronic
    condition. This is especially true for treating chronic conditions such
    as asthma where the popular and effective inhaler Flovent was recently
    removed from the market. Now, PBMs are refusing to include the cheaper,
    generic version on their formularies. The influence PBMs have on drug
    availability should be put into question, especially for treating
    chronic conditions. The Advocacy Council has endorsed the Senate
    Finance Committee's efforts to reform PBMs. We urge the Committee to
    continue its strong push to pass a law that would reign in the
    influence of PBMs and improve patient access to medications. We applaud
    the bipartisan efforts this committee has taken thus far to achieve
    this goal.

    In conclusion, the ACAAI Advocacy Council expresses our deep
    appreciation for the Senate Committee on Finance's commitment to
    bolstering chronic care through Medicare physician reimbursement. Our
    recommendations span key areas, including reforming Medicare
    reimbursement, eliminating fees on electronic fee transfers (EFTs), and
    reigning in PBMs. We believe that these measures, if implemented, would
    go a long way in improving the care patients receive for their chronic
    conditions.

    We look forward to working with the Committee to address these vital
    issues to ensure that allergy patients dealing with chronic conditions
    receive the care they deserve. Please do not hesitate to contact Matt
    Reiter (reiterm@capitolassociates.com) if you wish to discuss our
    recommendations further. Thank you for your consideration.

    Sincerely,

    Gailen Marshall, Jr., M.D., Ph.D.,
    FACAAI                              Travis A. Miller, M.D., FACAAI
    President, ACAAI                    Chair, Advocacy Council

                                     ______

                     American College of Lifestyle Medicine

                                 P.O. Box 6432

                          Chesterfield, MO 63006-6432

                         https://lifestylemedicine.org/

    April 24, 2024

    Statement for the Record

    On behalf of the 11,000 medical professional members of the American
    College of Lifestyle Medicine (ACLM) who are dedicated to treating and
    reversing lifestyle-related chronic disease, we would like to thank the
    Senate Finance Committee for holding its April 11th hearing
    ``Bolstering Chronic Care through Medicare Physician Payment'' and
    appreciate this opportunity to submit this Statement for the Record. As
    the nation's only medical professional association dedicated to such an
    approach to chronic disease, we wholeheartedly agree that chronic care
    needs bolstering--chronic disease creates human suffering among both
    adults and a growing number of children, lowered workforce
    productivity, clinician burnout, and financial unsustainability for
    families and the nation as a whole.

    The incidence trajectory is alarming: According to the CDC, 51.8% of
    U.S. adults have at least one diagnosed chronic condition. Some 27.2%
    of U.S. adults suffer from multiple chronic conditions.\1\ Chronic
    diseases are responsible for 7 out of every 10 deaths in the U.S.,
    resulting in over 1.7 million fatalities annually. According to NIH
    data \2\ the adult obesity rate in 1980 in this country was 13.4%, and
    now stands at over 40%. This has led to similar large increases in the
    incidence of a wide range of comorbidities including cardiovascular
    disease, type 2 diabetes and pre-
    diabetes, chronic kidney disease and certain forms of cancer, most
    notably an increase in colon cancer among younger Americans. Only
    recently have we seen policy makers begin to call these comorbidities
    by their proper name: ``diet-related chronic disease.''\3\
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/pcd/issues/2020/20_0130.htm.
        \2\ https://www.ncbi.nlm.nih.gov/books/NBK44656/
    #::text=The%20prevalence%20of%20
    obesity%20changed,children%20during%20the%20same%20period.
        \3\ https://www.gao.gov/products/gao-21-593.

    The financial impact is sobering: CDC reports 90% of the $4.1 trillion
    in U.S. healthcare costs can be attributed to chronic or mental health
    conditions. Chronic disease accounts for 81% of all hospital
    admissions, 91% of all prescriptions filled, and 76% of all doctor
    visits. Furthermore, it's estimated that employees with chronic
    conditions cost employers $153 billion in lost wages each year.\4\ With
    the surge of demand for GLP-1 drugs and expansion of label usage, these
    costs will explode.
    ---------------------------------------------------------------------------
        \4\ https://news.gallup.com/poll/150026/unhealthy-workers-
    absenteeism-costs-153-billion.aspx
    #::text=WASHINGTON%2C%20D.C.%20%2D%2D%20Full%2Dtime,billion%20in%20lost
    %20
    productivity%20annually.

    And the effect on society is unmistakable: Americans are living
    shorter, less healthy lives. According to recent a Commonwealth Fund
    report, The U.S. has an obesity rate nearly double the average of the
    38 member countries of the Organization for Economic Cooperation and
    Development (OECD) with a life expectancy at birth 3 years lower on
    average and more than 7 years lower than leading member nations, all
    while spending nearly twice as much on health care per capita as any of
    them.\5\ As a result of its growing prevalence in the population,
    chronic disease now even threatens U.S. national security, affecting
    military recruitment eligibility and active-duty readiness. What's
    more, it is a matter of health equity, as communities of color suffer
    more instances of chronic disease, face more social barriers to care
    such as transportation, and are vulnerable to more complication rates
    as a result, notably amputations.
    ---------------------------------------------------------------------------
        \5\ https://www.commonwealthfund.org/publications/issue-briefs/
    2023/jan/us-health-care-global-perspective-2022.

    As patient disease, suffering and the associated financial impact
    continues its unsustainable upward trajectory, the need for improved
    primary care payment is unquestionable. Physician burnout has created
    primary care physician shortages with yearly Medicare payments cuts
    only add to the workforce retention issue. The U.S. is already running
    low on primary care physicians, according to the American Medical
    Association, with an estimated shortage of between 17,800 and 48,000
    predicted by 2034. The shortage of physicians has negative consequences
    for patients and communities, such as delays in access to care, poorer
    health outcomes, higher costs, and lower satisfaction.\6\ Nearly $1
    billion in annual excess health care expenditure are due to turnover of
    primary care physicians.
    ---------------------------------------------------------------------------
        \6\ https://www.msn.com/en-us/health/medical/where-have-all-the-
    doctors-gone-exploring-the-causes-and-consequences-of-the-physician-
    shortage-in-the-united-states/ar-AA1|EqpZ.

    We believe taking steps to expand and reward the practice of lifestyle
    medicine is an absolutely necessary part of any strategy that hopes to
    stem this epidemic tide of chronic disease, improve patient outcomes,
    reverse the trend of physician burnout and contain the growth of health
    care spending in this country.

    What is lifestyle medicine?

    Lifestyle medicine is a medical specialty that uses therapeutic
    lifestyle interventions as a primary modality to treat chronic
    conditions including, but not limited to, cardiovascular diseases, type
    2 diabetes, and obesity. Lifestyle medicine certified clinicians are
    trained to apply evidence-based, whole-person, prescriptive lifestyle
    change to treat and, when used intensively, often reverse such
    conditions. Applying the six pillars of lifestyle medicine--a whole-
    food, plant-predominant eating pattern, physical activity, restorative
    sleep, stress management, avoidance of risky substances and positive
    social connections--also provides effective prevention for these
    conditions.\7\
    ---------------------------------------------------------------------------
        \7\ https://lifestylemedicine.org/about-us/.

    You will notice the word you do not find in that definition: manage.
    When most practitioners--and policy makers, for that matter--discuss
    chronic care that is the term they use, reflecting the belief that
    managing such conditions to ensure patients are prescribed and take
    their medications and care is coordinated to avoids gaps in care that
    can result in hospitalizations and emergency rooms is the best we can
    do, that patients are consigned to having these conditions for life and
    the best we can do is slow the progression and mitigate the harmful
    side effects. ACLM and its members believes our health care system can
    ---------------------------------------------------------------------------
    and must do better.

    To be clear, ACLM physicians are not anti-prescription drugs. Our
    members recognize the important role they play and often do prescribe
    such treatments. They simply do not believe they are the only or even
    the best answer for many patients. As ACLM member and practicing
    preventive cardiologist Cliff Morris described it, ``Dr. Morris
    believes that in many instances medications are appropriate in
    maintaining the health of an individual; however, his goal is to treat
    the root cause of disease itself so the body no longer needs the
    medication, and thus does not have to live with the side effects of
    medications. If by adopting healthy lifestyle habits you can bring your
    numbers down naturally, then you will essentially no longer rely on the
    medication for your health. At that point, and only then, your provider
    will take you off of your medication. At Morris Cardiovascular we
    celebrate this moment as you take back your health.''

    Despite wide recognition that all of this is directly related to
    significant dietary changes in our country and other lifestyle
    elements, the health care system has simply not evolved nearly enough
    to create a work force or payment systems equipped to address these
    conditions their patient populations most often present with. Most
    notably, our physicians receive little to no training in nutrition or
    exercise science in most of our medical schools and residency programs,
    with data showing that an overwhelming majority feel ill equipped to
    provide the kind of expert guidance their patients need in these
    areas.\8\ According to a recent article in STAT,\9\ ``The average
    medical school student spends less than a day \10\ learning about
    obesity, despite the fact that over 40% of adults and 1 in 5 children
    \11\ in the U.S. have it, according to some estimates.'' The health
    care system did not cause this problem and there are major policy areas
    outside the system and the scope of the Finance Committee that need to
    be addressed, but the health care system does need to play a much
    larger and more direct role in addressing this epidemic if we are ever
    going to make real progress in improving outcomes.
    ---------------------------------------------------------------------------
        \8\ https://www.congress.gov/bill/117th-congress/house-resolution/
    784/text.
        \9\ https://www.statnews.com/2023/03/20/childhood-obesity-
    guidelines-eating-disorders-data-concerns/.
        \10\ https://www.wgbh.org/news/national-news/2023/01/31/scant-
    obesity-training-in-medical-school-leaves-docs-ill-prepared-to-help-
    patients.
        \11\ https://www.cdc.gov/mmwr/volumes/67/wr/
    mm6706a3.htm?s_cid=mm6706a3_w.

    ---------------------------------------------------------------------------
    This education and training does not need to be developed from scratch.

    ACLM, which has championed food as medicine and other lifestyle
    ``pillars'' to address existing chronic disease since its inception in
    2004, provides hundreds of hours of undergraduate, graduate (residency)
    and continuing medical education (CME) courses. We support student- and
    trainee-initiated Lifestyle Medicine Interest Groups at 132 academic
    and health institutions. Some 302 lifestyle medicine residency programs
    exist across 135 sites, with 6,900+ enrollees.

    In support of the 2022 White House Conference on Hunger, Nutrition, and
    Health and to date, ACLM has committed $44.1 million in complimentary
    coursework to 200,000 clinicians until September 2025, and lifestyle
    medicine certification support to one primary care provider in each of
    the nation's 1,400 Federally Qualified Health Centers.

    We help prepare physicians and other clinicians for that certification.
    Since certification began in 2017 by the American Board of Lifestyle
    Medicine, 3,085 physicians in the U.S. have become board certified in
    lifestyle medicine, along with 1,263 other health professionals.
    Worldwide, across 72 countries, 5,017 physicians and 1,671 other
    clinicians are certified for a total of 6,688.

    Lifestyle medicine training also has the ability to support better
    health behaviors for clinicians who are delivering care. One study, has
    shown that clinicians who practice LM are at a lower risk for burnout,
    which could help address the healthcare workforce shortages cited
    above.

    The time for change in this area is long past due. The situation has
    become so dire, that in 2023, the American Academy of Pediatrics began
    recommending Intensive Health Behavior and Lifestyle Treatment (IHBLT)
    for children as young as 2 years old (while also recognizing that it is
    not ``universally available''), obesity drugs for children as young as
    12 years old and bariatric surgery for children as young as 13 years
    old.\12\
    ---------------------------------------------------------------------------
        \12\ https://www.aap.org/en/news-room/news-releases/aap/2023/
    american-academy-of-pediatrics-issues-its-first-comprehensive-
    guideline-on-evaluating-treating-children-and-adolescents-with-obesity/
    #::text=Physicians%20should%20offer%20adolescents%20ages,health%20behav
    ior%20
    and%20lifestyle%20treatment.

    Those same obesity drugs, glucagon-like peptide 1 (GLP-1) agonists, are
    changing the landscape of obesity treatment with demand surging and
    cost projections raising great concerns over their systemic impact on
    Medicare Part D costs, as well as their impact on Medicaid and
    commercial insurance costs. Even with Medicare statutorily precluded
    from covering GLP-1s for treatment of obesity, Ozempic alone was the
    sixth most costly Part D drug in 2022 with its indication only for
    treatment of type 2 diabetes.\13\ With recent FDA of approval \14\ of
    Wegovy for treatment of cardiovascular disease, the potential Medicare
    patient pool is likely to continue grow regardless of whether Congress
    takes action to allow Medicare to cover these drugs for obesity.
    ---------------------------------------------------------------------------
        \13\ https://www.kff.org/policy-watch/medicare-spending-on-ozempic-
    and-other-glp-1s-is-skyrocketing/?utm_campaign=KFF-
    Medicare&utm_medium=email&_hsenc=p2ANqtz-8kEPIry
    T_Rgwgla_cOILCS3V1DDRlML5TJgT1LDuQBBKidrwenLhpzNajdUHx2CYsnJiR74102VRS
    _Cdixy24f2h_n6w&_hsmi=299684398&utm_content=299684398&utm_source=hs_emai
    l.
        \14\ https://www.fda.gov/news-events/press-announcements/fda-
    approves-first-treatment-reduce-risk-serious-heart-problems-
    specifically-adults-obesity-or.

    ACLM believes there is a role for the GLP-1s and is heartened by the
    positive short term impact they are having for patients not only in
    addressing obesity but also some of its most damaging comorbidities;
    however, given the high incidence of short term side effects, the
    potentially enormous systemic costs and the legitimate questions about
    the long term health effects to patients from taking appetite
    suppressants for a lifetime, we believe these drugs are best
    administered in combination with lifestyle medicine, to give patients a
    pathway to eventually no longer taking these drugs without quickly
    reversing the gains they have made. Again, the system is simply not
    equipped to offer that alternative right now with the rigor and at the
    ---------------------------------------------------------------------------
    scale that is required.

    So what are the policy prescriptions we recommend the Finance Committee
    pursue to meet this goal of building a health care system equal to the
    challenge of addressing this epidemic and truly ``Bolstering Chronic
    Care''?

    As mentioned earlier, we believed it starts with dramatically
    increasing the time and quality of the nutrition education our doctors
    receive in Undergraduate Medical Education (UME) and Graduate Medical
    Education (GME). This was an area of focus at the 2022 White House
    Conference on Hunger, Nutrition and Health and the Department of Health
    and Human Services (HHS) has taken up the mantle as well, working with
    stakeholders like ACLM to drive desperately needed change in this area.

    It is long past time for the Finance Committee to get involved in this
    as well. We recognize there are limits to how far Congress will go in
    dictating to schools and residency programs the content of their
    curriculum; however, there are clear steps the Committee can and must
    take to continue to help elevate this issue. We think that starts with
    the Committee simply holding hearings on the issue, bringing
    stakeholders such as that American Association of Medical Schools
    (AAMC) and the American Council for Graduate Medical Education (ACGME)
    up for questioning about what they are doing to address this glaring
    deficiency and, most importantly, an organization such as ACLM which is
    already offering scalable curriculum across the spectrum of medical
    education in this area. Given the number of hearings the committee has
    held to address issues related to chronic care such as the prices of
    the drugs used to treat the diseases, we think it is past time for the
    Committee to hold hearings on solutions that can reduce the need for
    those same medications.

    The Committee could also legislate to require the Government
    Accountability Office (GAO) to report on the status of nutrition
    education in our residency programs, including best practices that the
    majority of residency programs are falling far short of in this area
    and could seek to replicate.

    Along with creating a work force that is educated to work with patients
    to prevent and also to treat and reverse chronic conditions where
    possible, we also need payment models that incentivize models designed
    to reward physicians for taking such an approach. For instance, we have
    models where reducing hospitalizations is a quality measure. Why can't
    we also have quality measures that include reducing the need for
    prescription drugs while improving measurables for conditions such as
    high cholesterol, hypertension, and type 2 diabetes? In the fee-for
    service system, CPT codes that address lifestyle modifications are
    reimbursed far less than CPT codes for drug prescriptions and surgical
    procedures. This is despite the fact that lifestyle interventions have
    been proven to achieve better health outcomes than prescription drugs
    alone and often require more time and effort from the clinical care
    team than a prescription drug or surgical procedure might. Behavior
    change interventions also have far less harmful side effects.

    The current quality and payment models also don't reward medication de-
    escalation as the result of improved health outcomes or even reversed
    chronic conditions. As an example, in the Medicare Advantage insurance
    space, a large number of the measures in the Quality Bonus Program are
    focused on medication adherence as end result and punish plans whose
    physicians work with patients to improve or reverse their chronic
    conditions through lifestyle change. Success on these measures is what
    determines whether plans receive their 5% bonus payment for achieving
    four or five start status, so we know they ``teach to the test'',
    meaning these incentives flow through to their physician contracts.

    In the direct physician payment space, for instance, we have payment
    models where reducing hospitalizations is a quality measure. Why can't
    we also have quality measures that include reducing the need for
    prescription drugs while improving measurables for conditions such as
    high cholesterol, hypertension and type 2 diabetes?

    There was some discussion during the hearing, including from Ranking
    Member Mike Crapo (R-ID), about the role that was envisioned for the
    Physician-Focused Payment Model Technical Advisory Committee (PTAC)
    created as part of the Medicare Access and CHIP Reauthorization Act
    (MACRA) of 2015 in providing medical specialists an avenue to develop
    and advance payment models through a rigorous process that would to
    many of those recommended by the PTAC being implemented by the Center
    for Medicare and Medicaid Innovation (CMMI). In fact, none of the
    models recommended were ever implemented and as result the PTAC has
    withered on the vine. This process needs to be reinvigorated either
    through a renewed PTAC or some other model the committee creates.

    In addition, there are bills already introduced that the committee
    should advance that would represent some progress in advancing
    lifestyle medicine solutions to chronic disease. Those include the
    Medical Nutrition Therapy Act (S. 3297) led by Senators Susan Collins
    and Gary Peters. This bill expands Medicare coverage of medical
    nutrition therapy services. Currently, Medicare covers such services
    for individuals with diabetes or kidney disease under certain
    circumstances; such services must also be provided by a registered
    dietitian or nutrition professional pursuant to a physician referral.
    The bill extends coverage to individuals with other diseases and
    conditions, including obesity, eating disorders, cancer, and HIV/AIDS;
    such services may also be referred by a physician assistant, nurse
    practitioner, clinical nurse specialist, or (for eating disorders) a
    clinical psychologist. ACLM support passage of the Medically Tailored
    Meals Act (S. 2133) led by Senators Debbie Stabenow and Roger Marshall,
    which would create a medically-tailored meals home delivery
    demonstration program.

    Lastly, efforts at long term behavior change and maintenance
    interventions are often not as effective or efficient when delivered in
    the traditional, infrequent 1:1 provider-to-patient ratio, 15-minute
    medical appointment. A best practice for the delivery of lifestyle
    medicine and support of the necessary behavior change is through shared
    medical appointments (SMAs) in which patients receive both individual
    care and group education by a team of clinicians about therapeutic
    lifestyle changes that can treat or reverse their disease(s). SMAs are
    not new models, but have been very effective for our members in the
    delivery of therapeutic lifestyle interventions. SMAs have been shown
    to help patients learn and support each other in behavior change,
    increase access to care, achieve better health outcomes and alleviate
    provider burnout. However, there are a number of challenges related to
    the delivery of SMAs for both providers and patients. On the provider
    side, challenges include compliance concerns related to the number and
    frequency of E&M visits coded back-to-back as is common in an SMA
    model, place of service issues for delivering care in community-based
    settings where patients live and work, challenges in getting approval
    for the use of modifier 33 to waive patient copays. On the patient
    side, the number and frequency of SMA programs to address lifestyle-
    related behaviors can be financially unviable if they require a patient
    co-pay each visit.

    Winston Churchill is believed to have once observed ``You can always
    count on Americans to do the right thing--once they have tried
    everything else''. We urge the Committee as it considers policies to
    help ``bolster chronic care'' to take the steps we have recommended and
    others to address the root causes of this epidemic. It truly is the
    right thing and when it comes to chronic disease, we have tried
    everything else.

    For questions related to feedback and recommendations from the American
    College of Lifestyle Medicine, please contact Kaitlyn Pauly, Deputy
    Director of Practice Advancement and Administration, at
    kpauly@lifestylemedicine.org

    Regards,

    Beth Frates, M.D., DipABLM          Susan Benigas, BS
    President                           Executive Director

                                     ______

                         American College of Physicians

                     25 Massachusetts Avenue, NW, Suite 700

                           Washington, DC 20001-7401

                                  202-261-4500

                                  800-338-2746

                           https://www.acponline.org/

    On behalf of the American College of Physicians (ACP), we appreciate
    this opportunity to share our recommendations to improve the delivery
    of chronic care in Medicare. We applaud Chairman Wyden and Ranking
    Member Crapo for hosting this hearing on Bolstering Chronic Care
    through the Medicare Physician Fee Schedule (MPFS) and their
    willingness to consider policies to enhance care for seniors with
    chronic conditions. We were pleased to work with this Committee several
    years ago to strengthen chronic care through the passage of S. 870, the
    Creating High-Quality Results and Outcomes to Improve Chronic (CHRONIC)
    Care Act and look forward to working with you to ensure that the MPFS
    provides the support necessary for physicians to provide high quality
    chronic care for our seniors.

    ACP is the largest medical specialty organization and the second
    largest physician membership society in the United States. ACP members
    include 161,000 internal medicine physicians, related subspecialists,
    and medical students. Internal medicine physicians are specialists who
    apply scientific knowledge, clinical expertise, and compassion to the
    preventive, diagnostic, and therapeutic care of adults across the
    spectrum from health to complex illness.

    Although the Chronic Care Act made important changes in improving care
    for seniors with chronic conditions, additional steps are needed to
    ensure that our patients have access to high quality chronic care. Six
    in 10 American adults \1\ have at least 1 chronic disease and 4 in 10
    have 2 or more, and at $3.3 trillion in annual health costs, chronic
    disease is responsible for 75% of aggregate national health care
    spending and is the largest cause of disability and death.\2\
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/chronicdisease/resources/infographic/
    chronic-diseases.htm.
        \2\ https://www.mdpi.com/1660-4601/15/3/431.

    General internal medicine physicians assume principal responsibility
    for coordinating and managing patients' overall care, particularly for
    those with multiple complex chronic conditions.\3\ As the Senate
    Finance Committee examines policies to bolster chronic care, we urge
    you to adopt the following measures to ensure lower costs and improve
    the quality of chronic care in this country:
    ---------------------------------------------------------------------------
        \3\ https://www.acpjournals.org/doi/10.7326/0003-4819-159-9-
    201311050-00710.

    ---------------------------------------------------------------------------
          Strengthen and Stabilize the MPFS

          Revise Requirements for Budget Neutral Payment Cuts in the MPFS

          Ensure Accurate Estimates of Utilization of New Codes in the
    MPFS

          Remove Beneficiary Cost Sharing for Chronic Care Management
    Services

          Support Increased Access to Telehealth Services

          Support the Implementation of Medicare Code G2211

          Expand the Primary Care Physician Workforce

          Support the Elimination of Cost Sharing for Primary Care
    Services

          Support Increased Payment for Primary Care Physicians

    Strengthen the Medicare Physician Fee Schedule

    It is unrealistic to assume that the current MPFS provides the adequate
    stability and resources necessary for our physicians to deliver high
    quality chronic care for our patients. Unlike nearly every other
    segment of the Medicare payment system, the MPFS does not include
    annual inflationary adjustments. As a result, when accounting for
    inflation, current Medicare physician payment rates have decreased by a
    staggering 26% since 2001. The failure of Congress to provide
    consistent, positive, and stable payment updates is contributing to
    staffing shortages and service limitations that potentially result in
    longer wait times or other disruptions impacting patient care.

    We urge Congress to approve H.R. 2474, the Strengthening Medicare for
    Patients and Providers Act, which preserves access to care for Medicare
    beneficiaries by providing an annual inflation update equal to the
    Medicare Economic Index (MEI) for Medicare physician payment. This
    legislation is essential to physicians' ability to make needed
    investments in their practice that help ensure they can continue
    delivering high quality care to their patients.

     Revise Requirements for Implementing Budget Neutral Payment Cuts in
                        the MPFS

    In addition to a lack of inflationary updates, each year physician
    practices face arbitrary payment cuts due to budget neutrality
    requirements in the annual fee schedule that, unless addressed in a
    comprehensive way, will continue to plague physicians in the years to
    come. Although we appreciate that Congress has provided some financial
    relief to physicians to mitigate the impact of these payment cuts,
    these measures do not provide the consistency and stability for
    physicians to meet their expenses and provide high quality care to
    seniors.

    We urge the Finance Committee to approve legislation H.R. 6545, the
    Physician Fee Schedule Update and Improvements Act, which would update
    the threshold for implementing budget neutral payment cuts in the MPFS.
    It would raise the budget neutrality threshold to $53 million and would
    use cumulative increases in the MEI to update the threshold every 5
    years afterwards. We believe that this is a practical approach, which
    would help account for inflation.

    ACP also supports the provisions in the bill that would require CMS to
    update the direct costs associated with practice expenses (clinical
    labor, the prices of equipment, and the prices of medical supplies)
    simultaneously at least once every 5 years.

    We also support provisions in this bill that would allocate 3 percent
    to the 2024 Medicare conversion factor, as well as extend incentive
    payments for participation in eligible advanced alternative payment
    models (APMs) through 2026 and would tier bonuses according to how long
    a physician has participated in an APM, to account for increased
    upfront costs. The bill includes a provision that would provide the
    Secretary of Health and Human Services (HHS) with flexibility for
    tiering bonuses. ACP supports extending incentive payments for APMs to
    support physicians' transition from a volume-based fee-for-service
    health care system to one that is based on the value of health care
    delivered to the patient. Instead of having a tiered approach for
    bonuses, we recommend that Congress considers freezing the revenue
    threshold increase for 5 years to encourage more physicians to
    transition from fee-for service into APMs and maintain financial
    viability for those already participating in such programs.

     Ensure Accurate Calculation of Utilization of New Medicare Payment
                        Codes

    ACP is requesting that Congress directs the Government Accountability
    Office (GAO) to conduct a study and report back to Congress on the
    utilization estimates and actual payments incurred from the
    implementation of new Medicare codes by the Centers for Medicare and
    Medicaid Services (CMS). This language is needed to more accurately
    determine how much money in Medicare Part B was unnecessarily held back
    versus the actual amount needed to pay for those services within the
    first year of implementation. The concern is that money is often
    withheld from the fee schedule due to budget neutrality and if the
    estimates are above the actual code utilization, that money doesn't get
    put back into the fee schedule to fund other service costs. If there is
    an overestimation in utilization of new codes, it can lead to
    unnecessary physician payment cuts, which ultimately can hinder
    patients' access to timely care.

     Remove Beneficiary Cost Sharing for Chronic Care Management Services

    We remain concerned that many seniors have failed to access chronic
    care management services due to a patient cost-sharing requirement
    associated with this care. Current law mandates that Medicare
    beneficiaries are subject to a 20% coinsurance requirement to receive
    chronic care management services. This cost-sharing requirement creates
    a barrier to care, as beneficiaries are not accustomed to cost-sharing
    for care management services and may forego the services altogether as
    a result. The latest data \4\ reveals that only 4% of Medicare
    beneficiaries potentially eligible for chronic care management received
    these services. That amounts to 882,000 out of a potential pool of 22.5
    million eligible beneficiaries.
    ---------------------------------------------------------------------------
        \4\ https://aspe.hhs.gov/sites/default/files/documents/
    31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf.

    We urge you to approve H.R. 2829, the Chronic Care Management
    Improvement Act of 2023. This legislation would remove the cost sharing
    requirement for patients to access chronic care management services. We
    also support allowing the physician that performs chronic care
    management services to waive the requirement that the patient pay the
    20% coinsurance fee associated with this service.

     Support Increased Access to Telehealth Services for Medicare
                        Beneficiaries

    We support the expanded role of telemedicine as a method of health care
    delivery that will improve the health of patients with chronic
    conditions by enabling and enhancing patient-physician collaborations,
    increasing access to care and members of a patient's health care team,
    and reducing medical and resource costs when used as a component of a
    patient's longitudinal care.

    Telehealth flexibilities from the pandemic-era public health emergency
    (PHE) have been instrumental in improving access to care for patients
    across the U.S. We were pleased that the Consolidated Appropriations
    Act of 2023 extended many of those flexibilities through the end of
    2024.

    ACP believes that the following existing flexibilities should be
    continued--and not allowed to expire--to support making telehealth an
    ongoing and continued part of medical care now and in the future. We
    urge the Finance Committee to make these existing flexibilities
    permanent or to provide long-term extensions for them.

          Expand originating sites and lift geographic requirements for
    telehealth services

          Allow federally qualified health centers (FQHCs) and rural
    health clinics (RHCs) to continue to provide telehealth services

          Allow the furnishing of audio-only telehealth services for
    evaluation and management services

    ACP Supports S. 2016/H.R. 4189, the Connect for Health Act of 2023

    We urge Congress to approve S. 2016/H.R. 4189, the Connect for Health
    Act of 2023. This legislation would permanently expand access to
    essential telehealth services including expanding originating sites and
    lifting geographic requirements for telehealth services and allowing
    FQHCs and RHCs to continue to provide telehealth services. We urged the
    Finance Committee to include this legislation in the original CHRONIC
    Care Act and urge you to act to continue to ensure that seniors have
    access to these vital telehealth services after they expire at the end
    of this year.

    Ensure Access to Audio-only Telehealth Services

    We also support S. 1636/H.R. 3440, the Protecting Rural Telehealth
    Access Act, a bill that would ensure that seniors may continue to
    access audio-only telehealth consults with their physician after this
    option expires at the end of this year. ACP strongly supports the use
    of audio-only telehealth as an effective modality to address gaps in
    health equity. Primary care and other evaluation and management
    services delivered via telephone have become essential to a sizable
    portion of Medicare beneficiaries who lack access to the technology
    necessary to conduct video visits. These services are instrumental for
    patients who do not have the requisite broadband/cellular phone
    networks or have privacy concerns and do not feel comfortable using
    video visit technology or do not possess the digital literacy to use
    video technology.

    Support the Implementation of Medicare Code G2211

    We are pleased that at the beginning of this year, CMS implemented
    Healthcare Common Procedure Coding System (HCPS) add on code G2211 to
    compensate physicians for the extra work and resource costs required
    for the coordination of care for complex or serious conditions. This
    new Medicare code is essential to provide our physicians with the
    resources necessary to provide high quality care for patients with
    chronic conditions, and to ensuring that patients have access to a
    holistic, dynamic, and integrated \5\ system. With implementation,
    clinicians can now receive payment for services like chronic disease
    management tracking, review of consultative or diagnostic reports, and
    medication monitoring that would otherwise be unaccounted for in the
    current E/M coding structure.
    ---------------------------------------------------------------------------
        \5\ https://assets.acponline.org/acp_policy/policies/
    beyond_the_referral_position_paper_2022.
    pdf.

    A report by the National Academy of Sciences, Engineering, and Medicine
    \6\ calls on policymakers to increase the investment in primary care as
    evidence shows that it is critical for ``achieving health care's
    quadruple aim: enhancing patient experience, improving population
    health, reducing costs, and improving the health care team
    experience.'' The report urges reforms to ensure that the Medicare
    physician payment system no longer undervalues primary and cognitive
    care, and more adequately incentivizes the type of quality, value-based
    care that patients need. ACP greatly appreciates the changes by CMS and
    Congress to help patients and physicians to establish and maintain
    longitudinal relationships that improve health outcomes. The College
    looks forward to continuing to work with CMS and Congress to ensure
    patients have access to continuous and comprehensive care.
    ---------------------------------------------------------------------------
        \6\ https://www.nationalacademies.org/our-work/implementing-high-
    quality-primary-care.
    ---------------------------------------------------------------------------

    Expand the Primary Care Workforce

    It is estimated that there will be a shortage of 17,800 to 48,000
    primary care physicians by 2034.\7\ As our population ages with higher
    incidences of chronic diseases, it is especially important that
    patients have access to physicians trained in comprehensive primary and
    team-based care for adults--a hallmark of internal medicine GME
    training. It is worth noting that the federal government is the largest
    explicit provider of GME funding (over $15 billion annually), with most
    of the support coming from Medicare.
    ---------------------------------------------------------------------------
        \7\ https://www.aamc.org/media/54681/download?attachment.

    ACP appreciates Congress' continued GME expansion with the Consolidated
    Appropriations Act, (CAA), 2023, H.R. 2617, adding an additional 200
    GME slots, 100 for psychiatry and psychiatric subspecialties and 100
    for other physician specialties. We urge Congress to continue this
    momentum through the passage of the Resident Physician Shortage
    Reduction Act of 2023, H.R. 2389/S. 1302, which would gradually raise
    the number of Medicare-supported GME positions by 2,000 per year for 7
    years.

    Support the Elimination of Cost Sharing for Primary Care Services

    We support waiving beneficiary cost sharing for primary care services.
    We believe that cost sharing creates barriers to evidence-based, high
    value, and essential care and should be eliminated, particularly for
    low-income patients and patients with certain defined chronic
    illnesses. Evidence \8\ shows that even very low Medicaid copayments
    are associated with decreased use of necessary care. High deductibles
    may serve as a barrier to receiving high-value, preventive care and
    treatment after diagnosis.
    ---------------------------------------------------------------------------
        \8\ https://www.kff.org/medicaid/issue-brief/the-effects-of-
    premiums-and-cost-sharing-on-low-income-populations-updated-review-of-
    research-findings/.
    ---------------------------------------------------------------------------

     Support Sufficient and Sustained Increases in Medicare Payments for
                        Primary Care Services in a Manner that is not
                        Limited by Current Budget Neutrality Constraints

    It is essential that Congress develop policies to provide the financial
    stability needed to help physicians improve the quality and value of
    care they furnish. As indicated above, a first step would be modifying
    the current laws that impose arbitrary payment cuts in the MPFS every
    year. ACP also encourages Congress to develop policies to ensure that
    the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
    fulfills its goal as intended to transform Medicare physician payment
    from a fee-for-service (FFS) model that pays physicians based on the
    number of services provided to a value-based model that incentivizes
    the quality and outcome of care delivered to patients. Yet, concern is
    growing that these programs have fallen far short of truly shifting
    payments away from a still predominant FFS model or moving the needle
    toward achieving greater equity in the delivery of health care.

    Based on the 2020 ACP paper, Envisioning a Better U.S. Health Care
    System for All: Health Care Delivery and Payment System Reforms,\9\ we
    recommend that all payment systems substantially increase relative and
    absolute payments for primary care commensurate with its value in
    achieving better outcomes and lower costs. Inappropriate disparities in
    payment levels between complex cognitive care and preventive services,
    relative to procedurally oriented services, should be eliminated. It is
    essential that payment policies recognize the value of primary care,
    and that payment is sufficient to reverse the primary care physician
    shortage. Access to primary care has consistently been associated with
    higher quality of care,\10\ lower mortality rates,\11\ higher patient
    satisfaction,\12\ and lower total system costs.\13\ Compared with other
    developed countries, the United States ranked lowest in primary care
    functions as well as health outcomes, yet highest in health
    spending.\14\ Moreover, studies have shown health outcomes \15\ are
    better in states with higher ratios of primary care physicians \16\
    within the population than in those with lower ratios. Increasing one
    primary care physician per 10,000 people in one state was associated
    with a rise in that state's quality rank by more than 10 places and a
    reduction in overall spending \17\ by $684 per Medicare beneficiary.
    ---------------------------------------------------------------------------
        \9\ https://www.acpjournals.org/doi/epdf/10.7326/M19-2407.
        \10\ https://pubmed.ncbi.nlm.nih.gov/16202000/.
        \11\ https://jamanetwork.com/journals/jamainternalmedicine/
    fullarticle/2724393.
        \12\ https://pubmed.ncbi.nlm.nih.gov/9752374/.
        \13\ https://pubmed.ncbi.nlm.nih.gov/22418570/.
        \14\ https://pubmed.ncbi.nlm.nih.gov/11965331/.
        \15\ https://jhu.pure.elsevier.com/en/publications/when-doctors-
    share-visit-notes-with-patients-a-study-of-patient-a.
        \16\ https://jhu.pure.elsevier.com/en/publications/when-doctors-
    share-visit-notes-with-patients-a-study-of-patient-a.
        \17\ https://pubmed.ncbi.nlm.nih.gov/15451981/c.
    ---------------------------------------------------------------------------

    Conclusion

    We appreciate the Senate Finance Committee's efforts to bolster chronic
    care in Medicare and their support for strengthening the MPFS to
    provide physicians with the resources to provide high-quality care to
    our seniors. We look forward to working with the Committee to implement
    these policies as outlined in our statement. Should you have any
    questions, please do not hesitate to contact Brian Buckley, Senior
    Associate for Legislative Affairs at bbuckley@acponline.org.

                                     ______

                         American College of Radiology

                            1892 Preston White Drive

                                Reston, VA 20191

                                 (703) 648-8900

                              https://www.acr.org

    The American College of Radiology (ACR), representing approximately
    41,000 radiologists, radiation oncologists, medical physicists, and
    imaging professionals, appreciates the opportunity to submit a
    statement for the record in response to the Senate Finance Committee
    hearing titled ``Bolstering Chronic Care Through Medicare Physician
    Payment'' held April 11, 2024.

    As a physician medical specialty society, we are acutely aware of the
    many challenges our members face as they provide high quality care to
    Medicare beneficiaries. These challenges have been exacerbated by a
    long-broken Medicare physician payment system, which has failed to keep
    pace with the true cost of physician practices. According to an
    American Medical Association analysis of Medicare Trustees data, when
    adjusted for inflation, physician reimbursement has declined 26 percent
    from 2001 to 2023. Failure to address this basic underlying
    reimbursement deficiency threatens the continued ability of physicians
    to care for their patients.

    For many patients, especially those with chronic conditions, teams of
    physician specialists work in concert with the primary care provider to
    provide treatments for their patients. This coordinated, teamwork model
    of care is disincentivized in the Medicare Physician Fee Schedule
    (MPFS) due to statutorily required budget neutrality.

    Additionally, physicians have singularly been excluded in the Medicare
    system from any kind of annual inflation adjustment that directly
    impacts the costs of running their practices. Congress must act to add
    a Medicare Economic Index (MEI) based inflationary update to the MPFS.

    With the passage of the Medicare Access and CHIP Reauthorization Act of
    2015 (MACRA), Congress intended to encourage and incentivize a
    transition from traditional fee-for-service to a value-based care
    model, via either an alternative payment model (APM) or the Merit-based
    Incentive Payment System (MIPS). Much of diagnostic radiology is non-
    patient facing, however numerous significant exceptions are found in
    the provision of breast imaging, and in interventional radiology
    procedures. As largely non-patient facing physicians, as with a number
    of other medical specialties, diagnostic radiologists have found it
    extremely difficult to meaningfully participate in the MACRA statutory
    programs. Recent studies show that one third to nearly one half of
    radiologist interactions with Medicare beneficiaries are single,
    isolated interactions.\1\ In addition, outdated and contested CMS
    regulations prohibit diagnostic radiologists from billing evaluation
    and management codes,\2\ the codes most frequently billed for patient
    encounters. These two factors severely limit the ability of
    radiologists to participate in any value-based payment model. As
    Congress considers MACRA reform, the nature of practice for all
    physicians, including radiologists and other non-patient facing
    physicians, must be considered for true reform to take place.
    ---------------------------------------------------------------------------
        \1\ Eric W. Christensen, et al.; Prevalence of ``One-Off Events''
    in Radiology: Implications for Radiology in Episode-Based Alternative
    Payment Models, https://www.sciencedirect.com/science/article/abs/pii/
    S0363018823001238.
        \2\ Medicare Benefit Policy Manual, Ch. 15, Sec. 80.6.1, https://
    www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/
    bp102c15.pdf.

    As a specialty, diagnostic radiology is at the forefront of medical
    technological innovation and use. The science of radiology is the major
    component in the diagnosis of most injuries and diseases. If services
    are provided in a privately owned, non-hospital based practice, the
    cost and maintenance of the equipment used, the cost of owning or
    renting space to provide these services, employment of staff and
    dedicated technologists can only survive like all businesses if there
    is sufficient reimbursement to cover these expenses. Unfortunately,
    adequate reimbursement of the practice expense component of the MPFS,
    which is intended to account for both direct practice expense (clinical
    labor, supplies, and equipment) and indirect practice expense (rent,
    administration, and other overhead), falls grievously short of
    appropriate and necessary reimbursement to allow community based,
    ---------------------------------------------------------------------------
    privately owned practices to survive.

    In particular, collecting accurate indirect practice expense data has
    been challenging due to the complex nature of data sets while having to
    take into consideration of different specialties' practice patterns.
    The indirect practice expense data needs to be routinely updated to
    ensure it is accurate and representative to avoid potentially large
    swings in reimbursement due to redistributive effects in a budget
    neutral system.

    These reimbursement reductions are felt hardest by smaller, independent
    practices, like those in rural and underserved areas that continue to
    face significant health care access challenges. In response, many
    practices have been acquired by larger healthcare entities, including
    hospitals, health systems, and corporate healthcare networks,
    permanently impacting patient access to care. Private practices that
    have not consolidated are forced to make very difficult decisions when
    considering investing in technology, potentially hindering innovation
    and quality of care delivered to patients.

    The continued downward spiral of the MPFS and resulting changes in the
    practice of medicine have contributed to a workforce shortage that is
    being experienced by the entire physician community, radiology
    included. Recent data from the American Association of Medical Colleges
    (AAMC), projects a shortfall of up to 86,000 physicians by 2036. This
    is extremely concerning, especially considering an ageing population
    that has benefited from diagnostic imaging technological advances that
    have enabled patients to live longer with chronic conditions.

    Although many patients do not have a face-to-face encounter with their
    radiologist, radiologists care for more Medicare beneficiaries per year
    than any other physician, which indicates radiology's prominent role in
    patient care.\3\ As a result, the demand for imaging services continues
    to rise and the supply of radiologists is increasingly unable to meet
    that demand. One way to reduce the increasing demand for imaging
    services is to implement Section 218(b) of the Protecting Access to
    Medicare Act of 2014 (PAMA) which requires all ordering providers to
    consult appropriate use criteria (AUC) via a clinical decision support
    mechanism prior to the ordering of advanced diagnostic imaging services
    for Medicare beneficiaries. This educational tool is critical,
    particularly in areas where non-physician providers order advanced
    imaging to both educate the provider and ensure patients receive the
    right test at the right time. The program can also help eliminate ``low
    value'' imaging which can inconvenience the patient, cost both the
    patient and the Medicare system money and often be of little to no
    clinical relevance. Although Congress required the PAMA program be
    implemented by 2017, the Centers for Medicare and Medicaid Services
    (CMS) has faced significant logistical difficulty during the regulatory
    process and in the 2024 MPFS final rule indefinitely paused
    implementation pending statutory changes. CMS also reiterated their
    support for the program and estimated that if implemented, the PAMA AUC
    program could save the Medicare system approximately $700 million
    annually.
    ---------------------------------------------------------------------------
        \3\ Andrew B. Rosenkrantz et al.; Unique Medicare Beneficiaries
    Served: A Radiologist-Focused Specialty-Level Analysis, Journal of the
    American College of Radiology, https://www.
    sciencedirect.com/science/article/abs/pii/S1546144018300462.

    In order to move forward with AUC implementation, the ACR has proposed
    significant administrative simplification language to the Senate
    Finance Committee. We urge the swift adoption of the revised, updated
    legislative text to provide CMS with the statutory changes needed to
    implement the AUC program. These changes will first and foremost
    improve patient care by decreasing unnecessary utilization and
    associated copayment costs and provide a utilization management tool
    far superior to any prior authorization process. Winnowing down the
    number of unnecessary advanced imaging studies will also have a direct,
    dramatic impact on unnecessary imaging studies which will advantage the
    ---------------------------------------------------------------------------
    current status of workforce shortages in diagnostic radiology.

    The ACR encourages swift Congressional action to increase both the
    current and future supply of radiologists. To address current supply,
    the expansion of the Conrad 30 program (S. 665) would allow more
    physicians who have trained in the United States on a J-1 visa to
    continue to practice medicine in the U.S. without having to return to
    their home country post residency. The Healthcare Workforce Resilience
    Act (S. 3211) would recapture unused immigrant visas for physicians and
    nurses, which will ultimately lead to an increase in currently
    practicing physicians to meet the needs of our population. To address
    future supply, the ACR encourages passage of the Resident Physician
    Shortage Reduction Act (S. 1302), and add Medicare funded graduate
    medical education (GME) slots and help close the projected physician
    shortfall.

    We are encouraged that Congress is recognizing the need for substantive
    Medicare physician payment reform and look forward to future
    discussions. If you have any questions, please contact Cindy Moran,
    Executive Vice President, Government Relations, Economics and Health
    Policy, at cmoran@acr.org.

    Thank you,

    Cynthia R. Moran
    Executive Vice President

                                     ______

                          American College of Surgeons

              Statement of Firpo Carr, Ph.D., Health Psychologist

    As a Health Psychologist who is an Affiliate Member of the American
    College of Surgeons (ACS), I listened with rapt attention to testimony
    by a panel of experts appearing before The Senate Finance Committee on
    April 11, 2024, about ``Bolstering Chronic Care through Medicare
    Physician Payment.'' There was an abundance of rich, invaluable
    information to digest.

    Of course, I watched the proceeding through the lens of a psychologist
    interested in studying surgeons' mental health and well-being.

    However, I surmised that the challenges confronting surgeons and
    physicians treating chronic care patients and navigating the morphing
    puzzle pieces of the Medicare Physician Payment system are daunting and
    inescapably cause significant stress. In this regard, self-care must be
    emphasized.

    Undoubtedly, all had a vested interest in the subject matter. For
    instance, it was reassuring to witness Senators tincture their
    observations on chronic care with experiences of family members'
    interactions with the medical system. In doing so, they made themselves
    relatable to their constituents and sensitive to the American people's
    general needs.

    Accolades aside, there was also reason for pause.

    For example, it was concerning to learn from Senator Elizabeth Warren
    that a particular American Medical Association (AMA) committee has an
    overrepresentation of specialty physicians who, by sheer numbers,
    overwhelm primary care physicians (PCP) when voting on payments.
    Specialists vote to pay themselves considerably more than PCPs. This
    disparity, which negatively impacts physicians in private practice and
    their patients, should be addressed.

    Moving forward, I was pleased to observe the alertness, acuity, and
    measured passion of Senators and panelists alike. Self-care should not
    be underestimated, particularly when politicians and panelists wrestle
    with the nuts and bolts of effective ways of bolstering chronic care
    through Medicare physician payment.

    Unsurprisingly, I was keenly interested in what ACS Executive Director
    & CEO Patricia L. Turner, M.D., MBA, FACS, had to say and was pleased
    to see her emphasize how the ACS is a pacesetter for high-quality,
    evidence-based surgical care as substantiated by its 13 quality
    programs.

    Additionally, I especially appreciated that, along with Dr. Turner's
    insightful expert testimony, she showed deference to the profound
    thoughts of her fellow expert panelists--each representing their
    respective organizations--stating that all the boats in the harbor can
    rise together.

    The main takeaway for me was that, while there is still plenty of work
    to be done, the perseverance of the Senate Finance Committee should be
    applauded. The endurance and stick-to-itiveness of panelists
    representing their colleagues should be celebrated.

    To be sure, the issues are formidable and can only be dealt with
    through a concerted effort. All will do well to be mindful that the
    first step to resolution is self-care as reflected in the maxim
    expressed in Latin, Medice, cura te ipsum, that is, ``Physician, heal
    thyself'' (Luke 4:23).

    Humble thanks to Senator Ron Wyden and the rest of the Senate Finance
    Committee, as well as to all the esteemed panelists.

                                     ______

                         American Diabetes Association

                         2451 Crystal Drive, Suite 900

                              Arlington, VA 22202

                               tel: 800-342-2383

                             https://diabetes.org/

               Statement of Lisa Murdock, Chief Advocacy Officer

    Thank you, Chairman Wyden, Ranking Member Crapo, and distinguished
    members of the Finance Committee, for providing the American Diabetes
    Association (ADA) the opportunity to submit written comments regarding
    the impact of Medicare physician reimbursement policy on care for
    Americans with diabetes and other chronic conditions. We appreciate you
    considering this important topic at this critical time.

    The ADA is the nation's leading voluntary health organization fighting
    to bend the curve on the diabetes epidemic and help people living with
    diabetes thrive. For more than 80 years, the ADA has been driving
    discovery and research to treat, manage and prevent diabetes, while
    working relentlessly for a cure. We help people with diabetes thrive by
    fighting for their rights and developing programs, advocacy and
    education designed to improve their quality of life.

    Access to care for the 38.4 million Americans with diabetes is critical
    to effective management of this condition and to preventing
    unnecessary, dangerous and often life-threatening complications. That
    access is at risk as our country faces shortages of physicians--and in
    particular endocrinologists and primary care doctors--who are crucial
    to the treatment of diabetes.

    Adequate Medicare reimbursement across physician specialties is a
    necessary step toward addressing this country's shortage of physicians
    and other health workers. Since the beginning of the COVID-19 pandemic,
    nearly one in five health care workers has resigned, and surveys
    suggest that nearly 50 percent of the U.S. health care workforce has
    considered or is considering leaving within the next 2 years.\1\ This
    situation is dire for people with diabetes, who outnumber practicing
    endocrinologists by a ratio of 40,000 to 1.\2\ Partly as a result, the
    diabetes community relies overwhelmingly on primary care providers--who
    care for some 90 percent of people with Type 2 diabetes, the fastest-
    growing subset of the diabetes population--to oversee their insulin
    regimens, provide diabetes education, and prescribe continuous glucose
    monitors and other diabetes management tools. Nearly 70 percent of
    outpatient visits for all adults with diabetes take place in primary
    care settings, and 76 percent of visits are scheduled specifically due
    to diabetes.\3\ The post-pandemic ``great resignation'' is having an
    impact here too. In 2021 and 2022, this wave of clinician resignations
    already included 145,213 physicians and 34,834 nurse practitioners,
    coming predominantly from internal medicine and family practice.\4\
    ---------------------------------------------------------------------------
        \1\ Ethan Popowitz, ``Addressing the Healthcare Staffing
    Shortage,'' Definitive Healthcare, September 2023, https://
    www.definitivehc.com/sites/default/files/resources/pdfs/Addressing-the-
    healthcare-staffing-shortage-
    2023.pdf?utm_source=newsletter&utm_medium=email&utm_
    campaign=newsletter_axiosvitals&stream=top.
        \2\ ``Number of People per Active Physician by Specialty, 2021.''
        \3\ Scott J. Pilla, MD, MHS, Jodi B. Segal, MD, MPH, and Nisa M.
    Maruthur, MD, MHS, ``Primary Care Provides the Majority of Outpatient
    Care for Patients with Diabetes in the US,'' Journal of General
    Internal Medicine, July 2019, https://www.ncbi.nlm.nih.gov/pmc/
    articles/PMC6614213/
    #::text=Among%20non%2Dhospital%2Dbased%20office,a%20patient%20reason%
    20for%20visit.
        \4\ Popowitz, ``Addressing the Healthcare Staffing Shortage.''

    To improve the stability of primary care practitioners, the federal
    government should increase Medicare reimbursement rates and especially
    focus payments on expanding under-resourced primary care teams. Team-
    based care is a critical part of the answer to the problems of
    physician shortage and increased workload. Research shows that nurse
    practitioners, physician assistants and other advanced care providers,
    in addition to pharmacists and community health workers, help patients
    reduce A1C, begin and adjust medications without physician approval,
    and generally improve clinical outcomes for patients with type 2
    ---------------------------------------------------------------------------
    diabetes in primary care settings.

    This approach does not require Medicare to reinvent the wheel. Congress
    and the administration can encourage team-based care delivery in
    primary care practices by increasing reimbursement rates through
    existing federal health care programs for providers and their community
    partners. The Centers for Medicare and Medicaid Services (CMS) is
    already doing some of this important work. CMS proposed changes to its
    Physician Fee Schedule for calendar years 2023 and 2024 to increase
    reimbursement rates for primary care clinicians and chronic care
    management services and pay for services provided by ``auxiliary
    personnel'' such as community health workers. CMS has also launched a
    series of demonstration projects that use prospective-based payments to
    incentivize advanced primary care delivery. Its recently announced
    project--the ACO Primary Care Flex Model--will test whether and how
    these payment models can improve outcomes and reduce costs in the
    Medicare Shared Savings Program, especially for those Medicare
    beneficiaries living in medically underserved communities. Congress and
    the patient community stand to learn a great deal from the outcome of
    this primary care payment model in particular, as the findings from ACO
    Primary Care Flex can inform how Medicare reimbursement affects
    outcomes for patients living with chronic conditions.

    Medicare can also reduce expensive complications from diabetes by using
    reimbursing policy to encourage more preventive care services. ADA
    recently launched the Amputation Prevention Alliance to spread
    awareness about preventive interventions, including those that can be
    performed in a primary care office, to limit diabetes-related
    amputations. Eighty-five percent of diabetes-related amputations are
    preventable, and amputees with diabetes experience a significantly
    elevated risk of mortality following the loss of a limb--one in 10 dies
    within 30 days of surgery, and one in six dies within 90 days.\5\
    Minimally invasive procedures to diagnose cases of peripheral artery
    disease (PAD) and critical limb ischemia (CLI) are generally not
    covered by federal health care programs like Medicare. The ADA urges
    Medicare to cover PAD screening for at-risk beneficiaries without cost-
    sharing requirements.
    ---------------------------------------------------------------------------
        \5\ Jason K. Gurney, James Stanley, Juliet Rumball-Smith, Steve
    York, ``Postoperative Death After Lower-Limb Amputation in a National
    Prevalent Cohort of Patients with Diabetes,'' Diabetes Care, April 5,
    2018, https://care.diabetesjournals.org/content/41/6/1204.

    Congress may also consider a value-based payment model in which
    reimbursement rates for primary care providers are adjusted based on
    access to diabetic foot ulcer and PAD assessments and patient-reported
    outcome metrics (e.g., wound healing time, wound free time, wound
    recurrence rates and low to high amputation ratios). Ultimately,
    achievable Medicare reimbursement reforms that prioritize all members
    of the primary care team and focus on chronic care management and
    preventive care can improve patient outcomes and significantly reduce
    ---------------------------------------------------------------------------
    long-term costs to the U.S. health care system.

    Thank you for the opportunity to submit this testimony for the record.
    The ADA looks forward to continuing to work with Congress to make sure
    our community has access to the health care providers and resources
    they need to effectively manage their diabetes.

                                     ______

                          American Geriatrics Society

                          40 Fulton Street, Suite 809

                               New York, NY 10038

                                212-308-1414 tel

                      https://www.americangeriatrics.org/

        The American Geriatrics Society (AGS) greatly appreciates the
    opportunity to provide feedback to the Senate Committee on Finance as
    it begins its efforts to develop legislation to reform the Physician
    Fee Schedule and update MACRA.

        The mission of the AGS, a nationwide not-for-profit organization
    comprised of nearly 6,000 geriatrics clinicians is to improve the
    health, independence, and quality of life of all older adults. Our
    members are pioneers in advanced-illness care for older individuals,
    with a focus on championing interprofessional teams, eliciting personal
    care goals, and treating older people as whole persons. AGS believes in
    a just society, one where we all are supported by and able to
    contribute to communities where ageism, ableism, classism, homophobia,
    racism, sexism, xenophobia, and other forms of bias and discrimination
    no longer impact healthcare access, quality, and outcomes for older
    adults and their caregivers. AGS believes increased payment accuracy
    for clinicians paid under the Physician Fee Schedule and through the
    Quality Payment Program (QPP), established by the Medicare Access and
    CHIP Reauthorization Act (MACRA) is a cornerstone to improving access
    to care in rural and historically minoritized communities. AGS is
    actively engaged in efforts to advance value-based, high-quality care
    for older Americans, and we appreciate the committee's willingness to
    listen to our concerns and experience with these programs.

        MACRA replaced the unworkable cost control mechanism of the
    Sustainable Growth Rate (SGR) with a new payment system intended to
    incentivize value-based care. However, MACRA--particularly the
    provisions establishing the Merit-based Incentive Payment System
    (MIPS)--uses an ``accountability'' mechanism that is largely siloed by
    individual disease states and conditions, focuses disproportionately on
    performance and payment at the individual clinician and individual
    specialty level, and, as a result of its budget neutrality
    requirements, picks clinician ``winners'' and ``losers.'' We cannot
    achieve the promise of value-based care with this fragmented approach,
    which is organized around organ-specific care and does not take a whole
    person approach to health and well-being. In our view, a high-quality,
    cost-effective healthcare system results from care that is person-
    centered, team-based and grounded in strong primary care--the payment
    system must reflect, reinforce, and incentivize this type of care.

        Specifically, the AGS believes that truly value-based care
    requires:

              Multi-disciplinary teams of physicians and non-physician
            practitioners caring for patients, with the primary care
            practitioner central to facilitating care coordination.
              Strong primary care, as envisioned in the report of the
            National Academies of Sciences, Engineering and Medicine:
            ``Implementing High Quality Primary Care,''\1\ with meaningful
            education for beneficiaries on the importance of every person
            having an established source of primary care.
    ---------------------------------------------------------------------------
        \1\ National Academies of Sciences, Engineering, and Medicine.
    2021. Implementing High-
    Quality Primary Care: Rebuilding the Foundation of Health Care.
    Washington, DC: The National Academies Press. doi: 10.17226/25983.
    ---------------------------------------------------------------------------
              A whole-person orientation with input from patients and
            their families, where areas of quality measurement focus on
            patient goals and experiences, person-oriented outcomes, and
            the total cost of care for that patient rather than on
            condition- or specialty-specific outcomes as a metric for
            higher reimbursement.
              An intentional commitment to equitable care and reducing
            disparities by, among other strategies, financially supporting
            organizations embedded in underserved communities, including
            rural and urban Health Professional Shortage Areas, and
            providing financial incentives for care management services,
            particularly to historically minoritized and rural communities
            (e.g., support for self-care or navigating complex health
            systems). Importantly, the payment system must not financially
            ``punish'' those who care for communities with less advantage
            or people with greater complexity.
              A regulatory, payment, and technological framework that
            permits providers flexibility to establish practice
            organizations that are best for the people they care for and
            that reduces the financial, legal, and regulatory burdens that
            have led to the rapid consolidation and monetization of
            healthcare in the United States. Nearly three-quarters of U.S.
            doctors work for corporate entities such as private equity
            firms, health insurers and hospitals in 2022, up from 69
            percent in 2021.\2\ Rather than driving system efficiencies and
            savings, studies show that private equity acquisitions of
            physician practices are associated with increased healthcare
            spending and patient utilization, with the average charge per
            claim increasing 20 percent and the average allowed amount per
            claim up 11 percent post-acquisition.\3\
    ---------------------------------------------------------------------------
        \2\ Physicians Advocacy Institute, COVID-19's Impact on
    Acquisitions of Physician Practices and Physician Employment 2019-2021,
    a study prepared by Avalere Health, April 2022, http://
    www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/
    PAI%20Avalere%20
    Physician%20Employment%20Trends%20Study%202019-
    21%20Final.pdf?ver=ksWkgjKXB_yZfI
    mFdXlvGg%3d%3d.
        \3\ Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of
    Private Equity Acquisition of Physician Practices With Changes in
    Health Care Spending and Utilization. JAMA Health Forum.
    2022;3(9):e222886. doi:10.1001/jamahealthforum.2022.2886.
    ---------------------------------------------------------------------------
              Accessible care settings for people, including care that is
            accessible to patients in their homes through telemedicine and
            programs such as ``hospital at home'' and ``Independence at
            Home,'' when clinicians deem it appropriate based on shared
            decision-making with their patients.
              Administrative expertise and analytic support for clinical
            teams, with an overall goal of reducing administrative burden,
            so that clinicians can both maintain focus on care and still
            have ownership and involvement in quality measurement (and
            prevent unnecessary consolidation of physician practices).
              Electronic health information exchanges and electronic
            health records (``EHR'') systems that are helpful, not a
            hassle, and that easily permit patient information to be shared
            across different entities that care for the patient to support
            clinical decision-making and care coordination and mitigate
            patient risk and waste (including through use of data-driven
            tools that take advantage of artificial intelligence
            technologies).
              Both stability and flexibility whereby investments in value-
            based care transformation can be confidently made, but with
            enough flexibility to correct for the inevitable
            miscalculations and missteps inherent in any change.
              Greater diversity in the health care professions through
            more reasonable cost of education and greater consideration of
            programs like the National Health Services Corps.
              Payments that include:
                      Incentives that are generally positive,
                    with limited negative incentives for maintaining the
                    fee-for-service status quo.
                      Reasonable payment updates that reflect
                    changes in the cost of providing care as well as
                    inflation. Adjusted for inflation in medical practice
                    costs, as measured by the Medicare Economic Index
                    (MEI), Medicare physician payment rates declined 20
                    percent from 2001 to 2021.

        The AGS believes that these are attainable goals and ones that must
    be reflected in any legislative effort that considers the future of
    physician payment. It is also critical that Congress recognize that the
    long-term vision of developing a better performing health care system
    at times may be in tension with saving Medicare dollars in the short
    run. Congress should not preoccupy itself with short-term savings to
    the detriment of long-term goals. As with any system seeking
    transformation, we must be willing to make upfront investments in order
    to achieve long-term efficiencies and quality improvements.

        With these goals in mind, we recommend that the Committee take a
    holistic approach to reviewing physician payment under Medicare. At a
    minimum, Congress must establish a stable, annual Medicare physician
    payment update that keeps pace with inflation and practice costs and
    allows for innovation to ensure Medicare patients continue to have
    access to multi-disciplinary team-based care across specialties.

        Our recommendations for steps that Congress could take that
    stabilize the payment system include:

        1.  Foster performance-based care that values and supports
    geriatrics care teams for complex and high-cost patients.

              The Center for Medicare and Medicaid Innovation has
            comprehensive primary care programs. These programs allow the
            physician practice to increase capacity and skill sets by
            providing a monthly fee that is designed to allow practices to
            bring in nurse care managers, pharmacists, integrated
            behavioral health, staff to support assistance in patients with
            disadvantaged social determinants of health, for example. This
            promotes more effective panel management and greater access to
            primary care. It allows practices to be ready to assume the
            obligations of accountable care payment programs. They also
            promote partial capitation for primary care services, so
            practices are not just focused on visit volumes. These programs
            should be rapidly expanded for practices that wish to enroll in
            them. They implement the National Academies of Sciences,
            Engineering, and Medicine \4\ recommendations to strengthen
            interprofessional teams and ensure that care teams reflect the
            diversity of the communities they serve. However, expansion
            will require infrastructure support, funding, and attitudinal
            shift.
    ---------------------------------------------------------------------------
        \4\ National Academies of Sciences, Engineering, and Medicine.
    2021. Implementing High-
    Quality Primary Care: Rebuilding the Foundation of Health Care.
    Washington, DC: The National Academies Press. https://doi.org/10.17226/
    25983.

              Comprehensive Primary Care Plus (``CPC+'') is a national
            advanced primary care medical home model that aims to
            strengthen primary care through regionally-based multi-payer
            payment reform and care delivery transformation. This program
            not only strengthens primary care for all beneficiaries but is
            also designed to meet the specific needs of the chronically ill
            patient. Currently, participation is limited to certain
            geographic regions and not all practices that hoped to
    ---------------------------------------------------------------------------
            participate were selected.

              Beyond CPC+, there are many successful models and innovations
            that help achieve the goal state for primary health care. We
            urge the Committee to review ``Complexities of Care: Common
            Components of Models of Care in Geriatrics'' (2022)\5\ as well
            as the models listed in the NASEM's report, ``Implementing
            High-Quality Primary Care: Rebuilding the Foundation of Health
            Care (2021).''\6\ Complexities of Care, published in the
            Journal of the American Geriatrics Society explored the common
            components of models of care in geriatrics when caring for
            older adults with ``care complexity.'' The article defines care
            complexity in older adults, reviews healthcare models and the
            most common components within them and identifies potential
            gaps that require attention to reduce the burden of care
            complexity in older adults. While these models show great
            promise, most are, unfortunately, limited in scope and not
            universally available.
    ---------------------------------------------------------------------------
        \5\ https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/
    jgs.17811.
        \6\ https://www.nationalacademies.org/our-work/implementing-high-
    quality-primary-care.

    ---------------------------------------------------------------------------
        2.  Reinstate the Primary Care Bonus Payment

              As part of the Affordable Care Act (ACA), Medicare
            implemented a 10 percent bonus payment for primary care
            physicians for 5 years. The bonus payment expired at the end of
            2015. The AGS urges Congress to consider restoring the payment
            indefinitely, which would help create a more stable environment
            and provide an incentive for new physicians, advanced practice
            nurses, and physician assistants to enter and stay in primary
            care, including geriatrics. The current shortage is the result
            of under-funding of primary care, which has made careers in
            primary care medicine unattractive to graduating physicians
            because of the relatively low incomes they generate compared to
            other medical fields. Primary care also has greater levels of
            responsibility between visits, in quality reporting, and in
            dealing with the shortcomings of electronic health records
            (EHRs).

        3.  Expand Telehealth

              Medicare beneficiaries need permanent access to telehealth
            and practices need adequate payment for it. We have learned
            telehealth can improve safety and access for Medicare
            beneficiaries when they receive healthcare services. We also
            have experienced the need to cover audio only services due to
            issues with patients' technology management challenges and
            broadband access. These services can effectively substitute for
            in person visits \7\ and create access for those that
            previously lacked the ability to get medical and behavioral
            healthcare needs met. Payment must be adequate for these
            services. These services require the use of clinical staff and
            indirect practice expenses. Insufficient payment undermines a
            practice's ability to provide the services.
    ---------------------------------------------------------------------------
        \7\ Cuellar A, Pomeroy JML, Burla S, Jena AB. Outpatient Care Among
    Users and Nonusers of Direct-to-Patient Telehealth: Observational
    Study. J Med Internet Res. 2022 Jun 6;24(6):e37574. doi: 10.2196/37574.
    PMID: 35666556; PMCID: PMC9210206.

    ---------------------------------------------------------------------------
        4. Revamp Quality Measurement

              AGS strongly encourages the development and deployment of
            quality metrics related to patient goals and treatment burden.
            Medicare should create and adopt a more holistic approach to
            quality measurement in older adults with multiple chronic
            conditions that does not rely on single disease payments.
            Elements of such a system could be modeled upon the 4Ms of age-
            friendly care with an emphasis on what matters to the
            person.\8\
    ---------------------------------------------------------------------------
        \8\ Institute for Healthcare Improvement. ``Age-Friendly Health
    Systems: Guide to Using the 4Ms in the Care of Older Adults'' (2020).
    https://www.americangeriatrics.org/sites/default/files/inline-files/
    IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf.

    Thank you for your leadership and commitment to reforming MACRA to
    stabilize physician practices and strengthen primary care, particularly
    for older adults living with chronic conditions and/or functional
    limitations. The AGS believes that traditional Medicare must remain a
    strong, viable option to help balance market forces in Medicare
    Advantage and preserve beneficiary choice and access. It is crucial
    that reforms to MACRA ensure that we have a robust primary care
    workforce that is equipped and able to deliver the person-centered care
    that Medicare beneficiaries deserve; that is, assuring the primacy of
    individuals' health and life goals in their care planning and in the
    care they receive. The AGS looks forward to working collaboratively
    ---------------------------------------------------------------------------
    with you to achieve these goals as you develop legislative solutions.

                                     ______

                          American Medical Association

                     25 Massachusetts Avenue, NW, Suite 600

                              Washington, DC 20001

                                (P) 202-789-7426

    The American Medical Association (AMA) appreciates the opportunity to
    submit this Statement for the Record for the U.S. Senate Finance
    Committee hearing entitled ``Bolstering Chronic Care through Medicare
    Physician Payment.'' This hearing signifies a critical step forward in
    the ongoing endeavor to modernize traditional Medicare, focusing on the
    management and treatment of chronic illnesses and the payment
    structures for physicians and other health professionals. The AMA
    commends the Committee for its dedication to enhancing Medicare's
    support for individuals with chronic conditions, such as cancer,
    diabetes, and heart disease. This commitment was exemplified by the
    passage of the CHRONIC Care Act in 2018, which instituted comprehensive
    policy improvements to better meet the complex health care needs of
    seniors. The AMA is fully supportive of these efforts to update and
    strengthen Medicare and looks forward to collaborating with the
    Committee to aid in shaping policies ensuring high-quality, sustainable
    care for future generations.

    CHRONIC CARE MANAGEMENT IMPROVEMENT ACT OF 2023

    The AMA supports H.R. 2829, the Chronic Care Management Improvement Act
    of 2023, which is a critical avenue for enhancing chronic disease
    management within the Medicare program. This legislation, aimed at
    eliminating patient cost-sharing for Chronic Care Management (CCM)
    services, addresses a significant barrier that has hindered the
    widespread adoption of these essential services. Despite the
    demonstrated benefits of CCM in improving patient outcomes and reducing
    hospitalizations, the latest data points to a stark underutilization,
    with only 4 percent of eligible Medicare beneficiaries receiving CCM
    services representing only 882,000 out of an estimated 22.5 million.

    In addition to the legislative removal of cost-sharing obligations, a
    concerted effort by the Centers for Medicare & Medicaid Services (CMS)
    to partner with states could further increase access to CCM services.
    This could be achieved through the inclusion of CCM services in state
    Medicaid plans. Such measures would not only amplify the reach of CCM
    but also enhance patient engagement in self-management of their health
    conditions to prevent exacerbations, particularly for those managing
    chronic diseases.

    Waiving patient cost-sharing for CCM services is an important step
    towards removing obstacles to care management services, including
    patient-initiated navigation (PIN), and ensuring that Medicare
    beneficiaries receive the comprehensive care coordination they require.
    This legislative action, coupled with enhanced CMS and state
    collaboration, can improve the use of CCM services and health outcomes
    for millions of Americans living with chronic conditions.

     AMA'S COMMITMENT TO PREVENTING AND TREATING CHRONIC DISEASE

    Chronic disease is a leading cause of death and disability in the
    United States (U.S.). According to the Centers for Disease Control and
    Prevention (CDC), each year more than 877,500 Americans die of heart
    disease or stroke, more than 1.7 million people are diagnosed with
    cancer, and more than 37.3 million Americans have diabetes, with an
    additional 98 million adults diagnosed with prediabetes, which puts
    them at risk for type 2 diabetes.\1\ CDC estimates indicate that these
    diseases, along with other conditions such as obesity, Alzheimer's, and
    mental health issues, place a significant burden on the economy,
    accounting for 90 percent of our nation's $4.1 trillion in annual
    health care spending. These figures will undoubtedly worsen as the
    population ages.\2\
    ---------------------------------------------------------------------------
        \1\ https://www.cdc.gov/chronicdisease/about/costs/index.htm.
        \2\ Id.

    The AMA is committed to improving the health of the nation and reducing
    the burden of chronic diseases. Our primary focus is preventing
    cardiovascular disease (CVD), the leading cause of death in the U.S.,
    accounting for one in four deaths among adults. Two major risk factors
    for CVD are hypertension and type 2 diabetes. CVD risk factors and
    associated morbidity and mortality inequitably impact Black, Hispanic/
    Latinx, Indigenous, Asian/Pacific Islanders, and other people of color.
    While specific causes of the inequities vary by each respective group,
    ---------------------------------------------------------------------------
    structural and societal barriers are attributed as primary reasons.

    To prevent CVD and address related health inequities, the AMA is
    developing and disseminating CVD prevention solutions in collaboration
    with health care and public health leaders. These solutions educate
    clinical care teams and patients, guide health care organizations
    (HCOs) in clinical quality improvement and promote policy changes to
    remove barriers to care. The AMA disseminates these solutions through
    strategic alliances with various organizations, including the CDC, the
    American Heart Association (AHA), and West Side United in Chicago.
    Another CVD risk is obesity which is associated with cardiovascular
    disease mortality independent of other cardiovascular risk factors. The
    AMA is working with other medical societies, including the American
    College of Physicians and the Obesity Medicine Association, to identify
    opportunities to improve access to evidence-based obesity treatments.
    The AMA supports S. 2407/H.R. 4818, the Treat and Reduce Obesity Act,
    which would provide Medicare beneficiaries with access to safe,
    effective, and life-saving treatments. The bill aims to effectively
    treat and reduce obesity in older Americans by enhancing Medicare
    beneficiaries' access to health care professionals who are best suited
    to provide intensive behavioral therapy and by allowing Medicare Part D
    to cover Food & Drug Administration (FDA)-approved anti-obesity
    medications.

    PREVENTIVE HEALTH SAVINGS ACT

    Allowing Congress the ability to look at the financial impact of
    preventive health legislation beyond the 10-year CBO scoring window is
    another important tool that is critical for addressing chronic
    conditions in this country. Consequently, the AMA has endorsed \3\ S.
    114/H.R. 766, originally named as the Preventive Health Savings Act,
    and renamed in the House of Representatives as the ``Dr. Michael C.
    Burgess Preventive Health Savings Act.'' Congress should be able to
    consider the long-term economic benefits of legislation that promotes
    wellness and disease prevention and reduces the incidence of chronic
    conditions, yet it is constrained from doing so by the 10-year CBO
    scoring window. This legislation will importantly provide the Chair and
    Ranking Member of either budget or health-related committees in the
    House and Senate with the ability to request an analysis of the two 10-
    year periods beyond the existing initial 10-year window. Furthermore,
    the legislation's definition of ``preventive health'' appropriately
    captures the unique nature of this concept by including actions that
    focus on the health of the public, individuals, and defined populations
    to protect, promote, and maintain health and wellness, as well as
    prevent disease, disability, and premature death as demonstrated in
    credible, publicly available studies and data. It is widely recognized
    that preventing a chronic condition will improve health outcomes,
    reduce costs to our health care system and provide patients with a
    better quality of life. It is well past time for the CBO to have a
    scoring methodology that accurately accounts for these long-term
    economic benefits.
    ---------------------------------------------------------------------------
        \3\ https://searchlf.ama-assn.org/letter/
    documentDownload?uri=%2Funstructured%2Fbinary%2
    Fletter%2FLETTERS%2Flfcts.zip%2F2024-2-5-Letter-to-Chair-Arrington-and-
    Ranking-Member-Boyle-re-HR-766-Preventive-Health-Savings-Act-118th-
    Congress-v3.pdf.
    ---------------------------------------------------------------------------

    PREVENT DIABETES ACT

    The CDC's National Diabetes Prevention Program (DPP), which has the
    objective of decreasing the incidence of patients developing Type 2
    diabetes by incorporating behavioral counseling, exercise, and
    nutrition counseling, is a proven program that has demonstrated a
    decrease in the incidence of patients with pre-diabetes, thereby
    reducing the incidence of Type 2 diabetes. This successful program was
    the first pilot approved by the Centers for Medicare and Medicaid
    Innovation (CMMI) for expanded Medicare coverage and is known as the
    Medicare Diabetes Prevention Program (MDPP). The limitations Medicare
    has placed on the MDPP have reduced uptake of these important diabetes
    prevention services and thereby limited the success of the program in
    preventing the incidence of Medicare beneficiaries with pre-
    diabetes. As of the end of 2022, cumulative MDPP enrollment stood at
    4,848 Medicare beneficiaries, which is striking considering more than
    half a million individuals participate in the CDC's National DPP
    program when offered through their health plan or employer. Many
    Congressional districts lack in-person MDPP locations to serve the tens
    of thousands of at-risk constituents otherwise eligible for these
    services under Medicare. Almost one in three adults aged 65 and older
    have diabetes. According to CMS, medical care for seniors with diabetes
    and its complications cost the U.S. $205 billion in 2022, most of it
    paid by Medicare. According to the CDC, some 98 million Americans have
    prediabetes, including 27.2 million who are aged 65 and older. Without
    a significant course correction, those numbers will only grow.
    Consequently, the AMA has endorsed H.R. 7856, the PREVENT DIABETES Act.
    This legislation, which would broaden access to diabetes prevention
    services by aligning the MDPP with the CDC's DPP, make MDPP a permanent
    benefit in Medicare, ensure seniors can participate in the program more
    than once, and expand access to all CDC-recognized delivery modalities,
    including virtual diabetes prevention platforms in the program, will
    help ensure that the full potential of this program to reduce the
    incidence of Medicare beneficiaries with pre-diabetes, and prevent Type
    2 diabetes, is realized.

     PRESERVING PATIENT ACCESS TO CARE THROUGH PHYSICIAN FINANCIAL
                        STABILITY

    Need for an Inflation-Based Update to Physician Payment
    For services provided to Medicare beneficiaries in the first 2 months
    of the year, physicians' payments were cut 3.37 under current law. We
    appreciate Congress for acting to partially mitigate that reduction,
    however as of March 9th, physicians are still experiencing a Medicare
    cut of nearly 2 percent. At the same time, the cost of practicing
    medicine is rising at the fastest rate in decades, as CMS estimated the
    cost to run a medical practice increased by 4.6 percent in 2024. An
    inflation-based update to physician payment is critical to change the
    unsustainable trajectory of the current payment system, which not only
    jeopardizes patients' access to physician services but also poses
    significant challenges in managing chronic conditions effectively. The
    consequences of the continued real-dollar cuts to Medicare payments,
    exacerbated by the absence of statutory updates aligned with the
    inflation in medical practice costs and the problems with Medicare's
    budget neutrality rules has resulted in a 29 percent decline in
    physician payments adjusted for inflation in medical practice costs
    since 2001.

    Physician practices cannot continue to absorb increasing costs while
    their payment rates dwindle. In multiple annual reports, the Medicare
    Trustees have stated that they ``expect access to Medicare-
    participating physicians to become a significant issue in the long
    term'' unless Congress takes steps to bolster the system. The Trustees
    noted in 2023, for example, that ``the law specifies the physician
    payment updates for all years in the future, and these updates do not
    vary based on underlying economic conditions, nor are they expected to
    keep pace with the average rate of physician cost increases.'' The
    current Medicare physician payment system--with its lack of an adequate
    annual update--is particularly destabilizing as physicians, many of
    whom are small business owners, contend with a wide range of shifting
    economic factors when determining their ability to provide care to
    Medicare beneficiaries.

    Hospitals, skilled nursing facilities, and nearly every other Medicare
    provider receive an automatic annual update tied to inflation.
    Physicians compete in the same marketplaces as these providers for
    clinical and administrative staff, equipment, and supplies. Yet
    physicians are at a significant disadvantage due to payment cuts and
    because their payments have failed to keep up with inflation.
    Furthermore, hospitals have multiple sources of relief during times of
    high inflation, including the 340B program and Disproportionate Share
    Hospital (SDH) payments to account for uncompensated care. It is no
    wonder that these trends are driving consolidation, which is highly
    likely to increase future Medicare costs as these other providers
    receive increasingly higher payments than the diminishing number of
    independent medical practices. A recent AMA analysis \4\ shows that by
    far, the most cited reason that independent physicians sell their
    practices to hospitals or health systems had to do with inadequate
    payment. Next were the need to better manage payers' regulatory and
    administrative requirements and the need to improve access to costly
    resources. The AMA strongly supports policies that promote market
    competition and patient choice. Payment adequacy is necessary for
    physicians to continue to have the ability to practice independently.
    ---------------------------------------------------------------------------
        \4\ https://www.ama-assn.org/system/files/2022-prp-practice-
    arrangement.pdf.

    In its recent March Report \5\ to Congress, the Medicare Payment
    Advisory Commission (MedPAC) called for a physician payment update tied
    to the Medicare Economic Index (MEI) in 2025, following a similar
    recommendation \6\ for increasing physician payment in 2024. Unlike the
    temporary patches that Congress has adopted in recent years, MedPAC
    calls for permanent updates to physician payment that would be built
    into subsequent years' payment rates. While the AMA has commended the
    Commission for taking this significant step, we note that implementing
    an inflation-based update based on only half of the full MEI growth
    rate, as recommended, would be a missed opportunity to meaningfully
    address the perennial issue of Medicare physician underpayment that
    threatens stable access to care for millions of Medicare beneficiaries.
    ---------------------------------------------------------------------------
        \5\ https://www.medpac.gov/wp-content/uploads/2024/03/
    Mar24_Ch4_MedPAC_Report_To_
    Congress_SEC.pdf.
        \6\ https://www.medpac.gov/wp-content/uploads/2023/03/
    Ch4_Mar23_MedPAC_Report_To_
    Congress_SEC.pdf.

    We continue to believe that MedPAC's rationale that half of MEI is
    sufficient because the practice expense component of physician payment
    accounts for approximately half of total Medicare physician payments
    reflects an incomplete picture of the cost of running a medical
    practice. It is well understood that the practice expense component
    does not cover all practice costs. For example, in the 2024 Medicare
    Physician Payment Schedule (MPS) final rule, the Centers for Medicare &
    Medicaid Services (CMS) applies a direct cost scaling adjustment of
    0.4637. In other words, for a supply that costs $100, CMS will include
    $46.37 or a reduction of $53.63 from the invoice cost of the item in
    the direct expense allocation for the service. Additionally, practice
    expense is only one component of a multifactorial formula to compensate
    physicians for the total costs of running a medical practice and caring
    for Medicare beneficiaries. Payment for physician work--the time,
    energy, and expertise devoted to treating patients by physicians, nurse
    practitioners, physician assistants and other qualified health care
    professionals--is no less important, also contributes to total cost in
    the provision of a service and is equally impacted by inflation.
    Therefore, an inflation-based payment update is equally warranted for
    physician work and other aspects of total physician payment, all of
    which could be addressed by finalizing an update that is tied to full,
    ---------------------------------------------------------------------------
    rather than half, of MEI.

    We appreciate that Congress passed legislation that, again, mitigated
    severe Medicare payment cuts. However, these temporary, partial patches
    are a distraction, exacerbate budgeting challenges for practices, and
    divert resources that both medicine and Congress could be spending on
    other meaningful health care policies and innovations. Therefore,
    organized medicine is united in support of a long-term payment solution
    that centers on annual inflationary updates. Specifically, we ask
    Congress to pass H.R. 2474, the ``Strengthening Medicare for Patients
    and Providers Act,'' which provides a permanent annual update equal to
    the increase in the MEI. Such an update would allow physicians to
    invest in their practices and implement new strategies to provide high-
    value, patient centered care and enable CMS to prioritize advancing
    high-quality care for Medicare beneficiaries without the constant
    specter of market consolidation or inadequate access to care.
    Improvements to Budget Neutrality
    Another way to help ensure physicians have ample resources to provide
    more care in the home is via reforms to statutory budget neutrality
    requirements within the Medicare Physician Fee Schedule. The AMA urges
    the Senate Finance Committee to introduce companion legislation to H.R.
    6371, the Provider Reimbursement Stability Act. The House Energy and
    Commerce Committee has taken action on a portion of this legislation
    when it passed H.R. 6545, the Physician Fee Schedule Update and
    Improvement Act, out of committee in December 2023. The reality is that
    physician payments are further eroded by frequent and large payment
    redistributions caused by these budget neutrality adjustments. CMS
    actuaries have on occasion overestimated the impact of Relative Value
    Units (RVUs) changes in the fee schedule. When these misestimates are
    not adjusted in a timely way, it results in permanent removal of
    billions of dollars from the payment pool. Given the statutory
    authority for budget neutrality adjustments to be made ``to the extent
    the Secretary determines to be necessary,'' current law allows CMS to
    account for past overestimates of spending when applying budget
    neutrality. Congress should consider requiring a look-back period (as
    have been implemented in other payment systems) that would allow the
    Agency to correct for misestimates and adjust the conversion factor to
    reflect actual claims data. In addition, the $20 million threshold that
    establishes whether RVU changes trigger budget neutrality adjustments
    was established in 1989--3 years before the current physician payment
    system took effect. There have been no adjustments for inflation. As a
    result, the amount should be increased to $53 million to best account
    for past inflation. Further, Congress should limit the year-to-year
    variance in the Physician Fee Schedule conversion factor due to budget
    neutrality to a no greater than 2.5 percent increase or decrease. This
    would help to add more stability and predictability to the physician
    payment system.
     Reduce Burdens in Merit-based Incentive Payment System (MIPS) and
            Provide Access to Key Data
    Since the enactment of the Medicare Access and CHIP Reauthorization Act
    of 2015 (MACRA), the AMA has worked closely with Congress and CMS to
    promote a smooth implementation of MIPS. We supported MACRA's goals to
    harmonize the separate, burdensome, and punitive Meaningful Use,
    Physician Quality Payment System, and Value-Based Payment Modifier
    programs. However, the implementation of a new Medicare quality and
    payment program for CMS and physicians has been a significant
    undertaking, which was drastically disrupted by the COVID-19 pandemic
    and the Change Healthcare cyberattack. Further refinements are urgently
    needed to achieve the goals of MACRA and reduce the administrative
    burden for physicians. Worse, there is a growing body of evidence that
    the program is disproportionately harmful to small, rural, safety net,
    and independent practices, as well as devoid of any relationship to the
    quality of care provided to patients.

    While CMS has tried to improve the program, such as by introducing the
    MIPS Value Pathways (MVPs) option, these changes are superficial as the
    agency believes it does not have statutory authority to remedy these
    problems directly. Congress must step in and act to prevent
    unsustainable penalties, particularly on small, rural, and underserved
    practices; ensure access to timely data; reduce unnecessary burdens;
    and increase clinical relevance to physicians and their patients.
    Specifically, we recommend the following legislative changes:

        1.  Mitigate steep MIPS penalties following the COVID-19 pandemic
    and Change Healthcare cyberattack that disrupted MIPS implementation
    and prevent financial disaster for small, rural, and underserved
    practices.
        2.  Hold CMS accountable for timely and actionable MIPS and claims
    data.
        3.  Enhance measurement accuracy and validity, align cost and
    quality performance, and promote clinical data registries and other
    promising technology to making MIPS more clinically relevant while
    reducing burden.

    We urge Congress to consider these recommendations and look forward to
    collaborating closely on these critical issues to ensure that health
    care providers, especially those in rural and underserved areas, are
    supported effectively through the MIPS framework.
    Alternative Payment Models
    Value-based alternative payment models (APMs) have a successful track
    record of improving health outcomes and reducing costs. The AMA
    supports S. 3503/ H.R. 5013, the Value in Health Care (VALUE) Act,
    introduced by Senators Whitehouse (D-RI) and Barrasso (R-WY.) in the
    Senate and Representatives Darin LaHood (R-IL) and Suzan DelBene (D-WA)
    in the House that would extend the 5 percent APM bonus and maintain the
    50 percent revenue threshold for 2 years.

    This bipartisan legislation would help ensure that physicians in
    communities across the country have meaningful incentives to
    participate in alternative payment models that will deliver high
    quality, coordinated health care for patients. APMs have played a key
    role in providing high-quality care for Medicare beneficiaries while
    producing billions of dollars in savings for taxpayers over the past
    decade.

    The AMA urges Congress to build on the success of current APMs by
    finding additional pathways to help develop a more robust pipeline of
    APMS available to all types of physicians in all geographic locations
    in the country.

     ELIMINATING EFT FEES TO STREAMLINE HEALTH CARE PAYMENTS

    The AMA urges the Committee to consider the passage of the ``No Fees
    for EFTs Act'' as a crucial step towards enhancing the efficiency and
    effectiveness of chronic care management across the U.S. By addressing
    this legislative issue, the Committee would not only be supporting the
    financial sustainability of health care practices but also contributing
    to the broader goal of improving care for patients with chronic
    conditions.

    The burden of electronic funds transfer (EFT) fees, as outlined in our
    support for H.R. 6487, the ``No Fees for EFTs Act'' in the House, and
    support for S. 3805, the corresponding Senate bill, highlights a
    significant barrier to the efficient operation of health care
    practices. EFT fees, often amounting to 2 to 5 percent of the claim
    payment, are levied by certain health plans and their intermediaries
    without a clear agreement from health care practices. This not only
    exacerbates the financial strain on these practices but also diverts
    valuable resources away from patient care and resources that are
    crucial for the management of chronic illnesses. In addition, for
    health care providers in rural and underserved areas, where chronic
    conditions are prevalent and resources are scarce, the impact of these
    fees is even more pronounced. These areas frequently face challenges in
    accessing comprehensive care, and administrative inefficiencies only
    serve to exacerbate these disparities.

    By eliminating EFT fees, the ``No Fees for EFTs Act'' would
    significantly reduce administrative complexities, freeing up resources
    that could be better allocated toward patient care. This is especially
    important in chronic care management, where continuous, comprehensive
    care is necessary for managing long-term health conditions. The
    reduction of administrative burdens would allow health care providers
    to invest more time caring for patients.

    TELEHEALTH ACCESS THROUGH LEGISLATIVE REFORM

    The AMA supports the role of telehealth in managing chronic illnesses
    and advocates for the permanent removal of restrictions limiting
    Medicare patients' access to these services. Through legislative
    proposals such as the Creating Opportunities Now for Necessary and
    Effective Care Technologies (CONNECT) for Health Act (S. 2016/H.R.
    4189) and the Telehealth Modernization Act (S. 3967/H.R. 7623), there
    is a pathway for permanency of the advances made in telehealth
    accessibility, particularly vital for patients managing chronic
    conditions.

    Introduced by Senators Schatz (D-HI) and Wicker (R-MS), the CONNECT for
    Health Act is bipartisan legislation that would permanently extend many
    important COVID-19 telehealth flexibilities that have significantly
    improved access to care for patients in rural and underserved areas.
    More specifically, the bill repeals the existing Medicare geographic
    site restrictions and permanently modifies the originating site
    requirements to allow patients to receive telehealth services wherever
    the patient can access a telecommunications system, including, but not
    limited, to the home. These COVID-19 policies have allowed patients to
    obtain telehealth services at home instead of having to travel to a
    medical facility to receive virtual care from a distant site. They have
    also allowed Medicare patients located in urban and suburban areas to
    have access to telehealth services for the first time. COVID-19
    flexibilities also enabled patients to access health care services
    through audio-only visits when they do not have reliable access to two-
    way audio-video telecommunications technology.

    Passage of the Telehealth Modernization Act (S. 3967/H.R. 7623), which
    was introduced by Senators Tim Scott (R-SC) and Brian Schatz (D-HI) in
    the Senate, and Representatives Buddy Carter (R-GA), Lisa Blunt
    Rochester (D-DE), Greg Steube (R-FL), Terri Sewell (D-AL), Mariannette
    Miller Meeks (R-IA), Jeff Van Drew (R-NJ), and Joe Morelle (D-NY) in
    the House, is also crucial because in addition to eliminating the
    originating and geographic restrictions of Medicare coverage for
    telehealth, it would permanently continue the ability to use audio-only
    telehealth services beyond the current statutory deadline of December
    31, 2024. Access to two-way audio-visual telehealth and audio-only
    services has lowered or eliminated barriers that many patients in rural
    and underserved areas face when trying to obtain in-person care, such
    as functional limitations that make it difficult to travel to physician
    offices, long travel times, workforce shortages, the need for a
    caregiver to accompany the patient, and patients experiencing unstable
    housing and lack of transportation and childcare.

    Permanently removing the antiquated geographic restrictions and the
    originating site requirements means patients will no longer have to
    travel, counterintuitively, to a limited set of brick-and mortar
    medical sites to access virtual care. In an effort to boost access to
    virtual mental health services, The Connect for Health Act also repeals
    the requirement within the Consolidated Appropriations Act, 2021,
    requiring patients to see a physician in-person within 6 months of an
    initial telehealth visit for a mental health condition.

    The integration of this legislation would be a forward-thinking
    approach to the way health care is delivered, particularly for chronic
    disease management. These acts collectively aim to dismantle outdated
    barriers that restrict telehealth's potential to enhance patient care.
    By permanently removing these restrictions. This is especially
    important for chronic care management where the need for regular and
    convenient access to health care services is necessary.
    Telemental Health Care Access Act
    Federal lawmakers have also introduced stand-alone bills, specifically
    S. 3651/H.R. 3432, the Telemental Health Care Access Act, to remove
    these in-person visit requirements that will only stifle access to
    mental health services. While federal lawmakers have, thus far, passed
    legislation delaying the mandate for patients to receive an in-person
    visit within 6 months of receiving an initial telemental health service
    from taking effect, it is crucial this policy is permanently removed to
    ensure patients retain ample access to virtual mental health services.
    Absent Congressional intervention, the in-person telemental health
    requirements will go into effect on January 1, 2025, so it is crucial
    legislative action occurs expeditiously.

    The dramatic increase in the availability of telehealth services has
    catalyzed the development and diffusion of innovative hybrid models of
    care delivery utilizing in-
    person, telehealth, and remote monitoring services so that patients can
    obtain the optimal mix of service modalities to meet their health care
    needs. These models can also reduce fragmentation in care by allowing
    patients to obtain telehealth services from their regular physicians
    instead of having to utilize separate telehealth-only companies that
    may not coordinate care with patients' medical home. Now, all
    Americans, including rural, underserved, minoritized and marginalized
    patients, can receive a combination of in-person and virtual care,
    which is crucial for patients with chronic diseases. Congress should
    not permit these flexibilities to expire as it will run counter to its
    goals of promoting more home-based care.

    In closing, the AMA looks forward to working with the Senate Finance
    Committee to pass the above-mentioned proposals that help promote
    prevention, the use of telehealth for chronic care management and
    continuity of care, provides for the solvency of independent physician
    practices (which form the bedrock of care for rural and underserved
    communities and our health care system in general), and eliminates the
    burdens many physician practices face to receive electronic payments
    for services rendered. The more we can stabilize the Medicare program
    and reduce the burdens that physician practices face, the more time and
    resources there are available to dedicate to improving patient care. We
    stand ready to work with the Committee to improve the Medicare program
    for the patients struggling with chronic conditions and the physicians
    who treat them.

                                     ______

                      American Medical Women's Association

                               Two Woodfield Lake

                        1100 E Woodfield Road, Suite 350

                              Schaumburg, IL 60173

                            Telephone (847) 517-2801

                              Fax: (847) 517-7229

                           https://www.amwa-doc.org/

    April 10, 2024

    The Honorable Ron Wyden
    Chairman
    Senate Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510

    The Honorable Mike Crapo
    Ranking Member
    Senate Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510

    Dear Senator Wyden and Senator Crapo,

    I am writing to share perspectives on the upcoming Senate Finance
    Committee hearing ``Bolstering Chronic Care through Medicare Physician
    Payment Reform'' scheduled to take place in the Senate Finance
    Committee on April 11, 2024. This discussion represents a critical
    opportunity to enhance the quality of care for individuals living with
    chronic conditions and to address systemic challenges within our
    healthcare system. Thank you for holding this discussion.

    Chronic diseases present formidable challenges for both patients and
    healthcare providers, necessitating ongoing management and support. By
    reforming Medicare physician payment structures to incentivize
    comprehensive, coordinated care for chronic conditions, we can
    revolutionize how we approach chronic care management. Adequately
    compensating physicians for their time and resources invested in
    managing chronic conditions is essential to ensuring that patients
    receive the comprehensive support they need to lead healthier lives.

    Moreover, implementing payment reforms aligned with the goals of
    chronic care management has the potential to reduce healthcare costs in
    the long term by minimizing hospitalizations, emergency room visits,
    and complications associated with unmanaged chronic conditions.
    Prioritizing preventive care and proactive management is crucial for
    creating a more sustainable and efficient healthcare system.

    Additionally, I urge the Senate Finance Committee to recognize the
    growing impact of obesity as a chronic disease and to consider the
    implications of Medicare coverage for anti-obesity medications under
    the Treat and Reduce Obesity Act (TROA). Currently, Medicare Part D
    does not provide coverage for these medications, despite their proven
    efficacy in helping individuals achieve significant weight loss and
    reducing the risk of developing chronic diseases such as diabetes and
    heart disease. TROA would address this gap by providing coverage for
    anti-obesity medications as well as the full range of obesity
    treatments, including nutrition counseling, behavioral therapy, and
    community-based programs.

    I commend the Senate Finance Committee for taking proactive steps to
    address these pressing issues and for their dedication to advancing
    healthcare. I hope that you will share these points with the committee
    members during the upcoming discussion. I eagerly anticipate the
    livestream of the hearing and look forward to the progress that will be
    made in bolstering chronic care and addressing the needs of patients
    with chronic conditions.

    Thank you for your attention to these important matters.

    Sincerely,

    Eliza Chin, M.D., MPH
    Executive Director

                                     ______

                          American Nurses Association

                          8515 Georgia Ave., Suite 400

                            Silver Spring, MD 20910

                         https://www.nursingworld.org/

    April 23, 2024

    The Hon. Ron Wyden                  The Hon. Mike Crapo
    Chairman                            Ranking Member
    United States Senate                United States Senate
    Committee on Finance                Committee on Finance
    219 Senate Dirksen Office Building  219 Senate Dirksen Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Wyden and Ranking Member Crapo,

    On behalf of the American Nurses Association (ANA), I would like to
    thank you for holding the hearing, ``Bolstering Chronic Care through
    Medicare Physician Payment,'' on April 11, 2024. While physician
    payment has been discussed for decades, there also needs to be focus
    placed on how public payers such as Medicare ensure access to nursing
    care. The roles registered nurses (RN) and advanced practice registered
    nurses (APRN) play in health care delivery has changed significantly
    since the inception of the Medicare program.

    ANA appreciates the Committee's recognition that more fully valuing
    primary care providers is essential to helping the Medicare program
    better address chronic conditions. The shortage of primary care
    physicians in the United States is projected to be between 20,200 and
    40,400 physicians by 2036.\1\ Consequently, APRNs will be needed to
    fill this void in primary care, and they stand ready to be utilized to
    the fullest extent of their education and clinical training--Nurse
    Practitioners (NP), for example, already make up around 50 percent of
    the primary care workforce. Appropriately, Medicare rules and
    statements increasingly refer to Qualified Health Practitioners (QHP),
    in addition to physicians, in order to be more inclusive of APRNs. ANA
    would appreciate the Committee's urging of the Centers for Medicare and
    Medicaid Services (CMS) to continue to do so. Moreover, RNs are
    significant providers of care coordination and related services that
    render team-based care effective for patients with chronic conditions.
    We appreciate this opportunity to share with you how several of our
    policy priorities align with the Committee's goals for physician
    payment reform.
    ---------------------------------------------------------------------------
        \1\ https://www.aamc.org/media/75231/download?attachment.

    ANA is the premier organization representing the interests of the
    nation's over 5 million registered nurses, through its constituent and
    state nurses associations, organizational affiliates, and individual
    members. RNs serve in multiple direct care, care coordination, and
    administrative leadership roles, across the full spectrum of health
    care settings. RNs provide and coordinate patient care, educate
    patients and the public about various health conditions, and provide
    advice and emotional support to patients and their family members. ANA
    members also include those practicing in the four advanced registered
    nurse roles: NPs, clinical nurse specialists (CNS), certified nurse-
    midwives (CNM), and certified registered nurse anesthetists (CRNA). ANA
    is dedicated to partnering with health care consumers to improve
    practices, policies, delivery models, outcomes, and access across the
    health care continuum.
     National Provider Identifier (NPI) Numbers for All Practitioners
    NPIs remain the gold standard for determining eligibility and
    reimbursing the health care clinicians for care provided to patients.
    RNs are integral parts of the health care team and spend significant
    time with patients providing clinical services. However, though they
    are eligible to receive them, NPIs are not required for RNs and they do
    not typically obtain them. In the current health care financing system,
    RN work is generally not accounted for, other than in the practice
    expense (PE) component of the relative value unit (RVU). The time spent
    by the RN is the main element of RN work that is captured in the PE of
    billing providers. The lack of NPIs for nurses makes it extremely
    difficult to record, measure, and value the services they provide and
    their impact on patient outcomes.

    Obtaining an NPI is a first step to recognizing and evaluating the
    value of the nurse in the health care delivery system. Obtaining and
    recording RNs' NPIs in relevant health care data systems would allow
    health systems, payers, and enterprise resource planning systems to
    distinguish the value of nursing services from that of other providers.
    This would allow for a quantitative analysis and substantive
    demonstration of the nurse's role and value as an integral member of a
    patient's health care team. As such, ANA urges the Committee to explore
    utilization of the NPI for RNs as a means of better capturing the
    significant contributions of RN care. NPIs would not change RN
    reimbursement or pay as RN times and services provided are now included
    in the PE component of relative value unit RVUs.
    Recognizing RN Value
    As the Committee looks at ways to evolve and reform the health care
    system, ANA strongly advocates for changes in current reimbursement
    models to recognize the value of the nurse. The American Medical
    Association (AMA) created the CPT and RUC systems to value the work
    done by physicians and other qualified healthcare providers. While
    APRNs and other non-physician providers have NPIs and bill for services
    attributed to them, patient care provided by RNs is not billed and
    identified separately. The result is that RNs have historically been
    included as part of PE when the RUC either establishes or modifies the
    value of procedures in the CPT code set. However, this only captures
    the time it takes rather than fully capturing the scope of services
    that RNs provide to patients. Payment innovations centered on value
    should encompass the expertise of RNs and the clinical services they
    provide. As such, ANA encourages the Committee to explore reimbursement
    models that would capture the actual value of the RN as part of any
    broader Medicare payment reforms.
    Incident To Billing
    In the same vein as assigning NPI numbers to RNs, MedPAC has
    recommended for several years that Congress should require APRNs and
    physician assistants to bill the Medicare program directly, eliminating
    ``incident to'' billing for services they provide.\2\ ANA agrees with
    MedPAC. Because of incident to billing, it is unknown what care is
    being delivered by physicians directly or by other practitioners. The
    data generated by eliminating incident to billing would give Congress
    and other policymakers a more complete understanding of how our health
    care system is working and will help uncover efficiencies and cost
    savings. Not only would eliminating incident to billing generate cost
    savings, but we believe the benefits of the data derived will provide
    significant value to policymakers, particularly with respect to
    appropriately valuing primary care.
    ---------------------------------------------------------------------------
        \2\ https://www.medpac.gov/recommendation/issues-in-medicare-
    beneficiaries-access-to-primary-care-5-1-june-2019/.

     Discounted Reimbursement for Nurse Practitioners and Clinical Nurse
            Specialists
    Under current law, NPs and CNSs receive 85 percent of the Physician Fee
    Schedule for the same work as their physician colleagues. In addition,
    only physicians receive a 10 percent bonus if they work in designated
    health professional shortage areas (HPSA), meaning NPs and CNSs receive
    less than 78 percent of the reimbursement as their physician colleagues
    for the same work in HPSAs. Furthermore, practice expenses do not
    change based on your professional designation. There is no reason the
    discounted reimbursement should include a discount on practice expenses
    when a difference between practice expenses of those of a physician and
    those of another qualified provider does not exist.

    APRNs are educated under the nursing model, where clinical training is
    integrated into their core curriculum. APRN programs are competency-
    based, not time-based. A student must demonstrate mastery of content
    before advancing. While the nursing and medical models of training are
    different, the safety and quality of APRN competency-based education is
    consistently demonstrated in more than 40 years of patient care
    research. For example, the American Enterprise Institute released a
    report that found that ``beneficiaries who received their primary care
    from NPs consistently received significantly higher-quality care than
    physicians' patients in several respects. While beneficiaries treated
    by physicians received slightly better services in a few realms, the
    differences were marginal.''\3\ ANA appreciates the Committee's
    recognition of the need to bolster primary care in rural and
    underserved areas and expanding the 10% HPSA bonus eligibility for
    APRNs is a commonsense way to help address this growing challenge.
    ---------------------------------------------------------------------------
        \3\ https://www.aei.org/research-products/report/nurse-
    practitioners-a-solution-to-americas-primary-care-crisis/.
    ---------------------------------------------------------------------------
    Improving Care and Access to Nurses (ICAN) Act (S. 2418/H.R. 2713)
    ANA reiterates our staunch support for the ICAN Act, which contains a
    host of provisions that would increase access to cost-effective, high-
    quality care for Medicare and Medicaid beneficiaries. This legislation
    would increase patient access to care by removing outdated and
    unnecessary federal barriers on services provided by APRNs under the
    Medicare and Medicaid programs, further benefiting beneficiaries,
    especially those with chronic care conditions that must be closely
    monitored.

    Recognizing the importance of APRNs to our health care workforce, and
    for patient access to care, the Institute of Medicine (IOM) issued The
    Future of Nursing: Leading Change, Advancing Health report in 2010,
    which called for the removal of laws, regulations, and policies that
    prevent APRNs from providing the full scope of health care services
    they are educated and trained to provide. In 2021, this position was
    reaffirmed by the National Academy of Medicine (previously named the
    IOM) in their 2021 The Future of Nursing 2020-2030: Charting a Path to
    Achieve Health Equity.

    Unfortunately, there are still Medicare and Medicaid policies that have
    not been modernized to reflect the growing and essential role of APRNs.
    Various federal statutes and regulations remain which prevent APRNs
    from practicing to the full extent of their education and clinical
    training. Many of these policies were written before APRNs could
    participate in Medicare. These provisions reduce access to care,
    disrupt continuity of care, increase health care costs, and undermine
    quality improvement efforts. Removal of these outdated barriers should
    serve as a bedrock of Medicare reimbursement reform.

    The purpose of the ICAN Act is to increase access, improve quality of
    care, and lower costs in the Medicare and Medicaid programs by removing
    federal barriers to practice for APRNs, consistent with state law. We
    urge Congress to pass this important legislation. It will move our
    health care system forward in an effective and efficient manner for the
    benefit of patients and providers. More than 240 organizations have
    endorsed this legislation, including the National Rural Health
    Association, AARP, the American Health Care Association, and Leading
    Age.

    In closing, I would like to thank you for your leadership and for your
    willingness to consider our perspective on this critical issue to
    ensure that patients have access to qualified, high-quality providers.
    ANA stands ready to work with the Finance Committee to implement policy
    solutions to comprehensively address the nation's challenges addressing
    chronic care. If you have any questions, please contact Tim Nanof, Vice
    President of Policy and Government Affairs, at (301) 628-5081 or
    Tim.Nanof@ana.org.

    Sincerely,

    Debbie Hatmaker, Ph.D., RN, FAAN
    Chief Nursing Officer/EVP

                                     ______

                   American Occupational Therapy Association

                      6116 Executive Boulevard, Suite 200

                         North Bethesda, MD 20852-4929

                                  301-652-6611

                             https://www.aota.org/

    The American Occupational Therapy Association (AOTA) is the national
    professional association representing the interests of more than
    230,000 occupational therapists, occupational therapy assistants, and
    students of occupational therapy. The science-driven, evidence-based
    practice of occupational therapy enables people of all ages to live
    life to its fullest by promoting participation in daily occupations or
    activities. In so doing, growth, development, and overall functional
    abilities are enhanced, and the effects associated with illness,
    injuries, and disability are minimized.

     Crucial Role of Occupational Therapy in Supporting Chronic Conditions

    Occupational therapy (OT) can contribute to the overall effectiveness
    of a primary care program focused on managing and supporting chronic
    conditions. However, OT has faced increasing challenges providing
    services under the Medicare Physician Fee Schedule over the last
    decade, even as more and more evidence emerges about the efficacy of OT
    in improving the overall health and wellness of Medicare Beneficiaries.

    At its most basic, the goal of occupational therapy is to evaluate the
    person, their needs, and their capabilities to optimize their ability
    to perform day-to-day activities and to maximize health. Occupational
    therapy self-management interventions can improve the health outcomes
    in type 2 diabetes and provide a cost-effective option for reducing the
    burdens placed on patients and healthcare systems.\1\ Supporting self-
    management facilitates individuals' ability to function in their
    desired environment, often preventing higher utilization of more costly
    care.
    ---------------------------------------------------------------------------
        \1\ Self-Management Support Interventions Integrated into
    Occupational Therapy Practice With People Having Type 2 Diabetes.
    https://natsci.upit.ro/issues/2019/volume-8-issue-16/self-management-
    support-interventions-integrated-into-occupational-therapy-practice-
    with-people-having-type-2-diabetes.

    Occupational therapy enables individuals with a chronic condition to
    ---------------------------------------------------------------------------
    have healthier, productive, and meaningful lives by:

          Addressing performance deficits in daily self-care (ADLs) and
    home management tasks (instrumental ADLs), resulting from specific
    chronic conditions, to sustain or improve current status in these
    areas.
          Developing strategies to incorporate energy conservation and
    activity modification techniques into daily activities to cope with
    physical demands and reduce the fatigue associated with many chronic
    conditions.
          Individualizing adaptations to perform health management tasks
    effectively (e.g., ensuring that someone with hand weakness can manage
    daily insulin shots for diabetes).
          Teaching and incorporating health management tasks into existing
    habits and routines, so they become part of the daily routine (e.g.,
    setting up a schedule and reminder system to take medications).
          Developing coping strategies, behaviors, habits, routines, and
    lifestyle adaptations to support physical and psychosocial health and
    well-being.

    Building Routines and Habits for Overall Self-Management of Conditions

    Living with a chronic condition can bring with it changing physical
    and/or mental abilities. In addition, the environment, both physical
    and psychosocial (e.g., family dynamics), may need to be addressed.
    Occupational therapy practitioners analyze the demands of activities
    meaningful to the client and evaluate the fit between abilities and
    challenges.

    Self-management is about taking charge of one's life and managing one's
    condition instead of being controlled by that condition and is
    recognized as an effective approach to chronic health conditions by
    ``empowering patients to understand their conditions and take
    responsibility for their health'').\2\ The client-centered nature of
    occupational therapy is ideal for supporting self-management. Whether a
    client is newly diagnosed or has lived with a chronic condition for
    many years, occupational therapy supports patients in managing the
    disease with positive behaviors and strategies while also engaging in
    daily life activities.
    ---------------------------------------------------------------------------
        \2\ https://www.ninr.nih.gov/sites/files/docs/ninr-focus-self-
    management.pdf.

    Occupational therapy practitioners analyze the demands of meaningful
    activities to the client and evaluate the fit between client abilities
    and challenges imposed by those activities and the environment. They
    may make recommendations on conserving energy, decreasing or preventing
    pain, simplifying activities, and improving the safety and ease of
    ---------------------------------------------------------------------------
    functioning in a given environment (e.g., home, school, work).

    Managing chronic conditions also involves learning specific health-
    management skills. These may include regularly monitoring blood
    pressure or weight; planning, shopping for, and preparing meals
    according to specific requirements or restrictions; monitoring blood
    glucose; administering oral, injected, or inhaled medications; or
    increasing physical activity. It is not enough for clients to learn and
    demonstrate these skills. To be effective, they must be consistently,
    habitually, and correctly performed and the client must successfully
    integrate those skills into existing routines. Occupational therapy
    practitioners look at barriers that prevent clients from integrating
    health management tasks into their daily routines and, if necessary,
    incorporate adaptations to overcome these barriers. They are
    particularly skilled in helping clients manage chronic conditions in a
    way that fits with existing routines and patterns, so changes feel less
    disruptive and are more likely to be consistently integrated into the
    daily routine.

    Focus on Developing Medication Management Strategies

    Medication non-adherence in patients with chronic conditions results in
    higher hospitalization rates, poorer outcomes, and dramatically
    increased health care costs. Studies have shown that between 50-70% of
    older adults fail to take medications according to physician
    instructions--resulting in an estimated 3 million older adults being
    admitted to skilled nursing facilities each year and causing as many as
    125,000 deaths annually.\3\
    ---------------------------------------------------------------------------
        \3\ https://pubmed.ncbi.nlm.nih.gov/14717268.

    As experts in the development of habits and routines, as noted above,
    occupational therapy practitioners play a pivotal role in helping
    patients develop medication management routines. Working with
    occupational therapy practitioners to establish daily practices aimed
    at significantly improving medication compliance have proven to
    increase overall health and functional status, decrease the risk of
    falls, improve cognition, and increase driver safety for older
    adults.\4\
    ---------------------------------------------------------------------------
        \4\ https://www.researchgate.net/publication/
    284362391_Relationship_of_Number_of_Medica
    tions_to_Functional_Status_Health_and_Quality_of_Life_for_the_Frail_Home
    -Based_Older_
    Adult.

    Studies in this area indicate that medication habits need to be
    customized to the individual to promote integration into existing life
    routines. This finding is consistent with client-centered practice.
    Evidence also strongly suggests that patients would significantly
    benefit from skilled interventions, such as developing cues, arranging
    for equipment, assessing the environment, or arranging for monthly
    refills. These findings substantiate occupational therapy
    practitioners' role in developing specific, individualized, concrete
    plans for integrating med es, thus exponentially increasing the
    patient's odds of adherence.

             Alarming Trends in the Occupational Therapy Workforce
                         Threaten Future Access to Care

    Occupational therapy (OT) services are provided by both occupational
    therapists (who are trained either through a 2-year master's program or
    a 3-year doctoral program) and occupational therapy assistants (who
    either receive an associate's degree or a bachelor's degree).

    Since 2018, there has been a steady decrease in the number of
    applicants (-33%) and total applications (-41%) to OT programs.
    Occupational therapy assistant programs have seen the most significant
    of these declines. In 2015 these programs filled 85% of their available
    seats. In 2022, only 66% of seats were filled--a 19% decrease.

    However, the U. S. Bureau of Labor Statistics projects an increase in
    the need for occupational therapy practitioners (OTPs) over the next 10
    years; projecting a 14% increase in employment for occupational
    therapists \5\ and a 25% increase in employment of occupational therapy
    assistants.\6\
    ---------------------------------------------------------------------------
        \5\ https://www.bls.gov/ooh/healthcare/occupational-
    therapists.htm#tab-6.
        \6\ https://www.bls.gov/ooh/healthcare/occupational-therapy-
    assistants-and-aides.htm#tab-6.

    [GRAPHIC] [TIFF OMITTED] T1124.009

    .epsThe following recommendations focus on ways Congress can increase
    access to innovative programs under Medicare, ensure adequate payment
    for occupational therapy services, ensure that occupational therapy
    practitioners are included in future payment models that focus on
    beneficiary outcomes, and ensure beneficiary access to occupational
    therapy services in rural and medically underserved areas.

              Congress Must Increase Access to Innovative Programs

    Cost Savings Through Supporting Aging in Place and Reducing Falls.
    Multiple programs and studies have demonstrated the effectiveness and
    cost savings of an occupational therapy led home-safety evaluation
    centered on a client's identified goals and preferences and followed by
    suggested low-cost home modifications and adaptive equipment. Despite
    demonstrated cost savings and improved quality of life, there is no way
    for these types of services to be provided to Medicare beneficiaries
    outside of grant funding and demonstration projects.

    The CAPABLE Model, which was developed through funding by the Center
    for Medicare and Medicaid Innovation (CMMI) and the National Institutes
    of Health is the most well-known of these interventions. This 5-month,
    interprofessional, team-based intervention is delivered by an
    occupational therapist (six visits), a nurse (four visits), and a
    handy-person (up to 1 day). The handy-person will make home repairs,
    install assistive devices, and make home modifications as prescribed by
    the occupational therapist. CAPABLE as American Occupational Therapy
    Association Page 2 of 5 a model promotes safe and effective aging in
    place by addressing Medicare beneficiary issues that directly drive
    healthcare costs yet are not addressed in current care models. The
    model has resulted in reduced disability, healthcare cost savings, and
    the promotion of aging in place. Studies have demonstrated that the
    CAPABLE model produced $922 per Medicare beneficiary per month in
    savings for up to 2 years \7\ and $867 per month for up to a year in
    Medicaid savings \8\ due to a reduction in hospitalizations and other
    institutional based care.
    ---------------------------------------------------------------------------
        \7\ Ruiz S, Snyder LP, Rotondo C, Cross-Barnet C, Colligan EM,
    Giuriceo K. Innovative Home Visit Models Associated with Reductions in
    Costs, Hospitalizations, and Emergency Department Use. Health Affairs.
    2017;36(3):425-432.
        \8\ Szanton SL, Alfonso YN, Leff B, et al. Medicaid Cost Savings of
    a Preventive Home Visit Program for Disabled Older Adults. Journal of
    the American Geriatrics Society. 2018;66(3):614-620.

    While the CAPABLE model has undergone multiple clinical trials and
    studies, there is other ample evidence for the cost-effectiveness of
    low cost, high intensity home modifications directed by an occupational
    therapist. A study in the American Journal of Preventative Medicine
    identified ``home modifications delivered by an occupational
    therapist'' as the intervention with the greatest potential to help
    older adults by preventing falls. The study estimated a cost savings of
    $38.2 million and estimated that 45,164 falls would be prevented.\9\
    Another study combined weatherization/energy services with a home
    safety assessment conducted by an occupational therapist and subsequent
    home modifications/repairs. The study group saw a significant reduction
    in falls (from 94% to 9%) and calls for assistance (from 23% to 3%)
    within a 6-month period.\10\
    ---------------------------------------------------------------------------
        \9\ Stevens, Judy A. and Robin Lee. ``The Potential to Reduce Falls
    and Avert Costs by Clinically Managing Fall Risk.'' Am J Prev Med 55
    no. 3 (2018): 290-297. doi:10.1016/j.amepre.2018.04.035.
        \10\ Tohn, Ellen, Jonathan Wilson, Tracy Van Oss, and Michael
    Gurecka. ``Incorporating Injury Prevention into Energy Weatherization
    Programs.'' J Public Health Manag Pract (2019) doi:10.1097/
    PHH.0000000000000947.

    When Congress directed the Department of Housing and Urban Development
    (HUD) to establish a grant program to help enable low-income elderly
    persons to remain in their primary residence, HUD chose OT to lead home
    modifications as the intervention with the most evidence of success and
    cost savings and also based the Older Adults Home Modification Grant
    Program (OAHMP) around this intervention model.\11\ The grant program
    highlights that occupational therapy practitioners are ``trained to
    evaluate clients' functional abilities and the home environment'' and
    have ``knowledge of the range of low-cost, high-impact environmental
    modifications and adaptive equipment used to optimize the home
    environment and increase independence.''
    ---------------------------------------------------------------------------
        \11\ https://www.hud.gov/program_offices/spm/gmomgmt/grantsinfo/
    fundingopps/oahmp.

    Occupational therapy practitioners (OTPs) also play a distinct role in
    helping those with Alzheimer's and dementia continue to engage in the
    activities that are most meaningful to them, thereby helping to
    optimize their quality of life. A crucial component of supporting
    meaningful engagement for a person with dementia, is supporting and
    training the caregiver, as well as promoting caregiver wellness, a
    focus of both Skills2Care and COPE. While these programs are supported
    by the Administration on Aging and some state Medicaid programs, there
    is currently no pathway to reimbursement for these interventions under
    ---------------------------------------------------------------------------
    Medicare.

    Congress has established the Physician-Focused Payment Model Technical
    Advisory Committee (PTAC) so that ideas on value-based care could be
    generated from the diverse provider community. The ability of the PTAC
    to approve smaller, innovative Alternative Payment Models (APMs) is now
    more important than ever, as CMMI has pledged to focus on fewer, larger
    APMs. Despite the promise of the PTAC, however, it has failed to create
    a pathway for meaningful participation in APMs. The CAPABLE model is an
    example of an evidence-based intervention, approved by the PTAC, that
    was never implemented by CMS even though it was first developed through
    funding from CMMI research grants.

    Recommendations:

    Congress could allow healthcare practitioners to pilot test PTAC-
    approved APM models: This is not allowed under current law, but
    granting such permission would allow participants to show CMS and other
    policymakers how the model would work and perform in real-world
    settings for the benefit of Medicare beneficiaries. Once the pilot
    period concludes and an appropriate amount of data was collected and
    analyzed, CMS could make its final approval or denial decision. If
    approved, this would allow for other providers to more easily replicate
    real-world use of the piloted model and build upon lessons learned to
    allow for more effective, broad-scale implementation.

    Congress must be able to look beyond current CBO analysis when judging
    potential savings for innovative programs: Under current rules, CBO
    would not take into account the massive savings which would be
    generated by a national roll-out of CAPABLE or a similar program.
    Therefore, the cost would be prohibitively high, and real savings would
    not be realized as patients would continue to suffer preventable
    accidents which result in costly emergency room visits,
    hospitalizations and institutionalization.

                  Eroding Reimbursement under Medicare Part B

    Occupational therapy practitioners and other therapy providers have
    been particularly hard hit by the recent redistribution of resources on
    the Physician Fee Schedule to increase payments for Evaluation &
    Management (E/M) codes as a result of budget neutrality requirements.
    Unlike other medical specialties, therapy providers are not allowed to
    bill evaluation and management codes, meaning therapy practitioners
    have taken and will continue to face the full reduction in the
    conversion factor caused by these payment changes. In addition to the
    decreases in the conversion factor caused by changes to the E/M values,
    payment for therapy services received additional cuts in 2024 after the
    Congressional moratorium on implementation of the G2211 code ended. We
    appreciate Congressional action to phase these cuts in, however at the
    end of this phase in, payment for occupational therapy services will
    have been reduced by as much as 9%.

    The negative impacts of past and future budget neutrality cuts on OT
    are felt nationally; however, rural providers face greater challenges
    given that they serve smaller and often shrinking patient populations.
    Total Medicare payments for OT services increased nationwide from $1.1B
    to $1.6B from 2009-21 which represents a 37 percent increase; however,
    this was driven by a 48% increase in patient volume, not the number of
    services per beneficiary which actually dropped by 6.9% during this
    time. Given that the rural population in the U.S. has declined from
    nearly 59.5 million to 56.8 million during this time, downward
    pressures on reimbursement cannot be addressed by increased patient
    volume, which would be difficult to achieve anyway given decreases in
    applications for OT programs, OTA reimbursement cuts and other factors.

    While the challenges of the current payment system cut across multiple
    specialties, they have been particularly difficult for therapy
    providers, including occupational therapy practitioners. From the
    beginning, the Quality Payment Program (QPP) offered few options for
    participation for therapy practitioners, and outpatient therapy
    services provided in facility-based settings were never eligible for
    the QPP. Occupational therapy practitioners in private practice have
    limited or no options to receive bonus payments. As Congress considers
    policies to create a more affordable, patient-centered health care
    system focused on overall health, policies must include all Medicare-
    eligible professionals equally. Further, we ask that Congress consider
    updating legacy Medicare payment policies that continue to harm therapy
    providers and threaten access to care for Medicare beneficiaries.

    Recommendations:

    End the Multiple Procedure Payment Reduction (MPPR) for therapy
    services: The multiple procedure payment reduction (MPPR), is a payment
    policy that was first implemented in 2011, and applies to physical
    therapy (PT), occupational therapy (OT) and speech language pathology
    (SLP) services provided under Medicare Part B. Because of MPPR, when a
    beneficiary receives more than one 15-minute therapy services on the
    same day, all subsequent therapy services beyond the first, across
    therapy disciplines, are cut. Under this policy, the therapy service
    with the highest practice expense value is reimbursed at 100%, and the
    practice expense values for all other subsequent therapy services are
    reduced by 50%.

    The MPPR is a flawed policy that was never based on actual data backing
    the 50% reduction. The Centers for Medicare & Medicaid Services (CMS)
    initially proposed a 25% reduction, even while acknowledging that this
    number was not backed up with concrete data. Later Congress moved the
    25% reduction to 50% in order to pay for a month's long patch to the
    Sustainable Growth Rate. As a result, therapy services received, whit
    is now estimated to be a 15.8% cut to payments, only a few years before
    their payment rates were frozen under MACRA.

          The application of MPPR to the ``always therapy'' codes results
    in an excessive reduction of these codes and is having a significant
    impact on the financial viability of therapy practices and the
    occupational therapy workforce--ultimately impacting access to vital
    therapy services. We strongly recommend that Congress end this policy
    or reduce the level of cuts.

    MACRA and the Medicare Quality Payment Program: In order to move to a
    payment system that truly values quality and patient outcomes, all
    providers must be engaged from the outset. CMS's current one-size-fits
    all development of MIPS eligible quality measures has focused primarily
    on physicians and does not reflect the services (and outcomes) of many
    providers paid through the Medicare Physician Fee Schedule.

          CMS must provide a way for all providers to participate in
    current and future payment programs throughout their development. This
    includes identification of cost measures that occupational therapy
    practitioners can participate in, outcomes measures that are reflective
    of the services provided by occupational therapy practitioners and
    other non-physician providers, and outcomes measures that are not
    limited to the use of a specific outcomes management systems.

    Allow Occupational Therapy Practitioners to Opt Out of Medicare: Unlike
    many other health providers, occupational therapy practitioners cannot
    opt out of being a Medicare enrolled provider, if they provide services
    to Medicare-eligible beneficiaries. This prevents Medicare
    beneficiaries from exercising their right should be empowered to select
    the health care professional of their choice, including allowing
    beneficiaries to privately contract with occupational therapists. As
    discussed below, Medicare's inflexible policies have stifled the
    ability to implement innovative programs that can support the long-term
    health and wellness of Medicare beneficiaries. There are evidence-based
    therapy interventions that cannot be reimbursed under current Medicare
    payment policies, but could be provided under private pay, if that were
    allowed.

          Allowing therapy providers to opt out would give Medicare
    beneficiaries the opportunity to benefit from these critical
    interventions to which they are currently denied access, and improve
    overall health outcomes, thus keeping people out of the acute
    healthcare system.

               Ensuring Access to Occupational Therapy Services
                         in Rural and Underserved Areas

    Telehealth

    OT interventions delivered via telehealth have enabled patients to
    develop, regain, and build functional independence in everyday life.
    Telehealth has also demonstrated advantages over in-person visits in
    some situations, especially for people in rural and underserved areas,
    and for the large number of seniors in all communities who face
    transportation and mobility issues, especially those with disabilities.
    Telehealth is also an ideal platform for conducting home safety
    evaluations as it provides a window into the person's home and often
    greater access to their caregivers. However, occupational therapy
    practitioners are only allowed to provide Medicare telehealth services
    under temporary waivers.

    Recommendation:

    Enact legislation such as S. 2880--the Expanded Telehealth Access Act
    in order to make therapy practitioners permanent Medicare telehealth
    providers. Congressional action is essential to enable Medicare
    beneficiaries to continue to receive OT services via telehealth when
    appropriate. Passage of the Expanded Telehealth Access Act (S.2880)
    would enable OT professionals as well as PTs, SLPs, and audiologists to
    provide services via telehealth under Section 1834(m) of the Social
    Security Act. Unless Congress acts, Medicare beneficiaries will face a
    telehealth ``cliff'' on December 31, 2024, whereby beneficiaries who
    are now accustomed to receiving some OT services via telehealth
    suddenly lose access to such services. We urge Congress to prevent this
    outcome.

    Support Occupational Therapy Assistants

    Access to occupational therapy in rural, medically underserved areas is
    directly dependent on the availability of occupational therapy
    assistants. An analysis of 2021 Medicare Part B claims \12\ shows that
    46% of all occupational therapy services provided in rural and
    medically underserved areas are provided by OTAs, compared to 34% in
    all other geographic areas. The recent trends in enrollment for
    occupational therapy assistant programs are particularly worrisome for
    rural and medically underserved areas, where beneficiaries already tend
    to receive fewer minutes of therapy in settings such as skilled nursing
    facilities, and where occupational therapy assistants provide a much
    higher percentage of those minutes.\13\
    ---------------------------------------------------------------------------
        \12\ https://acrobat.adobe.com/link/
    track?uri=urn:aaid:scds:US:afa395e4-8b46-30fc-9687-fd85
    ecb1aa95.
        \13\ https://www.aota.org/-/media/corporate/files/advocacy/federal/
    otaworkforceinsnfsfinal
    report922.pdf.

    Current enrollment trends and projected workforce needs paint an
    alarming picture for the future of the occupational therapy workforce
    and people's ability to access occupational therapy services in rural
    and medically underserved areas. Compounding the enrollment challenge
    is a recent reimbursement cut for services provided by OTAs. On January
    1, 2022, Medicare outpatient services provided by occupational therapy
    assistants and physical therapist assistants (PTAs) began receiving a
    15% reduction in payment. This cut is the result of a provision in the
    Balanced Budget Act of 2018, and is separate from, and in addition to,
    other cuts to therapy payments under the Medicare Physician Fee
    Schedule that have been imposed over the last several years.

    Recommendation:

    Enact the Enabling More of the Physical and Occupational Workforce to
    Engage in Rehabilitation (EMPOWER) Act (H.R. 4878/ S. 2459): The
    EMPOWER Act would change the Medicare supervision requirement for OTAs
    and PTAs in private practice so that it cannot exceed requirements
    under State law. Currently, private practice is the only setting under
    Medicare Part B that requires ``direct'' supervision instead of
    ``general'' supervision. Therapy providers in all settings must comply
    with their state practice act if state or local practice requirements
    are more stringent than Medicare, and currently 48 states require
    general supervision of physical therapist assistants, and 49 states
    require general supervision of occupational therapy assistants. This
    Medicare regulation, which only applies to private practices, is also
    more burdensome than in all other settings including those where more
    acute patients are generally seen, i.e., hospital outpatient/SNF, etc.

          Enacting this bill would remove barriers to care provided by
    OTAs in a private practice setting and would reinforce the important
    role of occupational therapy assistants as part of the care team,
    especially in rural areas. The bill also requires the Government
    Accountability Office (GAO) to examine the impact of the 15% payment
    cut to OTAs and PTAs on access to services in rural and medically
    underserved areas. AOTA believes strongly that these cuts have already
    impacted access to services in rural and underserved areas, but more
    data is needed.

    Thank you for your attention to this crucial issue. AOTA looks forward
    to working with the Senate Finance Committee as you seek to improve
    payments for Medicare services and support beneficiaries with chronic
    conditions.

                                     ______

                        American Osteopathic Association

                               511 2nd Street, NE

                              Washington, DC 20002

                                  312-202-8000

                            https://osteopathic.org/

    On behalf of the American Osteopathic Association (AOA), and the more
    than 186,000 osteopathic physicians (DOs) and medical students we
    represent, we write to express our appreciation for the Committee's
    interest in improving patient access to care and making meaningful
    strides toward addressing the substantial gaps in Medicare fee for
    service payment. This is a particularly important opportunity to
    provide insight on matters impacting osteopathic physicians and our
    patients.

    Among the core principles of osteopathic medicine are providing
    patient-centered, coordinated care across the health care spectrum. We
    recognize that health care stakeholders across the United States share
    the responsibility of promoting reforms and policies that ensure
    individuals with chronic diseases have access to high-
    quality, continuing and comprehensive care when and where they need it.
    As such, the AOA unequivocally believes that the current Medicare
    physician payment model cannot sufficiently provide the stability
    physicians need to be able to deliver coordinated, longitudinal care--
    particularly for patients with chronic diseases.

    Medicare Payment and Patient Access

    Nearly 95 percent of adults aged 60 and older have at least one chronic
    illness or condition, and nearly 80 percent of the same cohort have two
    or more chronic conditions.\1\ Over the next decade, the projected
    number of patients with at least one chronic condition is expected to
    double and encompass more than 142 million Americans by 2050, placing
    increasing strain on the U.S. healthcare system and workforce.\2\ At
    the same time, the United States could see a shortage of as much as
    124,000 physicians by 2034 if the current trends are not reversed.\3\
    The current structure and unsustainable rates for physician payment is
    a key driver in practice closures and physician shortages, particularly
    in rural areas.
    ---------------------------------------------------------------------------
        \1\ National Council on Aging. Chronic Inequities: Measuring
    Disease Cost Burden Among Older Adults in the U.S. A Health and
    Retirement Study Analysis. Page 5, Figure 2. April 2022. Accessed
    online at: https://ncoa.org/article/the-inequities-in-the-cost-of-
    chronic-disease-why-it-matters-for-older-adults.
        \2\ Ansah JP, Chiu CT. Projecting the chronic disease burden among
    the adult population in the United States using a multi-state
    population model. Front Public Health. 2023 Jan 13;10:1082183. doi:
    10.3389/fpubh.2022.1082183. PMID: 36711415; PMCID: PMC9881650.
        \3\ Association of American Medical Colleges: Report Reinforces
    Mounting Physician Shortage. June 11, 2021. Accessed online at: https:/
    /www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-
    physician-shortage.

    Physicians across the country face ongoing uncertainty regarding the
    payment they will receive for services rendered year after year. This
    year, in the Medicare Physician Fee Schedule CMS finalized a 3.37% cut
    to Medicare's physician payments, which was only able to be partially
    mitigated by Congress. This cut coincides with ongoing increases in
    costs to practice medicine--which CMS acknowledges, as the projected
    increase in the Medicare Economic Index (MEI) for 2024 will be 4.6%.
    Unlike nearly all other Medicare providers and suppliers, physicians do
    not receive an annual inflationary payment update. Changing this would
    provide stability to independent physician practices facing unique
    economic challenges in rural areas. This type of reform has previously
    been proposed through the bipartisan Strengthening Medicare for
    Patients and Providers Act (H.R. 2474), and the AOA strongly urges the
    ---------------------------------------------------------------------------
    Senate Finance Committee to consider this legislation further.

    The AOA also recommends further supplementing support for rural
    physicians by utilizing economic levers that would make practicing in
    rural and underserved communities more accessible and appealing to a
    broader base of physicians. These levers include increasing Physician
    Health Professional Shortage Area incentives and/or creating new means
    of improving payment specifically for rural physicians. For example, in
    its March 2024 report, MedPAC recommended creating an add-on payment
    for physicians caring for low-income patients to better support
    physicians working with rural and underserved populations.\4\ Without
    predictable inflationary payment updates and additional incentives for
    rural and underserved areas, the physician workforce in these
    communities is likely to decline.
    ---------------------------------------------------------------------------
        \4\ MedPAC. ``March 2024 Report to Congress.'' April 18 2024.
    Accessed online at: https://www.medpac.gov/wp-content/uploads/2024/03/
    Mar24_Ch4_MedPAC_Report_To_Congress_
    SEC.pdf.

    Furthermore, Medicare's current budget neutrality obligations within
    the physician payment schedule exacerbate the lack of inflationary
    updates. A provision within the Omnibus Budget Reconciliation Act of
    1989 mandated that any adjustments to the MPFS due to upward payments
    or new procedures in one category that increase costs by $20 million or
    more must be offset by cuts in other areas of the fee schedule. This
    issue is reflected in the implementation of a new and controversial
    care complexity add-on code (G2211). Improved payment for longitudinal,
    coordinated primary care is necessary for physicians, but those payment
    improvements should not come at the expense of payment reductions in
    ---------------------------------------------------------------------------
    other specialties that would limit the benefits the new code provides.

    In comparing the United States with nine other high-income nations, the
    United States has significantly lower rates of patients reporting a
    longstanding relationship with a primary care physician.\5\ At the same
    time, evidence shows that longitudinal relationships, which are
    integral to both the philosophy of osteopathic medicine and delivering
    high-quality care, lead to better management of chronic conditions and
    improved patient outcomes.\6\ Investment in the physician workforce,
    especially in primary care, is needed to build capacity across the
    country. To help alleviate building pressure on the physician workforce
    and subsequent access impacts upon patients, the AOA strongly urges the
    Committee to consider the Resident Physician Shortage Reduction Act
    (H.R. 2389). The bill would increase the number of residency positions
    funded by Medicare, with particular emphasis on hospitals in rural
    areas and Health Professional Shortage Areas (HPSAs).
    ---------------------------------------------------------------------------
        \5\ Gumas ED et al. ``Finger on the Pulse: The State of Primary
    Care in the U.S. and Nine Other Countries,'' March 28, 2024. The
    Commonwealth Fund. Accessed online at: https://
    www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-
    pulse-primary-care-us-nine-countries.
        \6\ Jennifer Arnold, ``Fostering Long-Term Doctor-Patient
    Relationships to Improve Outcomes,'' Duke Health, January 17, 2017.

    Additionally, the Committee should evaluate proposals such as the
    bipartisan Rural Physician Workforce Production Act (H.R. 834), which
    would allow certain hospitals to receive additional payments from
    Medicare for employing resident physicians in rural areas. This would
    increase the number of physicians practicing in rural communities and
    would provide financial support to make these residencies more
    ---------------------------------------------------------------------------
    accessible.

    Continued patient access to high-quality care, particularly for chronic
    conditions, is contingent upon the confluence of all three factors:
    sustainable and predictable updates to physician payment under the
    Medicare Physician Fee Schedule, adjustments to the budget neutrality
    threshold, and investment in the physician workforce, particularly in
    rural and underserved communities.

    Aligning Sites of Service and Medicare Payment

    Differences in payment predicated upon the site of service create
    fundamental inequities in the care delivery landscape, and the MPFS
    cuts that went into effect January 1, 2024, would exacerbate existing
    site of service differences for services that are demonstrably similar.
    AOA supports policies that would require payments to physicians that
    reflect the resources required to provide patient care in each setting.
    These changes would also ensure that physicians delivering longitudinal
    care to patients with chronic conditions are not disadvantaged compared
    to Hospital Outpatient Departments (HOPDs) delivering urgent care for
    emerging issues related to chronic conditions. Not only would more
    equitable payment lower costs, but it would support better outcomes for
    patients.

    The inequities, in the current payment model, allow for HOPDs to net
    higher payments for certain services, driving up costs to both Medicare
    and patients, while driving consolidation and reducing competition in
    the care delivery ecosystem. As the Committee considers policies that
    will align payments for various sites of service, it should prioritize
    payment models that account for costs incurred to the provider while
    also taking into account the nature of the patient population being
    served. Payment policies should also include factors such as the
    provision of care coordination, after-hours care, emergency care,
    quality-based payments, and other costs.

    MedPAC recommended Congress implement site-neutral payment policies in
    its July 2023 report, and the AOA strongly echoes that
    recommendation.\7\
    ---------------------------------------------------------------------------
        \7\ MedPAC. ``Health Care Spending and the Medicare Program: July
    2023 Data Book.'' 2023.
    ---------------------------------------------------------------------------

    Value and Innovation

    The AOA has long advocated for payment predicated upon delivering high-
    quality, value-based care rather than the volume-based nature of the
    current fee-for-service payment model. Despite that, transitions to
    value-based payments must account for the unique needs of different
    specialties, practices current capacities, and the ways physicians
    deliver care. It also must not create additional barriers to entry,
    result in reduced or inequitable payment, or increase administrative
    burden. To better promote high-value care and reduce burdens, the
    Committee should look at Advanced alternative payment models (APMs)
    rather than the Merit-based Incentive Payment System (MIPS) when
    building new policies.

    Advanced APM pathways include Accountable Care Organizations (ACOs),
    including those under the Medicare Shared Savings Program (MSSP), and
    Centers for Medicare and Medicaid Innovation (CMMI) models. Many AAPMs
    are well suited for physicians helping patients manage chronic
    conditions, as they include added incentives for providers who take on
    additional risk when treating patients as they deliver high quality,
    coordinated, and efficient care. Ultimately, in considering any shifts
    towards expanding existing APMs or seeking to accelerate physician
    participation in such models, efforts must:

          Support practices in making the necessary infrastructure
    investments to succeed under such models;
          Ensure sufficient flexibility in the range of models available
    to account for differences across specialties and the ways different
    physicians deliver care;
          Minimize administrative burden to enable physicians who commit
    to value-based models to focus on patient care; and
          Ensure adequate payment for the range of services the particular
    physician provides, and in the case of primary care, support the
    comprehensive services that advanced primary care seeks to deliver.

    Ensuring that financial support is available to incentivize this
    transition is essential, and the AOA applauds Congress' extension of
    AAPM bonuses for PY2024, despite our disappointment at the reduced
    bonus rate.

    When Congress passed the Medicare Access and CHIP Reauthorization Act
    (MACRA) it clearly intended to deliver an accelerated pathway for
    physicians to participate in APMs. The transition to value-based
    payment has not materialized as Congress had hoped because practices
    have not been paid enough to be able to reinvest to have the capacity
    to succeed in APMs. It is important to note that most APMs are built
    upon the foundation of our FFS system, and continuously declining
    payment rates in FFS create a vicious cycle that only makes it more
    challenging to transition as revenue, and funds available to make
    investments, declines.

    Moreover, the current structure of MIPS does not effectively measure
    performance on meaningful outcomes or accurately predict care quality,
    and it is not an effective means of delivering value and penalizes
    small and rural practices.

    Further, the Committee should consider additional funding for the
    Quality Payment Program's Small Practice, Underserved, and Rural
    Support (QPP-SURS) program. This program ensures small and rural
    physicians can participate in quality payment models that will improve
    patient outcomes and access while lowering costs. Most small and rural
    providers do not have access to the technical or administrative staff
    necessary to ensure proper participation in the MIPS, which currently
    disadvantages small and independent physician practices. Physicians in
    small and rural practices consistently receive below-average MIPS
    scores, demonstrating that practice size and resources are better
    indicators of MIPS performance than patient outcomes. Research shows
    that association with large hospital systems and provider networks
    receive better MIPS performance ratings, despite large health systems
    not delivering demonstrably better quality of care.\8\ Physician-owned
    practices deliver high-quality and cost-effective care regardless of
    health system affiliation, and this research demonstrates the technical
    and administrative disadvantage small and independent physician
    practices are currently facing. Ensuring physicians at small or rural
    practices can participate in APMs that incentivize high-quality, cost-
    effective care is integral to improving patient access to care for
    chronic conditions.
    ---------------------------------------------------------------------------
        \8\ Johnston K, Wiemken T, Hockenberry J, et al. Association of
    Clinician Health System Affiliation with Outpatient Performance Ratings
    in the Medicare Merit-based Incentive Payment System. JAMA Netw Open.
    2020;324(10):984-992.

    Value-based payment is an important tool that can be used to enhance
    access to primary care, particularly for patients with chronic
    conditions. The AOA applauds the Committee's interest in taking steps
    to ensure physician payment reform drives patients access to high-
    quality, affordable, coordinated care, and we look forward to working
    with the committee further.

    Conclusion

    Again, thank you for the opportunity to submit comments for the record.
    The Committee's work on these important issues will support the
    stability of both the physician workforce and patient access to
    affordable, high-quality care. The AOA and our members stand ready to
    assist the Committee at large as you consider new policies and
    legislation to improve patient access to care and minimize red tape for
    doctors. If you have any questions or if the AOA can be a resource,
    please contact AOA Vice President of Federal Affairs and Public Policy,
    John-Michael Villarama, MA, at jvillarama@osteopathic.org, or (202)
    349-8748.

                                     ______

                     American Physical Therapy Association

                          3030 Potomac Ave., Suite 100

                           Alexandria, VA 22305-3085

                                  703-684-2782

                             https://www.apta.org/

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Wyden and Ranking Member Crapo,

    On behalf of our more than 100,000 member physical therapists, physical
    therapist assistants, and students of physical therapy, the American
    Physical Therapy Association appreciates the opportunity to submit
    comments for the hearing ``Bolstering Chronic Care through Medicare
    Physician Payment.''

    APTA is dedicated to building a community that advances the physical
    therapy profession to improve the health of society. As experts in
    rehabilitation, prehabilitation, and habilitation, physical therapists
    play a unique role in society in prevention, wellness, fitness, health
    promotion, and management of disease and disability for individuals
    across the age span, helping individuals improve overall health and
    prevent the need for avoidable health care services. Physical
    therapists' roles include education, direct intervention, research,
    advocacy, and collaborative consultation. These roles are essential to
    the profession's vision of transforming society by optimizing movement
    to improve the human experience.

    ``The Economic Value of Physical Therapy in the United States''\1\ a
    recently released APTA report, showcases the cost-effectiveness and
    economic value of physical therapist services for a broad range of
    common conditions. The report compares physical therapy with
    alternative care across a suite of health conditions commonly seen
    within the U.S. health care system. The report underscores and
    reinforces the importance of including physical therapists and physical
    therapist assistants as part of multidisciplinary teams focused on
    improving patient outcomes and decreasing downstream costs.
    ---------------------------------------------------------------------------
        \1\ https://www.valueofpt.com/.

    While the report highlights the economic value that physical therapy
    brings to the U.S. health care system, such value is not maximized due
    to the unique challenges faced by physical therapists under the
    Medicare Physician Fee Schedule (MPFS). Physical therapist and physical
    therapist assistants play a critical in the delivery of services to
    beneficiaries who have chronic care conditions; however, therapists and
    other non-physician providers who are paid under the MPFS are often
    overlooked when it comes to enacting meaningful reforms to payment and
    administrative burden challenges. To improve chronic care services,
    broader reforms to the current fee schedule to address these challenges
    ---------------------------------------------------------------------------
    must be made.

    APTA's comments below offer a series of policy recommendations for the
    committee's consideration to decrease health care costs and reduce
    administrative burden that are supported by APTA's recent economic
    report.\2\ Our comments also mirror the recommendations laid out in the
    ``Policy Principles of Outpatient Therapy Reform Under the Medicare
    Physician Fee Schedule''\3\ that provides a roadmap offering
    recommendations specific to outpatient therapy that need to be made for
    the continued sustainability of physical therapy under Medicare. The
    ``Policy Principles of Outpatient Therapy Reform Under the Medicare
    Physician Fee Schedule'' are endorsed by APTA, APTA Private Practice,
    the American Speech-Language-Hearing Association, and the American
    Occupational Therapy Association.
    ---------------------------------------------------------------------------
        \2\ https://www.valueofpt.com/globalassets/value-of-pt/
    economic_value_pt_u.s._report_from_
    apta-policy_paper-policymakers.pdf.
        \3\ https://apta1111-my.sharepoint.com/personal/
    justinelliott_apta_org/Documents/Desktop/Policy Principles for
    Outpatient Therapy Reform under the Medicare Physician Fee Schedule
    (apta.org).
    ---------------------------------------------------------------------------

    Background

    The 2015 Medicare Access and CHIP Reauthorization Act, known as MACRA,
    replaced the flawed Sustainable Growth Rate formula with the Quality
    Payment Program, or QPP. The QPP comprises two tracks: the Merit-based
    Incentive Payment System, or MIPS, and Advanced Alternative Payment
    Models, also known as AAPMs. The Centers for Medicare & Medicaid
    Services began implementing the QPP in 2017, with the eventual goal of
    moving providers out of MIPS and into AAPMs. There are a number of
    foundational issues with MACRA and the QPP that disproportionately
    impact nonphysician qualified health care providers such as physical
    therapists. In addition, there are logistical and operational barriers
    for therapists to participate in MIPS and AAPMs. Some of the current
    challenges facing therapy providers include:

      MACRA Has Not Stabilized Payment Under the Medicare Physician Fee
                Schedule. MACRA sought to stabilize payments by repealing
                the Sustainable Growth Rate formula and providing payment
                adjustments under the QPP. Despite that goal, these changes
                replaced relief from the growth rate cuts with payment cuts
                to the conversion factor--as a result, budget neutrality
                requirements limit the effectiveness of payment incentives
                provided under MIPS and have required annual legislative
                intervention to stave off untenable cuts to payment.
                Further, nonphysician providers, including therapists, have
                few options to receive payment adjustments under the QPP
                that would otherwise serve to offset payment cuts. In 2021,
                the average payment per therapy claim was the same as it
                was in 2010. Since 2021, therapy services have been cut
                further because of reductions to the conversion factor. An
                additional 15% cut to services provided by physical
                therapist assistants was implemented in 2023. This decrease
                in payment is simply not sustainable if we are to have a
                robust workforce that supports access to rehabilitation
                therapy services nationwide. Providers are suffering under
                a workforce shortage and MACRA policies are reducing
                resources needed for adequate therapists to meet patient
                access needs.

      Inability of facility-based outpatient therapy providers to
                participate in bonus payment structures. While outpatient
                private practice therapy services are paid under the
                Medicare Physician Fee Schedule, or MPFS, services provided
                in facility-based settings, such as hospital outpatient
                departments, rehabilitation agencies, and skilled nursing
                facilities are not considered to be a part of the MPFS.
                Rather, the 1997 Balanced Budget Act required that payments
                for facility-based outpatient therapy services be ``based-
                on'' the value of those services as set forward in the
                MPFS. While therapy services provided under the fee
                schedule are billed through an individual's National
                Provider Identifier, all facility-based outpatient therapy
                services are billed through the facility, and not the
                individual therapist. This distinction is not
                insignificant. According to MedPAC,\4\ 63% of all Medicare
                outpatient therapy services are provided in facility-based
                settings, yet facility-based outpatient therapy providers
                have had no way to receive payment updates or bonus
                payments. However, these services are subject to budget
                neutrality cuts and any other policy affecting therapy
                payments through the physician fee schedule--such as the
                multiple procedure payment reduction, also known as MPPR,
                and cuts to services provided by physical therapist
                assistants.
    ---------------------------------------------------------------------------
        \4\ https://www.medpac.gov/wp-content/uploads/2022/10/
    MedPAC_Payment_Basics_22_OPT_
    FINAL_SEC.pdf.

              QPP Does Not Promote Value-Based Care or Effectively Measure
            Quality of Care. The QPP does not allow for adequate
            participation for therapists in either MIPS or AAPMs. The lack
            of appropriate quality metrics and a failure to include all
            outpatient providers of therapy services in MIPS and AAPMs have
            prevented the shift to value-based care. These problems are
            compounded by slow and ineffective mechanisms used to innovate
            within the QPP. This means physical therapists who were not
            fully considered in the QPP's design still cannot meaningfully
    ---------------------------------------------------------------------------
            participate.

              Barriers to Therapist Participation in MIPS. Most physical
            therapists are not required to participate in MIPS but are
            encouraged to opt in to the program. However, extremely limited
            payment incentives serve to dissuade optional participation
            given that the cost of compliance outweighs even the highest
            historical incentives earned under the programs. Without
            specialty measurement sets, therapy cost measures, or otherwise
            comparable options available to most physicians, therapists
            have few reasons to participate under the program and suffer
            compounding pay cuts under the MPFS without any opportunity for
            mitigation through the QPP.

              CEHRT is a Threshold Barrier for Therapists in MIPS and
            AAPMs. Promoting interoperability through Certified Electronic
            Health Record Technology, or CEHRT, was part of MACRA's
            original vision. AAPMs promote this by requiring CEHRT as a
            prerequisite for AAPM opportunities, and under MIPS providers
            are scored on the ``promoting interoperability'' measure
            category. CEHRT options are simply not available for physical
            therapists, as their requirements are costly, burdensome, and
            contain many requirements that are specific only to physicians.
            As a result, physical therapists cannot participate in AAPMs,
            and will receive scores of zero under MIPS in the
            interoperability category. Without vendors working to develop
            CEHRT for therapists (in part because there aren't enough
            potential users to justify vendors' expense of CEHRT
            development), these providers will never be able to participate
            meaningfully. Requirements must be relaxed or modified,
            otherwise physical therapists will continue to be assessed on
            an uneven playing field.

              Barriers to Participation in AAPMs. In addition to CEHRT as
            a threshold barrier to participation, the Qualifying
            Participant, or QP, threshold to earn incentives under the
            program also is not realistically achievable for physical
            therapists. Further, while there is a Partial QP designation,
            it does not offer any incentives to participate, and serves
            more to prepare clinicians who believe they would meet the QP
            threshold in the future. AAPMs could have therapist-specific
            thresholds or offer incentives for partial QPs to incentivize
            participation by therapists.

    The challenges that MACRA has created for therapy providers are
    compounded by the current budget neutrality policies under the MPFS
    that have resulted in year-over-year cuts. Despite Congress's annual
    intervention since 2020 to provide additional funding to the fee
    schedule to mitigate the impact of the cuts, therapy providers still
    had to absorb multiple payment reductions. The challenges associated
    with budget neutrality threaten to re-create the decades-long problems
    created by the Sustainable Growth Rate; an urgently needed solution is
    necessary to prevent increased spending associated with temporary,
    year-end fixes.

    Recommendations

    To provide greater stability under the MPFS for nonphysician providers
    such as physical therapists, and to help account for a decade of cuts
    to payments to therapy services, we recommend the following policies be
    included in any legislative package aimed at reforming the Medicare
    Physician Fee Schedule to ensure patient access to care and stability
    of providers.
    Eliminate the Multiple Procedure Payment Reduction Policy
    The MPPR Policy, first implemented in 2011, applies to physical
    therapy, occupational therapy, and speech-language pathology services
    provided under Medicare Part B. Because of MPPR, when therapists bill
    more than one ``always therapy'' service (identified by CPT code) on
    the same day for the same patient, all therapy services beyond the
    first are subject to a reduction in the practice expense portion of
    that code.

    Under this policy, the therapy service with the highest practice
    expense value is reimbursed at 100%, and the practice expense values
    for all subsequent therapy services, provided by all therapy
    clinicians, are reduced by 50%. The work and malpractice components of
    the therapy service payment are not reduced. In the 2011 Medicare
    Physician Fee Schedule, CMS first proposed the implementation of a 25%
    MPPR across therapy services. Congress reduced this reduction amount to
    20% in the Physician Payment and Therapy Relief Act of 2010 (H.R.
    5712). This 20% MPPR was in place from January 1, 2011, to March 31,
    2013. Without any further analysis demonstrating a need to increase the
    MPPR, Congress implemented a permanent 50% MPPR in the American
    Taxpayer Relief Act of 2012, which was implemented by CMS on April 1,
    2013. The average payment per therapy claim in 2013 (after MPPR) was
    8.5% less than the average therapy claim in 2010 (before MPPR).

    Our organizations have opposed the MPPR policy since its inception. It
    is inherently flawed, because the American Medical Association Relative
    Value Scale Update Committee, which assigns values to CPT codes,
    already ensures that any potential duplication in work or practice
    expense is addressed as part of the code valuation process. Certain
    efficiencies that occur when multiple therapy services are provided in
    a single session were explicitly taken into account when relative
    values were established for these codes. The application of MPPR to the
    ``always therapy'' codes results in a duplicative and excessive
    reduction of these codes and is having a significant impact on the
    financial viability of therapy practices--ultimately impacting access
    to vital therapy services.

    The percentage of payment reduction was arbitrarily decided by the
    112th Congress and does not reflect actual utilization data regarding
    how many units of a therapy service are typically delivered in a
    treatment session, and it does not recognize that OT, PT, and SLP
    interventions are separate and distinct from each other. When CMS first
    proposed the MPPR, they purposefully did not consider how therapy
    services are provided in facility-based settings, even stating that it
    does ``not believe it would have been appropriate for us to consider
    institutional patterns of care.''\5\ (See page 70.)
    ---------------------------------------------------------------------------
        \5\ https://www.govinfo.gov/content/pkg/FR-2010-11-29/pdf/2010-
    27969.pdf.

    With the potential exception of greeting the patient, clinical staff
    activities that are elements of the practice expense are not
    duplicative in nature and should not be reduced in value, especially
    when delivering different services during the therapy session. For
    instance, if therapeutic exercises using hand weights are provided for
    one unit, followed by self-care retraining in the kitchen for one unit,
    then the equipment, supplies, and clinical staff activities are
    entirely separate for each of these procedures. Each requires its own
    disinfection, patient positioning, and other set-up and clean-up
    processes before and after the procedure. Under the current policy,
    despite those services being separate and distinct, and having a
    separate and distinct practice expense, payment for the second unit is
    reduced even though the values of the two codes do not include any
    ---------------------------------------------------------------------------
    duplicative cost.

    MPPR also applies across therapy disciplines delivered on the same date
    regardless of the distinct services and supplies provided to the
    patient. While the first therapy discipline (e.g., physical therapy)
    would receive payment under MPPR at 100% for the first unit and 50% of
    the practice expense for all other units, a second or third discipline
    (e.g., occupational therapy or speech-language pathology) delivering
    services on that date would have all provided service units reduced.
    This occurs even though the expertise, equipment, clinical staff, and
    supplies utilized for one therapy service have no overlap with the
    other services provided. This policy penalizes providers when
    scheduling multiple therapies on the same date, which
    disproportionately affects beneficiaries in rural and underserved
    communities where transportation issues may require therapy services to
    be delivered on the same day to reduce the need for repeat visits to
    the clinic.
     Provide Flexibility in the Supervision of Physical Therapy Assistants
            to Alleviate the Challenges Facing the Physical Therapist
            Workforce in Rural and Underserved Areas
    Medicare allows for general supervision of occupational therapy
    assistants (OTAs) by occupational therapists, and physical therapist
    assistants (PTAs) by physical therapists in all settings, except for
    outpatient private practice under Part B, which requires direct
    supervision. While therapy providers must comply with their state
    practice act if state or local practice requirements are more stringent
    than Medicare's, the standard in 49 states is general supervision of
    PTAs, making this an outdated Medicare regulation--which arbitrarily
    applies only to private practice--more burdensome than almost all state
    requirements. Standardizing a general supervision requirement for
    private practices will help ensure continued patient access to needed
    therapy services and give small therapy businesses more workforce
    flexibility to meet the needs of beneficiaries.

    The inconsistency of supervision policies between settings jeopardizes
    employment opportunities for OTAs and PTAs as well as the needs of
    Medicare beneficiaries in medically underserved and rural communities
    that rely so heavily on their services. Standardizing the supervision
    requirement from direct to general for private practices will help
    ensure continued patient access to needed therapy services and give
    private practices more flexibility in meeting the needs of
    beneficiaries. This small modification would better promote timely
    access to therapy services.

    Congress should enact the Enabling More of the Physical and
    Occupational Workforce to Engage in Rehabilitation Act, or EMPOWER Act
    (H.R. 4878/S. 2459),\6\ bipartisan legislation \7\ that would assist
    the therapy workforce by permitting general supervision of physical
    therapist and occupational therapy assistants under Medicare Part B
    outpatient practices. According to an independent report published by
    Dobson DaVanzo & Associates in September 2022, this change in
    supervision is estimated to save up to $271 million over 10 years.
    ---------------------------------------------------------------------------
        \6\ https://www.apta.org/advocacy/issues/medicare-physician-fee-
    schedule/position-paper-pta-differential.
        \7\ https://www.congress.gov/bill/118th-congress/senate-bill/2459.

    The EMPOWER Act also direct the Government Accountability Office to
    conduct an analysis of how the Medicare Part B 15% payment differential
    for services provided by OTAs and PTAs, which went into effect in 2022,
    has impacted access to occupational therapy and physical therapy
    services in rural and medically underserved areas, across all Medicare
    Part B settings. Beneficiaries in those areas are twice as likely to
    receive OT or PT services from an assistant. Rehabilitation therapy
    providers report that rural areas suffer significantly from the ongoing
    workforce shortage. A GAO report will provide greatly needed
    information and data regarding the impact of this payment differential
    and how it disproportionately impacts these regions.
    Reform MACRA to Allow Broader Participation by Therapy Providers
    Within MACRA, the QPP has posed significant challenges to nonphysician
    providers, including PTs, OTs, and SLPs. Therapists in particular have
    struggled to meaningfully participate in MIPS or engage in AAPMs, in
    part because CMS has failed to pilot or implement several alternative
    payment and delivery models applicable to therapy providers. Congress
    must enact meaningful reforms to the QPP that recognize the value of
    therapy providers and allow them to provide effective oversight of the
    QPP to determine its effectiveness at measuring therapy performance and
    outcomes.

    The value of any quality program depends on the ability of all
    providers to participate. To address the current shortcomings of the
    QPP including limited opportunities for therapists' participation in
    the program, Congress should authorize a stakeholder workgroup to
    identify barriers and develop recommendations for the Secretary of the
    Department of Health and Human Services on rulemaking to ensure that
    the QPP comprehensively measures the impact of all care received by
    Medicare beneficiaries.
    Reduce the Impact of Inflation on Providers and the Patients They Serve
    Providers paid under the Medicare Physician Fee Schedule do not receive
    the annual inflationary update upon which virtually all other Medicare
    providers can rely on to better weather periods of fiscal uncertainty.
    Providing an annual inflationary payment update to the Medicare
    Physician Fee Schedule's conversion factor based on the Medicare
    Economic Index, or MEI, will provide much-needed stability to the
    Medicare payment system. The MEI is a measure of inflation faced by
    health care providers with respect to their practice costs and general
    wage levels.

    Health care providers, including rehabilitation therapists, continue to
    face increasing challenges as they seek to provide Medicare
    beneficiaries with access to timely and quality care. Congress has
    taken action to mitigate some of the recent MPFS cuts on a temporary
    basis, nevertheless, reimbursement continues to decline. According to
    an American Medical Association analysis of Medicare Trustees data,\8\
    when adjusted for inflation, Medicare payments to clinicians have
    declined by 26% from 2001 to 2023. The failure of the MPFS to keep pace
    with the true cost of providing care, combined with year-over-year cuts
    resulting from the application of budget neutrality, sequestration, and
    alternative payment and value-based care models that are unavailable to
    therapists, clearly demonstrates that the fee schedule is broken.
    Increasingly thin operating margins disproportionately affect small,
    independent, and rural practices, as well as those treating low-income
    or other historically under-resourced or marginalized patient
    communities--undermining efforts to improve equity in health care and
    social determinants of health.
    ---------------------------------------------------------------------------
        \8\ https://www.ama-assn.org/system/files/medicare-updates-
    inflation-chart.pdf.

    An inflationary update will provide budgetary stability to clinicians--
    many of whom are small business owners--as they contend with a wide
    range of shifting economic factors such as increasing administrative
    burdens, staff salaries, office rent, and purchasing of essential
    technology. Providing an annual inflation update equal to the MEI for
    fee schedule payments is essential to enabling practices to better
    absorb payment distributions triggered by budget neutrality rules,
    performance adjustments, and periods of high inflation. A more stable
    payment system will also help providers to invest in their practices
    ---------------------------------------------------------------------------
    and implement new strategies to provide high-value care.

    APTA strongly support the Strengthening Medicare for Patients and
    Providers Act (H.R. 2474),\9\ legislation that would provide such an
    annual inflationary update to the Physician Fee Schedule's conversion
    factor based on the Medicare Economic Index to help ensure patient
    access to the critical services our members provide. H.R. 2474 was
    introduced by Reps. Raul Ruiz, D-CA, Larry Bucshon R-IN, Ami Bera, D-
    CA, and Mariannette Miller-Meeks, R-IA.
    ---------------------------------------------------------------------------
        \9\ https://www.apta.org/advocacy/issues/medicare-physician-fee-
    schedule/strengthening-medicare-for-patients-and-providers-act.
    ---------------------------------------------------------------------------
     Reduce Administrative Burden for Therapy Services Provided Under
            Medicare
            Part B
    Medicare Part B guidelines permit Medicare beneficiaries to receive
    therapy evaluation and treatment services with or without a physician
    order. The PT, OT, or SLP may evaluate that patient, formulate a plan
    of care, and commence treatment in either instance. However, under
    current certification requirements, the therapy provider must submit
    the plan of care to the patient's physician and have it signed within
    30 days in order to receive payment. If the deadline is approaching and
    the referring physician still hasn't returned the signed plan of care,
    the rules say it's up to the therapist to obtain that signature;
    without it, the PT is faced with halting treatment or face the prospect
    of not getting paid by Medicare.

    Given the current pressures on therapy providers, including recent
    year-over-year fee schedule cuts, we are united in seeking
    opportunities to reduce administrative burden without compromising
    patient safety or quality of care as a way to mitigate the impact of
    these payment cuts for therapy providers and our physician colleagues,
    as well as to best serve our patients expeditiously and without
    financial risk to their therapy providers. The time and resources spent
    by both therapists and physicians in procuring a timely signature when
    a physician order is already present adds unnecessary cost, potentially
    delays essential services, and fails to contribute to improved quality
    of care.

    Congress should enact legislation that would clarify a new care
    coordination model such that when outpatient therapy services are
    provided under a physician's order, the plan of care certification
    requirements shall be deemed satisfied if the qualified therapist
    submits the plan of care to the patient's referring physician within 30
    days of the initial evaluation. The order would confirm the physician's
    awareness of the therapy episode and proof of submission of the plan of
    care would demonstrate the coordination and collaboration between the
    physician and the therapist called for by CMS.

    APTA strongly supports the Remove Duplicative Unnecessary Clerical
    Exchanges Act, or the REDUCE Act (H.R. 7279).\10\ This bipartisan bill
    would streamline the current plan of care certification requirement
    under Medicare Part B to reduce administrative burden and paperwork for
    physical therapists and physicians. The REDUCE Act was introduced in
    the U.S. House of Representatives by Reps. Don Davis, D-NC, and Lloyd
    Smucker, R-PA.
    ---------------------------------------------------------------------------
        \10\ https://www.apta.org/advocacy/issues/administrative-burden/
    remove-duplicative-unnecessary-clerical-exchanges-act.
    ---------------------------------------------------------------------------
    Provide Patient Choice Under Medicare
    Currently, PTs, OTs, and SLPs may not opt out of being Medicare-
    enrolled providers if they provide services to Medicare-eligible
    beneficiaries. This prevents Medicare beneficiaries from exercising
    their right to select the health care professional of their choice,
    including allowing beneficiaries to privately contract with these
    therapists for their care regardless of whether the therapist has
    elected to enroll in Medicare. To provide true patient choice and
    ensure access to the most appropriate care, PTs, OTs, and SLPs must be
    able to opt out of the established enrollment rules set by the Medicare
    program and federal law along with physicians, physician assistants,
    dentists, podiatrists, optometrists, social workers, psychologists,
    nurse midwives, dietitians, and other eligible providers. Denying a
    patient access to a therapist with expertise because that provider is
    not enrolled in Medicare also negatively impacts patients' clinical
    outcomes and can lead to increased downstream costs to the system.

    It is imperative that Medicare enrollees have the opportunity to choose
    the most appropriate provider and model of care to meet their needs.
    Medicare's inflexible policies have stifled implementation of
    innovative programs that can support the long-term health and wellness
    of Medicare beneficiaries. Certain evidence-based therapy interventions
    cannot be reimbursed under current Medicare payment policies. Allowing
    therapy providers to opt out would give Medicare beneficiaries the
    opportunity to benefit from these critical interventions to which they
    are currently denied access.

    According to an independent report published by Dobson & Davanzo in
    October 2023, allowing physical therapists, occupational therapists,
    and speech-language pathologists the option to opt-out is estimated to
    save $139.6 million over 10 years. The American Physical Therapy
    Association urges Congress to enact legislation that would provide
    physical therapists and other therapy providers with the ability to
    privately contract with Medicare beneficiaries.
     Enact a Permanent Medicare Policy for Therapy Services Delivered via
            Telehealth
    In response to the coronavirus public health emergency in 2020,
    Congress passed and the President signed into law legislation that
    authorized CMS to significantly expand Medicare's coverage of
    telehealth services during the public health emergency to protect the
    health and safety of Medicare patients. Under the authority of Section
    1135 of the Social Security Act, CMS permitted virtually all medical
    providers, including physical therapists, occupational therapists, and
    speech-language pathologists, to provide services via telehealth to
    Medicare beneficiaries. In late 2022, Congress approved legislation
    that extended Medicare's telehealth flexibilities for another 2 years;
    Medical providers will be permitted to treat Medicare patients via
    telehealth until December 31, 2024. After that date, unless Congress
    acts, Medicare patients may lose coverage of telehealth visits.

    Continued access to telehealth services provided by physical
    therapists, occupational therapists, and speech-language pathologists
    would allow Medicare beneficiaries to maintain access to critical
    health care services utilizing the method of delivery in-person or
    telehealth of their choice. The June 2023 MedPAC Report highlighted
    that over 90% of Medicare beneficiaries surveyed who had at least one
    telehealth visit with a clinician stated that they were very or
    somewhat satisfied. Additionally, clinicians surveyed by MedPAC
    indicated that, on average, less than 10% of their services were
    delivered via telehealth. Finally, a report by the HHS Office of
    Inspector General found that less than 0.2% of Medicare telehealth
    claims were considered high risk. Telehealth presents a way to provide
    access to care for patients both in rural and urban areas who may have
    trouble getting to appointments due to distance, mobility or
    transportation issues, or who cannot afford to take time off of work.
    Services delivered using telehealth also provide access to therapy in
    areas of our country where there simply are no therapists available.
    Telehealth has been demonstrated to be a service delivery mechanism
    that is used judiciously by health care providers in consultation with
    their patients who maintain high levels of satisfaction. Furthermore,
    initial data indicates concerns over fraud, waste, and abuse may not be
    as significant as initially feared.

    APTA supports the Expanded Telehealth Access Act (H.R. 3875/S.
    2880),\11\ bipartisan legislation that would add therapy providers in
    private practice, as well as facility-based outpatient therapy
    providers under Medicare Part B, as permanent authorized providers of
    telehealth services under Medicare. H.R. 3875 was introduced by Reps.
    Mikie Sherrill, D-NJ, and Diana Harshbarger, R-TN, S. 2880 was
    introduced by Senators Steve Daines, R-MT, and Tina Smith, D-MN.
    ---------------------------------------------------------------------------
        \11\ https://www.apta.org/advocacy/issues/telehealth/expanded-
    telehealth-access-act.
    ---------------------------------------------------------------------------

    Conclusion

    APTA appreciates the opportunity to share our perspective and
    recommendations to the committee that will provide long-term stability
    and reform to the Medicare Physician Fee Schedule. Should you have any
    questions, please contact justinelliott
    @apta.org. Thank you for your time and consideration.

    Sincerely,

    Roger Herr, PT, MPA
    President

                                     ______

               American Psychological Association Services, Inc.

                              750 First Street, NE

                           Washington, DC 20002-4242

                                  202-336-5800

                                202-336-6123 TDD

                              https://www.apa.org/

    April 25, 2024

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Wyden and Ranking Member Crapo:

    On behalf of the American Psychological Association Services (APA
    Services), we are writing to share comments and recommendations for
    consideration as part of your committee's April 11th hearing,
    ``Bolstering Chronic Care through Medicare Physician Payment.'' APA
    Services is the companion organization of the American Psychological
    Association, which is the nation's largest scientific and professional
    nonprofit organization representing the discipline and profession of
    psychology, as well as over 157,000 members and affiliates who are
    clinicians, researchers, educators, consultants, and students in
    psychological science.

    We applaud your committee's attention to improving Medicare healthcare
    provider reimbursement policies, as they are not adequately supporting
    high-quality, cost-
    effective health care for the program's beneficiaries. We share the
    concerns of the broad provider community regarding the consistent
    failure of payment updates for Part B providers to keep pace with
    inflation. Steadily eroding reimbursement rates are increasingly making
    Medicare participation unsustainable for psychologists and other
    providers. We strongly support proposals to raise the budget neutrality
    cap on adjustments to the Medicare Physician Fee Schedule (PFS), and to
    connect annual conversion factor increases to the Medicare Economic
    Index or similar measures of inflation. However, our comments today
    will focus on aspects of the Medicare fee schedule and proposed payment
    policies that specifically impact psychological services.

    Because of their foundational importance, it is important for
    policymakers to understand that Medicare PFS payment formula
    methodologies for both work and practice expenses have consistently
    undervalued psychologists' services. This situation has been
    exacerbated by the statutory requirement that annual updates to the PFS
    be made in a budget neutral manner.

    Work Valuation

    As the committee has recognized, the Medicare fee schedule tends to
    undervalue cognitively intensive services, and psychologists' services
    are cognitively intensive. Thankfully, the Centers for Medicare and
    Medicaid Services (CMS) has recognized the need to set more appropriate
    work values for psychologists' services, and in the 2024 fee schedule
    CMS initiated a 19.1% increase in work relative value units (RVUs) for
    psychotherapy services over the next 4 years. However, CMS has not
    adopted a similar increase for psychological and neuropsychological
    testing and assessment services, which are as cognitively demanding as
    psychotherapy services.

    Psychological assessment is the process of systematically collecting
    reliable and valid information about behavior from multiple sources to
    inform decisions about a patient's mental or behavioral functioning,
    typically for the purpose of diagnoses, treatment planning, or
    treatment evaluation. Domains assessed in a psychological assessment
    typically consist of mood/emotional conditions and symptoms, mental
    status, adaptive functioning, and behavioral and interpersonal
    adjustment, with evaluation of acuteness vs. chronicity, severity,
    degree of functional impairment, comorbidity, and prognosis where
    information is available. Psychological testing has been shown to
    provide both clinical and financial benefit in treating psychiatric
    disorders.\1\
    ---------------------------------------------------------------------------
        \1\ Durosini, I., & Aschieri, F. (2021). Therapeutic assessment
    efficacy: A meta-analysis. Psychological Assessment, 33(10), 962-972.
    https://doi.org/10.1037/pas0001038.

    Neuropsychological assessments provide measurements of behavioral
    manifestations of central nervous system (CNS) disorders using
    techniques that provide objectivity, validity, and reliability.
    Information acquired from neuropsychological assessments can directly
    inform medical decisions by providing data relevant to diagnosis,
    progression or course of conditions, prognosis, and treatment of
    disorders. In addition, neuropsychological assessments can aid in
    making accurate predictions about functional abilities across a variety
    of disorders.\2\, \3\ Neuropsychological tests are
    administered in the context of a comprehensive evaluation that
    synthesizes data from clinical interviews, record review, medical
    history, and behavioral observations. Where appropriate, these
    evaluations consider neuroimaging, other neuro-diagnostic studies, and
    other lab/diagnostic studies to inform neuropsychologically oriented
    interventions.\4\
    ---------------------------------------------------------------------------
        \2\ Chaytor, N. & Schmitter-Edgecombe, M. (2003). The ecological
    validity of neuropsychological tests: A review of the literature on
    everyday cognitive skills. Neuropsychology Review, 13, 181-197.
        \3\ Gure, T. R., Kabeto, M. U., Plassman, B. L., Piette, J. D., &
    Langa, K. M. (2010). Differences in functional impairment across
    subtypes of dementia. Journals of Gerontology: Biological Sciences and
    Medical Sciences, 65, 434-441.
        \4\ Board of Directors. (2007). American Academy of Clinical
    Neuropsychology (AACN) practice guidelines for neuropsychological
    assessment and consultation. The Clinical Neuropsychologist, 21, 209-
    231.

    Neuropsychological evaluation remains the most sensitive cognitive
    testing method for discriminating pathophysiological dementia from age-
    related cognitive decline, cognitive difficulties that are depression-
    related, and other related disorders, and are the gold standard in both
    reliably establishing a diagnosis and developing treatment plans by
    clinically justifying relevant therapies and interventions.\5\ This is
    important in dementia care, as medications used to treat Alzheimer's
    disease have virtually no benefit for patients with other forms of
    dementia. An estimated 17% of Medicare beneficiaries with vascular
    dementia and 8% with Parkinson's disease are initially misdiagnosed
    with Alzheimer's disease, resulting in unnecessary treatment costs
    until they are accurately diagnosed.\6\
    ---------------------------------------------------------------------------
        \5\ Weintraub S. Neuropsychological Assessment in Dementia
    Diagnosis. Continuum (Minneapolis, Minn.). 2022 Jun 1;28(3):781-799.
    doi: 10.1212/CON.0000000000001135. PMID: 35678402; PMCID: PMC9492323.
        \6\ Hunter CA, Kirson NY, Desai U, Cummings AK, Faries DE, Birnbaum
    HG. Medical costs of Alzheimer's disease misdiagnosis among US Medicare
    beneficiaries. Alzheimer's Dement. 2015 Aug;11(8):887-95. doi: 10.1016/
    j.jalz.2015.06.1889. Epub 2015 Jul 21. PMID: 26206626.

    CMS stated in the CY 2024 proposed rule, ``because the physician/
    practitioner work RVU is developed based on the time and intensity of
    the service, the issues regarding the valuation of these types of
    services are particularly pronounced for services that are billed in
    time units (like psychotherapy codes) that directly reflect the
    practitioner time inputs used in developing work RVUs, compared to
    other services that are not billed in time units in which work RVUs are
    based on estimates of typical time, usually based on survey data.''\7\
    ---------------------------------------------------------------------------
        \7\ Medicare and Medicaid Programs; CY 2024 Payment Policies Under
    the Physician Fee Schedule and Other Changes to Part B Payment and
    Coverage Policies. 88 Fed. Reg. 52262. (proposed August 7, 2023).

    As with psychotherapy services and their corresponding codes, all
    psychological and neuropsychological testing services are time-based
    services and meet CMS' rationale for the proposed increase in value. We
    believe that parallel increases in the work RVUs for all psychological
    and neuropsychological testing and assessment services are warranted to
    maintain relativity across the current procedural terminology (CPT)
    codes, and to avoid disincentivizing provision of these services.

    Practice Expense (PE) Valuation

    As CMS has noted, behavioral health services have very little to no
    direct expenses, and additionally, clinical psychology has the lowest
    Indirect Practice Cost Indices (IPCI) of all specialties. CMS has
    recognized that the methodology used to allocate practice expense RVUs
    produces an anomaly for services with very low direct practice expense
    inputs, and that psychologists' services are also disadvantaged under
    the formula for allocating indirect practice expenses. CMS began to
    address this issue in 2018 by modestly increasing the indirect PE RVUs
    for services falling below the indirect PE valuation for a physician
    office visit.

    APA appreciates CMS's alternative methodology and efforts to establish
    a reasonable minimum value in the allocation of indirect PE RVUs. CMS
    has made important progress to help ensure beneficiary access to these
    vital services through review and update of payment policies and
    continues to request recommendations to systematically address how
    behavioral health services are valued under the Medicare PFS. However,
    further adjustments to reimbursement for behavioral health services are
    needed to shift market dynamics and increase participation, and
    ultimately to achieve the CMS Behavioral Health Strategy. APA is urging
    CMS to close the gap in practice expense valuations between
    psychologists and other healthcare provider specialties.

    It is important for Congress to understand these valuation issues since
    alternative payment models (APMs) and bundled payments are frequently
    based upon PFS reimbursement rates.

     Supporting Behavioral Health Integration in Alternative Payment Models

    In order to effectively respond to the ongoing mental health crisis, it
    is imperative that new payment models and incentives adequately support
    integrated primary and behavioral healthcare. Integrated primary care,
    in which primary care and behavioral health clinicians work together as
    a team to care for patients and their families, can improve patient
    outcomes and satisfaction with care and reduce overall treatment costs.
    It can also increase access to mental health treatment, since as many
    as 80% of patients with a mental illness visited a primary care
    provider within the last year, and up to 75% of primary care visits
    include mental or behavioral health components, including behavioral
    factors related to chronic disease management and patient health and
    well-being.\8\, \9\ In addition to improving the
    identification and treatment of individuals with behavioral disorders
    and care of patients' chronic conditions, research shows that
    integrated care can reduce treatment costs. One study found that
    integrating a psychologist into a primary care practice resulted in
    cost savings of $860 per member per year.\10\ We applaud the
    Committee's approval of the Better Mental Health Care, Lower-Cost
    Drugs, and Extenders Act, and its provisions in Sec. 104 to support
    adoption of evidence-based models of integrated care. We urge the
    Committee to continue to support integrated care in its development of
    new payment models and policies.
    ---------------------------------------------------------------------------
        \8\ Jetty, A., Petterson, S., Westfall, J. M., & Jabbarpour, Y.
    (2021). Assessing primary care contributions to behavioral health: a
    cross-sectional study using medical expenditure panel survey. Journal
    of primary care & community health, 12, 21501327211023871.
        \9\ Robinson, P. J., & Reiter, J. T. (2007). Behavioral
    consultation and primary care: A guide to integrating services. New
    York: Springer.
        \10\ Ross, K. M., Klein, B., Ferro, K., McQueeney, D. A., Gernon,
    R., & Miller, B. F. (2019). The cost effectiveness of embedding a
    behavioral health clinician into an existing primary care practice to
    facilitate the integration of care: A prospective, case--control
    program evaluation. Journal of Clinical Psychology in Medical Settings,
    26, 59-67.

    Without a clear and sustained effort to track, report, and make
    progress on behavioral health, new payment models and value-based
    payment initiatives risk hindering, not improving, access to behavioral
    health services. One recent study found that beneficiaries who were
    assigned to an Accountable Care Organization (ACO) had worse mental
    health outcomes than those who remained outside ACOs. The authors
    concluded, ``Among patients not enrolled in ACOs at baseline those who
    newly enrolled in ACOs in the following year were 24% less likely to
    have their depression or anxiety treated during the year than patients
    who remained unenrolled in ACOs, and they saw no relative improvement
    at 12 months in their depression and anxiety symptoms.''\11\ A recent
    report issued by the Bipartisan Policy Center on integrated primary
    care concluded:
    ---------------------------------------------------------------------------
        \11\ Hockenberry, J. M., Wen, H., Druss, B. G., Loux, T., &
    Johnston, K. J. (2023). No Improvement in Mental Health Treatment or
    Patient-Reported Outcomes at Medicare ACOs for Depression and Anxiety
    Disorders: Study examines mental health treatment and patient outcomes
    at Medicare ACOs. Health Affairs, 42(11), 1478-1487.

            Payment models, such as CPC+ were intended to incorporate care
            coordination and behavioral health integration as cost
            effective means of improving health outcomes. However, these
            models remain based in Medicare's fee for service structure and
            lack accountability for behavioral health outcomes and
            integration. The CMMI Primary Care First model builds on CPC+
            and moves practices closer to taking on full risk, while
            focusing on high need, seriously ill patients. Yet, like CPC+
            and Patient Centered Medical Homes, it focuses on physical
            health rather than behavioral health outcomes. Without adequate
            quality metrics, there is limited accountability and assessment
            of the value of integration.\12\ (p. 51)
    ---------------------------------------------------------------------------
        \12\ Hartnett, T., Loud, G., Harris, J., Curtis, M., Hoagland, G.
    W., Serafini, M., Glassberg, H., Chung, H. (2023). Strengthening the
    Integrated Care Workforce. Bipartisan Policy Center. https://
    bipartisanpolicy.org/report/strengthening-the-integrated-care-
    workforce/.

    Access to psychological services is critical to the overall success of
    several CMS Innovation Center model: Innovation in Behavioral Health
    (IBH) Model; Making Care Primary (MCP) Model; Integrated Care for Kids
    (InCK) Model; Primary Care First Model Options; Maternal Opioid Misuse
    (MOM) Model; and Transforming Maternal Health (TMaH) Model. Integrating
    behavioral health screening and management services into these models
    allows more frequent psychological testing to assist with differential
    diagnosis and treatment recommendations. This is especially important
    in the classification of severe and persistent mental illness.
    Identification of these conditions is uniquely important due to high
    co-morbidity rates, significant negative impacts on mental and physical
    well-being, and financial burden (e.g., lost income, healthcare
    ---------------------------------------------------------------------------
    spending) associated with the conditions.

    To highlight a specific example, neuropsychological testing services
    will be vitally important to the success of the CMS Innovation Center's
    Guiding an Improved Dementia Experience (GUIDE) Model, designed to
    support people living with dementia and their unpaid caregivers. In the
    GUIDE model, the first recommendation in identifying beneficiaries is
    to utilize an interdisciplinary approach to the ``Initial Comprehensive
    Assessment Visit,'' which includes a cognitive assessment. We are also
    urging CMS to revise the ACO Primary Care Flex model to better
    incentivize and scale integrated primary and behavioral health
    treatment, and to establish behavioral health spending reporting
    requirements to help assess the model's impact on access to behavioral
    health services.

    We appreciate the opportunity to provide comments on this critical
    issue, and we look forward to working with the committee to establish
    more effective Medicare payment policies for the benefit of the
    program's millions of beneficiaries.

    Sincerely,

    Katherine B. McGuire, MSc
    Chief Advocacy Officer

                                     ______

                 American Society of Health-System Pharmacists
    April 11, 2024

    The Honorable Ron Wyden
    Chairman
    United States Senate
    Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510-6200

    The Honorable Mike Crapo
    Ranking Member
    United States Senate
    Committee on Finance
    219 Dirksen Senate Office Building
    Washington, DC 20510-6200

    Re: Senate Finance Committee Hearing on Bolstering Chronic Care Through
    Medicare Physician Payment.

    Dear Chairman Wyden and Ranking Member Crapo:

    We applaud the Senate Finance Committee for examining how to bolster
    chronic care through the Medicare physician payment. The American
    Society of Health-
    System Pharmacists (ASHP) is the largest association of pharmacy
    professionals in the United States, representing over 60,000
    pharmacists, student pharmacists, and pharmacy technicians in all
    patient care settings, including hospitals, ambulatory clinics, and
    health-system community pharmacies. Our members play a critical role,
    as part of a comprehensive care team, assisting physicians in their
    treatment of Medicare beneficiaries suffering from chronic medical
    conditions. We recommend Congress require the Centers for Medicare &
    Medicaid Services (CMS) to clearly enable physicians to bill for the
    entirety of services pharmacists provide incident to the physician.

    In inpatient and outpatient settings, pharmacists have traditionally
    provided team-based clinical services, working collaboratively with
    physicians, nurses, and other healthcare professionals to enable safe
    and effective medication. This collaborative approach is necessary
    because drug therapy is involved in 76% of physician office visits and
    is the sole treatment for many acute and chronic conditions.\1\
    Unfortunately, a 2020 CMS policy change limited physicians to billing
    only the lowest-level evaluation and management (E/M) code for
    pharmacist-provided incident-to services, regardless of the duration
    and complexity of the E/M services provided.\2\ This policy shift
    undermines care models that enable clinical pharmacists to support
    physicians and the care teams on which they participate in providing
    comprehensive care to seniors, thereby threatening patient access to
    critical services, such as comprehensive medication management. This is
    particularly worrisome for patients suffering from chronic conditions
    requiring extensive medication management, such as diabetes,
    hypertension, or Parkinson's disease.
    ---------------------------------------------------------------------------
        \1\ Budnitz DS, Pollock DA, Weidenbach KN, et al. National
    surveillance of emergency department visits for outpatient adverse drug
    events. JAMA. 2006;296:1858-1866; See also Watanabe JH, McInnis T,
    Hirsch JD. Cost of Prescription Drug--Related Morbidity and Mortality.
    Annals of Pharmacotherapy 2018, Vol. 52(9) 829-837.
        \2\ Centers for Medicare & Medicaid Services, Physician Fee
    Schedule CY 2021 Final Rule, 85 Fed. Reg. 84592-3 (Dec. 28, 2020),
    available at https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/
    2020-26815.pdf (Limiting physicians supervising pharmacist-provided
    incident-to services to billing code 99211 for those services, despite
    the fact that many of the services provided by pharmacists meet the
    complexity and duration criteria set forth for code 99212-14).

    Problems associated with medication use, such as non-adherence,
    polypharmacy errors, and adverse events, result in 500,000 emergency
    room visits and 100,000 hospitalizations yearly, costing the health
    system over an estimated five billion dollars.\3\ Pharmacists educate
    patients and caregivers about their medications, monitor drug therapy,
    and coordinate communication between patients, insurers, and
    interdisciplinary specialty providers. Pharmacists' management of
    medication therapy such as this has been shown to improve transitions
    of care and reduce hospital readmissions.\4\, \5\
    ---------------------------------------------------------------------------
        \3\ Budnitz DS, Pollock DA, Weidenbach KN, et al. National
    surveillance of emergency department visits for outpatient adverse drug
    events. JAMA. 2006;296:1858-1866; See also Watanabe JH, McInnis T,
    Hirsch JD. Cost of Prescription Drug--Related Morbidity and Mortality.
    Annals of Pharmacotherapy 2018, Vol. 52(9) 829-837.
        \4\ Ni, W., Colayco, D., Hashimoto, J., Komoto, K., Gowda, C.,
    Wearda, B., McCombs, J. Budget Impact Analysis of a Pharmacist Provided
    Transition of Care Program. Journal of Managed Care & Specialty
    Pharmacy. Feb 2018.
        \5\ Budlong, H, Brummel, A, Rhodes, A, Nici, H. Impact of
    Comprehensive Medication Management on Hospital Readmission Rates.
    Population Health Management 2018. 21(5): 395-400.

    In order for it to be financially feasible for care teams to use their
    pharmacists to provide medication and chronic disease services, ASHP
    recommends that physicians be allowed to bill for E/M codes for
    established patients (99211-99215), including when provided by a
    ---------------------------------------------------------------------------
    pharmacist, if the incident-to requirements are met.

    ASHP thanks you for your work on this issue. We look forward to
    continuing to work with you on this issue. If you have questions or if
    ASHP can assist in any way, please contact Frank Kolb at
    fkolb@ashp.org.

    Sincerely,

    Tom Kraus
    Vice President, Government Relations

                                     ______

                    American Society of Pediatric Nephrology

                         6728 Old McLean Village Drive

                                McLean, VA 22101

                                ph. 703-556-9222

                                fax 703-556-8729

    April 25, 2024

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    Washington, DC 20510                Washington, DC 20510

    Dear Chair Wyden and Ranking Member Crapo:

    On behalf of the American Society of Pediatric Nephrology (ASPN) we
    appreciate the opportunity to provide this statement for the record on
    the Senate Finance Committee's April 11th hearing on ``Bolstering
    Chronic Care through Medicare Physician Payment.'' Pediatric
    nephrologists serve as the medical home for children with kidney
    disease who need specialized care for this chronic condition. We would
    like to provide input on several of the issues raised during the
    hearing, including improvements to the Medicare Physician Fee Schedule
    (MPFS), increasing provider participation in value-based care models,
    and prior authorization. We also want to raise issues related to
    Medicaid, as one-third of pediatric patients with end-stage kidney
    disease (ESKD) are covered by this program.

    Founded in 1969, ASPN is a professional society composed of pediatric
    nephrologists whose goal is to promote optimal care for children with
    kidney disease and to disseminate advances in the clinical practice and
    basic science of pediatric nephrology. ASPN currently has over 700
    members, making it the voice for pediatric kidney disease. Our members
    strive to ensure that affected infants, children, adolescents, and
    young adults receive appropriate and high-quality care. Approximately
    one third of pediatric patients with ESKD are covered by Medicare,
    making reforms to the Medicare Access and CHIP Reauthorization Act
    (MACRA) critical to pediatric nephrologists.
    Recommended Changes to the Conversion Factor
    Children with end-stage renal disease (ESRD) are automatically eligible
    for Medicare, and one-third of our patient population has Medicare
    coverage. Most of the care billed to Medicare falls under the ESRD
    Prospective Payment System (PPS). However, care delivered to children
    who receive kidney transplants as part of the Medicare program receive
    3 years of post-transplant care under the MPFS, making the stability of
    the payment system a concern for our members. MACRA provided 0.5%
    updates to the MPFS conversion factor from 2015-2019. Since then, the
    lack of statutory updates to the conversion factor combined with the
    system's budget neutrality requirements has created significant
    downward pressure on payment.

    Children with kidney disease, including those post-transplant, are
    medically complex and require high levels of care coordination to
    support their continued growth, development, and health that is not
    recognized under the MPFS. To support high-quality care for medically
    complex patients, the Finance Committee must first stabilize the MPFS
    by providing inflationary updates to the conversion factor and update
    the budget neutrality factor for the first time since 1992. Once these
    changes that benefit all physicians are in place, the Finance Committee
    and the Centers for Medicare & Medicaid Services (CMS) can implement
    policies to provide incentives to provide high-quality coordinated
    care.
    Increasing Provider Participation in Value-based Payment Models
    As discussed, pediatric nephrologists and pediatric ESKD centers serve
    as the medical home for many children with kidney disease. Since only
    one-third of children with ESKD have Medicare coverage, the potential
    for reimbursement for care coordination is low and contributes to the
    scarcity of pediatric ESRD resources by disincentivizing programs from
    offering such pediatric care. This reimbursement issue must be
    addressed both to prevent the loss of existing ESKD resources due to
    ongoing financial pressures and to allow for consideration of their
    expansion in a cost-conscious environment. The medical home is
    particularly important for pediatric ESKD patients, as they also
    receive hypertension care, which is an important screening for this
    vulnerable population.

    Most pediatric nephrologists practice at children's hospitals. ESKD
    patients are these institutions only exposure to the Medicare program,
    which makes participation in value-based programs and models a
    challenge. To truly incentivize value-based care, quality measures and
    requirements should be harmonized across payers to reduce confusion and
    burden. It is also critical that institutions have the staff to be able
    to participate in data tracking and in reporting measures, which can be
    difficult for small practices.

    The quality programs should be integrated into the existing electronic
    medical record (EMR) to collect data. There are multiple pain points
    with silos of care and integrating quality structures into EMRs that
    need to be addressed. It would also help to increase the number of
    pediatric measures if they spanned payers beyond Medicare. Measures
    could look at the entire pediatric ESKD population and better reflect
    the quality of care.
    Recommendations Related to Medicaid Coverage
    While the recent hearing did not address the Medicaid program, ASPN
    urges the Finance Committee to explore improvements to the Medicaid
    program to improve care coordination and chronic care delivery. As
    stated earlier, one-third of pediatric ESKD patients are on Medicaid,
    and so any policy changes must ensure that these patients are able to
    access the same quality of care as patients on Medicare or private
    insurance. Medicaid reimburses at approximately 80% of the Medicare
    rate and rates vary across states and services.

    Many medically complex children, including those with chronic kidney
    disease and ESKD, are covered by Medicaid. While covered by Medicaid,
    medical care supports their growth and development and manages their
    disease. The program needs to support this complex, coordinated care.
    Therefore, the solutions that the Finance Committees present should not
    be limited to Medicare, or we risk creating health disparities based on
    the patient's insurance coverage.
    Recommendations to Improve Prior Authorization
    Children and adolescents undergoing dialysis or transplants are unique,
    and very different from adults. The causes for ESKD in children
    predominantly include congenital abnormalities, glomerular diseases and
    rare genetic disorders, not hypertension and diabetes as seen in adults
    undergoing the same treatment. Children with ESKD also suffer from
    impaired growth and development, including impaired neurocognitive
    development. They also have different drug metabolism, which changes
    over time as they grow to be adults.

    These differences between children and adults with kidney disease, and
    specifically ESKD, are particularly important when considering prior
    authorization policies, which may delay access to medically appropriate
    care and therapies for pediatric patients. These children regularly
    require genetic testing, imaging studies, durable medical equipment,
    including scales and blood pressure cuffs, 24-hour ambulatory blood
    pressure monitoring, mental health services, special formulas and
    feeding tube supplies. All may require prior authorization.

    One member reported that prior authorization requirements resulted in a
    significant delay for a 4-year-old patient suffering from severe
    hypertension who required CT vascular imaging. When the provider
    completed the peer-to-peer to complete the prior authorization, the
    approval delay was because the imaging was to examine the patient's
    aorta and vasculature rather than the lung parenchyma, which would be
    examined in adults. Because of the delay, our member considered
    admitting the child as an inpatient, which would have been at a
    significantly higher cost to the health care system, to expedite the
    testing, and ultimately, the necessary treatment. The delay in
    diagnosis and surgical treatment put the child at risk for stroke and
    seizure from uncontrolled hypertension. ASPN urges the Finance
    Committee to consider the unique needs of pediatric ESKD patients when
    considering prior authorization reforms. Additionally, we recommend
    that reviewers of prior authorization requests for pediatric patients
    have pediatric expertise. These vulnerable patients should not
    experience unnecessary, and potentially dangerous, delays in care
    because these requirements do not reflect the needs of these children
    who are commonly covered by Medicare and Medicaid.

    Thank you again for the opportunity to submit this statement for the
    record to the Senate Finance Committee. We look forward to working with
    the Committee and with the Bipartisan Working Group on Physician
    Payment reform led by Senators Stabenow and Thune as you develop
    legislative solutions to improve physician payment and care for
    patients with chronic conditions. Please reach out to Erika Miller,
    ASPN's Washington Representative, at emiller@dc-crd.com with any
    questions or if we can provide additional information.

    Sincerely,

    Jodi Smith, M.D., MPH
    President

                                     ______

                     American Society of Retina Specialists

                       20 North Wacker Drive, Suite 2030

                               Chicago, IL 60606

                               phone 312-578-8760

                                fax 312-578-8763

                             https://www.asrs.org/

    The American Society of Retina Specialists (ASRS) is the largest retina
    organization in the world, representing over 3,500 board-certified
    ophthalmologists who have completed fellowship training in the medical
    and surgical treatment of retinal diseases. The mission of the ASRS is
    to provide a collegial open forum for education, to advance the
    understanding and treatment of vitreoretinal diseases, and to enhance
    the ability of its members to provide the highest quality of patient
    care.

    We appreciate this opportunity to provide input to the committee as it
    begins its work on reforming and modernizing Medicare physician
    payment. As physicians who care for a high volume of Medicare
    beneficiaries with chronic and potentially-blinding eye disease, we are
    pleased that the committee has begun its work by exploring how best to
    meet the needs of these patients.

    Among our key recommendations for the committee to ensure beneficiaries
    have continued access to high-quality chronic care are the following:

          Ensure beneficiaries suffering from chronic disease will have
    continued access to the specialty care they need and physicians receive
    adequate reimbursement for the care they provide by:

              establishing regular, inflation-based updates to
            the Physician Fee Schedule conversion factor, and

              reforming budget neutrality requirements in the
            fee schedule to allow for necessary value modifications to
            existing services, and the adoption of new technologies and
            treatment protocols without causing unwarranted reductions to
            other unrelated services.

          Eliminate or modify the Merit-based Incentive Payment System
    (MIPS) to focus on clinically-relevant measures that address identified
    gaps in care, particularly to target improving measurement of chronic
    care services.

          Require the Center for Medicare and Medicaid Innovation (CMMI)
    to engage with specialists caring for chronic disease patients and work
    toward implementing alternative payment models (APMs) that address
    these needs.

          Provide additional funding to physicians and other stakeholders
    to develop APMs.

    Fee Schedule Reform and Modernization

    Retina specialists and other physicians are committed to providing the
    highest quality of care to Medicare beneficiaries with chronic disease.
    In return, Medicare must provide an adequate and predicable baseline
    payment level that ensures physicians will have the resources to care
    for these patients. Two elements of the physician fee schedule--the
    lack of inflation-based payment updates and outdated budget neutrality
    limits--are limiting those resources. Thus, practices are having a
    difficult time staying financially solvent while making necessary long-
    term investments and meeting growing patient demand. ASRS recommends
    Congress focus its work on modifying these elements to prevent the need
    for yearly payment ``fixes'' and ensure long-term stability.
                Inflation-Based Updates
    For more than 2 decades, Medicare physician payments have not kept pace
    with inflation. According to the American Medical Association (AMA),
    physicians' purchasing power has eroded by approximately 30% since
    2001, while during that time all other Medicare payment systems have
    realized payment updates that have kept pace with or even surpass the
    Medical Economic Index (MEI), the chief measure of inflation in
    healthcare. In fact, the Medicare Physician Fee Schedule is the only
    payment system without a built-in inflationary adjustment. It is far
    past time for Congress to act to bring payments in line with current
    prices and provide assurances that future payment will be adequate.
    ASRS recommends implementing regular, inflation-based updates to the
    fee schedule to meet that need.
                Budget Neutrality Limits
    In addition, Congress must increase the current $20 million budget
    neutrality threshold on the Medicare Physician Fee Schedule. It has
    created unintentional inequities in payment, disrupted the relativity
    of the fee schedule, and unnecessarily pitted procedural and non-
    procedural specialists against each other in a fight for value.

    As physician services are regularly reviewed by the RUC and CMS, even
    minor adjustments in a particular service's value can cause ripple
    effects across the fee schedule, increasing or decreasing other
    specialties' reimbursement without any coordinating change in the
    services they are providing. Relative value units (RVUs) are
    painstakingly assigned to account for the unique work and practice
    expense for each physician service relative to all others. But the
    annual neutrality adjustments caused by the low threshold are
    disrupting that balance.

    Most concerning is when CMS acts outside of the current relative value
    system and adds new services to the fee schedule, such as the new E/M
    add-on code G2211, which necessitate budget neutrality adjustments.
    Specifically, G2211 was not valued through the RUC process to maintain
    relativity in the fee schedule and more accurately gauge the potential
    utilization of the code. Almost half of the initial 2024 cut to the fee
    schedule was due to the implementation of this code. It required
    Congress to act well past the beginning of the year to modify the
    conversion factor which, unlike prior fixes, was not backdated. As a
    new and un-tested service, the add-on code should have been phased-in
    over several years without impacting budget neutrality until its full
    impact was known. ASRS recommends that Congress increase the dollar
    threshold that triggers budget neutrality adjustments and empower CMS
    with authority to override budget neutrality in certain circumstances.

    Problems with the fee schedule are borne out in the reimbursement for
    retina procedures. A 2022 study looked at the trends in reimbursement
    for 15 procedures commonly performed by retina specialists over 2011 to
    2020 and found that the average reimbursement change over that time was
    a decrease of 8.2%. Adjusted for inflation, the decrease grew to
    20.7%.\1\ This decline in reimbursement is directly attributable to
    both the lack of inflationary adjustment and budget neutrality factors
    that Congress must remedy.
    ---------------------------------------------------------------------------
        \1\ Trends in Medicare Reimbursement for Common Vitreoretinal
    Procedures: 2011-2020. Shriji Patel, MD MBA, et al. Ophthalmology. 2022
    Jul;129(7):829-831.
    ---------------------------------------------------------------------------
                Key Cost Pressures on Retina Specialists' Practices
    Retina practices are no different from other physician specialties or
    other small businesses operating in this period of high inflation.
    Rising equipment, supply, utility and labor prices are putting retina
    practices at a disadvantage. In 2023, 84% of U.S.-based retina
    specialists reported difficulty finding clinical staff for their
    practices, with 63.5% saying this led to mild or severe
    understaffing.\2\ Many retina specialists reported losing qualified
    staff to hospitals or other industries that can afford to pay more
    competitive wages.
    ---------------------------------------------------------------------------
        \2\ 2023 ASRS Preferences and Trends Survey, available: https://
    www.asrs.org/content/documents/_asrs-2023-pat-survey-for-website.pdf.

    Understaffing is troubling considering how important technicians and
    administrative staff are in the care of patients with chronic retinal
    disease. The high prevalence of diseases such as age-related macular
    degeneration (AMD), diabetic retinopathy, and diabetic macular edema
    (DME) in the Medicare population coupled with the frequency of
    necessary visits for these patients--approximately every 4-6 weeks--
    means that retina practices must run efficiently. Retina specialists
    rely on their clinical staff to help patients navigate through the
    process of imaging, exams and preparation for intravitreal injections
    so the physician can be solely focused on examining the patient,
    interpreting the imaging, performing the injections and managing the
    patient's individual care plan. For Medicare Advantage patients and
    those with commercial insurance, additional administrative staff is
    needed to deal with the onerous step therapy and prior authorization
    policies implemented by these payers. Without adequate reimbursement to
    pay clinical staff, retina specialists may have to reduce their patient
    load, thereby threatening the vision of patients with potentially-
    ---------------------------------------------------------------------------
    blinding conditions.

    While the lack of adequate reimbursement is immediately felt in the
    day-to-day operations of the practice, payment that does not keep pace
    with inflation also has a negative long-term impact on patients.
    Without assurance that payments will keep up, retina specialists are
    hesitant to expand their practices or invest in new equipment that
    would allow them to serve patients better. COVID-era delays and
    increased construction costs have prevented practices from expanding or
    opening new offices. Declining reimbursement makes it less likely the
    cost of new clinical or imaging equipment will be recouped.

    Like the COVID-19 pandemic, outside influences continue to impact
    physician practices. Retina specialists have been particularly hard hit
    by the recent cyberattack on Change Healthcare. This incident has
    ceased or significantly disrupted reimbursements to retina practices
    and negatively impacted cashflow--thereby over-
    extending their credit and forcing many to take out loans to purchase
    the Part B drugs that patients with chronic retinal disease rely on.
    This single incident demonstrates how fragile the healthcare
    infrastructure is and underscores that without sufficient physician
    payment, beneficiaries will lose access to care.
                Patient Demand and Administrative Costs Projected to Grow
    Evidence suggests that these long-term investments to expand access to
    care are imperative. The U.S. population will continue to age into
    chronic retinal disease necessitating even more care from retina
    specialists. A 2022 study found that currently about 20 million
    Americans over 40 have AMD with about 1.49 million suffering from late-
    stage AMD \3\--figures significantly higher than previous estimates.
    According to the American Diabetes Association, the number of Americans
    with diabetes is also projected to increase 165%, from 11 million in
    2000 to 29 million in 2050--which will likewise increase the number of
    people suffering from diabetic eye disease who will require care from
    retina specialists.
    ---------------------------------------------------------------------------
        \3\ ``Prevalence of Age-Related Macular Degeneration in the U.S. in
    2019.'' David B. Rein, Ph.D., MPA; John S. Wittenborn, BS; Zeb Burke-
    Conte, BS; et al; JAMA Ophthalmol. Published online November 3, 2022.
    doi:10.1001/jamaophthalmol.2022.440.

    However, it is unclear whether those patients will be able to receive
    the care they need in a timely manner. The projected shortage of
    primary care physicians is well-documented, however, specialties--
    including ophthalmology--also face shortages. A 2023 study found that
    from 2020 to 2035, the supply of U.S. ophthalmologists will decrease
    relative to demand and lead to a 30% shortfall.\4\ This shortage is
    already being felt with some retina fellowship programs not being able
    to fill all available slots. A recent increase in the number of
    resident slots across medicine was a much-needed first step, but more
    investment is required to ensure physician supply meets the demand over
    the coming decades.
    ---------------------------------------------------------------------------
        \4\ ``Ophthalmology Workforce Projections in the United States,
    2020 to 2035.'' Sean T. Berkowitz, MD, MBA; Avni P. Finn, MD, MBA; Ravi
    Parikh, MD, MPH; et al.; Ophthalmology. V.131, Issue 2, p. 133-139,
    February 2024.

    As mentioned above, the administration costs associated with MA and
    other private payers have skyrocketed in the last decade with the rise
    in utilization management. Care for nearly every non-original Medicare
    patient with chronic retinal disease is subject to some form of step
    therapy and/or prior authorization. Retina specialists employ dedicated
    employees to investigate benefits, determine the specifics of the
    insurer's step therapy policy, and submit authorizations. While the
    delay in care and potential poor outcomes for patients are the most
    concerning aspect of utilization management, the extra labor costs are
    endangering practices' ability to stay afloat. A 2022 study conducted
    by ASRS members found that 56.8% of patients experience delays in
    treatment and practices spend an average of 47 minutes per
    authorization request, all while 96.3% of prior authorization requests
    are ultimately approved.\5\ These costs are not associated with
    original Medicare beneficiaries, but since most private contracts are
    based on Medicare rates, the additional work required to take care of
    these patients is not compensated.
    ---------------------------------------------------------------------------
        \5\ Dang, S. ``Anti-VEGF Injection Prior Authorization Impacts on
    Retina Practices.'' 2022 ASRS Annual Meeting, July 16, 2022.

    Congress needs to take immediate action to tie physician payment to
    inflation and modify budget neutrality to address the current and
    future pressures that limit access to care.

    Repeal MIPS

    At its inception, the MIPS program seemed to include laudable goals,
    however, it has become clear that Congress should sunset this program.
    MIPS still functions as four separate and unrelated individual programs
    that are tedious to implement and do not relate to specialty care.
    Perhaps the most telling indicator of the program's failure is the lack
    of evidence to indicate it is improving care. A recent search of PubMed
    turned up no results of peer-reviewed literature that found a
    correlation between the MIPS program and improved quality.
                CMS' Flawed Implementation of MIPS
    At its core, CMS has failed to conceive of and implement MIPS as a
    unique program that would serve as a bridge between previous disparate
    reporting programs and new APMs. Each of the categories retains
    measures and structure from its predecessor and has individual, complex
    scoring methodologies. Rather than integrating the elements of the
    programs it replaced, MIPS simply aligns the performance periods and
    reporting deadlines and combines the scores to translate to one final
    payment adjustment. CMS' ever-shifting requirements complicate the
    program and insufficient specialty-specific measures mean retina
    specialists are typically reporting on primary care measures not
    meaningful to their practices.

    Considering the lack of documented improved outcomes, the significant
    cost practices incur to participate in MIPS becomes concerning.
    Infrastructure costs of EHR and hardware are added to the practice
    staff labor--and oftentimes that of outside consultants--to comply with
    MIPS. The recent bonus payments of 1-2% associated with MIPS are not
    significant enough to make the cost to participate worthwhile. For
    example, a large retina practice of 21 physicians recently analyzed
    their cost of participating in MIPS. The practice has two staff members
    each working about 10 hours per week to oversee the practice's
    participation in MIPS and found that documenting MIPS for each visit
    takes about 2 minutes. Added to the direct costs of consultants, the
    total cost of participating in MIPS is $13,000 per physician.
                Barriers to Specialty-Specific Measure Reporting
    Not only is it burdensome for physicians to participate in the program,
    but CMS largely outsources the creation of measures and infrastructure
    necessary to run the MIPS program. It relies on the work of non-
    government entities, such as medical societies, spending considerable
    resources to enable physicians' participation in the program. In our
    case, ASRS has acted to address the lack of retina-focused measures by
    developing three new MIPS quality measures that were implemented for
    the 2024 performance year. The multi-year process we undertook to
    develop these measures cost approximately $335,000, not counting our
    physicians' uncompensated time, and required multiple attempts to have
    them accepted by CMS. The physician experts developing these measures
    felt that the concepts they identified would address gaps in care that
    were within the power of the individual retina specialist to remedy.
    While we appreciated feedback from CMS throughout the process, the
    development was influenced by ensuring that the measures fit within the
    confines of the program, rather than solely on what was clinically-
    relevant. Chiefly, we were not able to even draft or test measure
    concepts around some of the chronic diseases retina specialists treat
    most frequently, such as AMD and diabetic retinopathy, because it was
    difficult to identify measurable endpoints for treatments that may last
    for many years.

    The ASRS investment in developing three quality measures pales in
    comparison to the investment required to establish a qualified clinical
    data registry (QCDR). The cost to start-up a fully-functional QCDR that
    includes MIPS reporting is estimated at upwards of $1 million with
    additional annual maintenance costs. Unfortunately, some societies that
    have made this investment have had significant problems. Some
    established registries, such as those run by the American College of
    Surgeons and the Society of Thoracic Surgeons, have left the QCDR
    program because of CMS' onerous programmatic requirements to
    participate in MIPS, as well as testing and validation criteria. Others
    have suffered from lack of participation or insufficient return on
    investment. Even when QCDRs are able to comply with CMS' regulations,
    the resulting system can be unworkable for practices to use, often
    forcing them to drop out. These examples show that on top of the cost
    to participate, MIPS is not only not contributing to improved quality
    of care, but it may be impeding efforts to collect and analyze clinical
    data.

    Given the lack of evidence that MIPS has improved outcomes, now is the
    time to repeal MIPS and rethink how to improve quality and value in the
    Medicare program.

    Increase Opportunities and Incentives for Specialty-Focused APMs

    CMS did not use any of the money Congress allocated in MACRA to fund
    grants to specialties to develop APMS. As Congress looks to reform the
    system, we recommend it make grants available to fund the
    infrastructure physician organizations need to develop and implement
    new models. In addition, CMS and CMMI must be required to review
    physician-submitted models and incorporate specialists' feedback in new
    models.

    Under the current system, no physician-developed model has been
    implemented by CMS or CMMI, even though MACRA created the Physician-
    Focused Payment Model Technical Advisory Committee (P-TAC) as a vehicle
    for physicians to submit their APM concepts. Given this situation many
    organizations are reluctant to invest time and money in developing new
    models. P-TAC's website lists dozens of clinician-
    submitted proposals it has reviewed and made recommendations on to
    CMS.\6\ However, we are not aware of any such proposal endorsed by P-
    TAC that has been tested or implemented by CMS to date. After seeing so
    many other specialty societies and physician groups fail to gain
    traction with their APM concepts, we are skeptical that CMS would take
    action on them without further Congressional intervention. Congress
    must take action to arm the P-TAC with more authority and require CMS
    to at least test and evaluate the feasibility of recommended models.
    ---------------------------------------------------------------------------
        \6\ Physician-Focused Payment Model Technical Advisory Committee,
    https://aspe.hhs.gov/collaborations-committees-advisory-groups/ptac/
    ptac-proposals-materials#1081. Accessed April 18, 2024.
    ---------------------------------------------------------------------------

    Conclusion

    As experts in chronic disease, retina specialists develop strong bonds
    with their patients over many years. They are focused on customizing
    each patient's care to help maintain their vision and allow them to
    continue living independently. The long-term erosion in physician
    payments, coupled with the rise of administrative burdens and
    irrelevant pay-for-reporting makes achieving that goal harder every
    year. We recommend Congress take this opportunity for full-scale reform
    and invest in the long-term stability of practices providing care to
    Medicare beneficiaries by implementing inflation-based updates,
    ameliorating the impact of budget neutrality adjustments, and truly
    working toward value-based care by removing MIPS and investing in
    efforts to develop specialty-specific models.

    We thank the committee for holding this hearing and appreciate the
    particular focus on chronic care. We would be happy to provide you with
    any assistance or additional information you may need. Please contact
    Allison Madson, vice president of health policy, at
    allison.madson@asrs.org for assistance.

                                     ______

                        American Urological Association

                            1000 Corporate Boulevard

                              Linthicum, MD 21090

                              Phone: 410-689-3700

                               Fax: 410-689-3800

                            https://www.auanet.org/

                           https://urologyhealth.org/

    April 23, 2024

    The Honorable Ron Wyden, Chair
    U.S. Senate
    Committee on Finance
    221 Dirksen Senate Office Building
    Washington, DC 20510

    The Honorable Michael Crapo, Ranking Member
    U.S. Senate
    Committee on Finance
    239 Dirksen Senate Office Building
    Washington, DC 20510

    RE: Statement for the Record, Hearing on ``Bolstering Chronic Care
    through Medicare Physician Payment''

    Dear Chair Wyden and Ranking Member Crapo:

    The American Urological Association (AUA) applauds the Senate Finance
    Committee for holding the recent hearing, Bolstering Chronic Care
    through Medicare Physician Payment. The Medicare program, its
    sustainability, and its payment policies are of great importance to our
    members and the Medicare beneficiaries they treat. The AUA commends the
    Committee for holding this hearing to examine policies to update and
    strengthen the Medicare program to improve beneficiary access to high-
    quality care.

    The AUA is a globally engaged organization with more than 22,000
    physicians, physician assistants, and advanced practice nursing members
    practicing in more than 100 countries. Our members represent the
    world's largest collection of expertise and insight into the treatment
    of urologic disease. Of the total AUA membership, more than 15,000 are
    based in the United States and provide invaluable support to the
    urologic community by fostering the highest standards of urologic care
    through education, research, and the formulation of health policy.

    Urologists play a crucial role in the care of patients with both
    chronic and acute urologic conditions, providing vital services that
    improve quality of life and often prevent serious complications.
    Despite the critical nature of urologists' work in enhancing patients'
    well-being, the existing Medicare reimbursement structure often fails
    to adequately compensate urologists for the advanced and specialized
    care they deliver. This discrepancy not only undermines the financial
    viability of urology practices but also jeopardizes patient access to
    high-quality care and innovative treatments.

    Physician payments have stagnated for the last 2 decades while
    hospitals and physician practices must continue to pay market rate for
    supplies, equipment, and staff wages.

    For the last several years, Congress has intervened to prevent or
    mitigate cuts to the Medicare Physician Fee Schedule (MPFS), and the
    AUA is grateful for these actions. However, our members and the
    patients they treat deserve better than the unstable and uncertain
    reimbursement and access environment the annual threat of cuts creates.

    The statutory constraints placed on the Centers for Medicare & Medicaid
    Services (CMS), including the lack of statutory updates and the budget
    neutrality requirement, limits the agency's ability to stabilize the
    MPFS and ensure appropriate access to the full range of specialty care
    without Congressional intervention. To address these constraints and
    protect Medicare beneficiary access to care, we recommend the following
    solutions.

    Implement Inflationary Updates

    According to an American Medical Association (AMA) analysis of Medicare
    Trustees data, Medicare physician payment has declined by approximately
    30% percent when adjusted for inflation from 2001-2024. The MPFS does
    not receive necessary increases or adjustments for inflation, in
    contrast to other Medicare fee schedules with the last statutory update
    of 0.5% implemented in 2019. The decline in reimbursement over the last
    2 decades undermines physicians' ability to deliver essential medical
    services, jeopardizing patient access to timely and high-quality care.
    Therefore, AUA recommends Congress provide a statutory update to the
    MPFS based on the Medicare Economic Index (MEI) to reflect the
    inflation in practice costs, including but not limited to clinical
    staff, rent, medical supplies and equipment, and insurance. It is
    important to note that greater financial stability will lead to
    improved physician retention ensuring patients have access to timely
    and high-quality care, and allowed investments in infrastructure, which
    can contribute to improved efficiency and quality of care delivery.

    Address Budget Neutrality

    Current Medicare statute requires changes to the MPFS be implemented in
    a budget neutral manner, which means that policies that increase or
    decrease Medicare spending by more than $20 million require that upward
    or downward adjustments be made by that excess amount to all physician
    services. Budget neutrality places unreasonable constraints on MPFS
    payments and potential policies. Therefore, AUA recommends that
    Congress consider raising the budget neutrality threshold from $20
    million to $53 million to accommodate changes in Medicare spending
    since this threshold has not been increased since 1992. This will allow
    for more flexibility in adjusting physician payments and prevent
    different specialties from being pitted against one another.
    Additionally, it will mitigate the dynamic where specialties feel they
    are pitted against each other when new codes are added to the MPFS or
    values for existing codes are proposed to be increased. Congress should
    also provide for an increase equal to the cumulative increase in the
    MEI every 5 years to allow this threshold to keep pace with inflation.

    Improving Quality Payment Programs

    AUA was pleased that the Committee is interested in improving the
    Merit-based Incentive Payment System (MIPS) and identifying strategies
    to bolster more widespread adoption of advanced alternative payment
    models (APMs). The Medicare Access to CHIP Reauthorization Act (MACRA)
    authorized the CMS Quality Payment Program (QPP) in to encourage
    physicians', including specialists like urologists, engagement in
    innovative healthcare delivery models, fostering a system that rewards
    improvements in the quality of care delivered. AUA believes that APMs,
    if implemented well, can incentivize improved quality and better care
    coordination, which can be especially valuable for conditions like
    prostate and bladder cancer that may require surgery, radiation, and
    medical oncology to treat. Unfortunately, MACRA's statutory
    requirements have impeded Congress' goals for the program and Congress
    must strive to revise the QPP such that its requirements support the
    delivery of value-based care and improved quality.

    There is a significant administrative burden and financial risk
    involved with participation in MIPS and APMs. Additionally, the large
    investment in training takes away time and resources that should be
    devoted to patient care. In addition, with so many variations in
    practices, including practice size, specialty type, practice location,
    and population demographics, a one-size fits all model simply does not
    work. To improve the MIPS program, CMS must have the authority and
    resources to create programs that are meaningful to all providers and
    patients regardless of specialty type, while lowering the burden to
    participate in these programs. Specialty physicians looking to
    participate in these programs will find few physician-focused APMs are
    available for them.

    Additionally, CMS has stated its intent to sunset traditional MIPS and
    move to MIPS Value Pathways (MVPs). The agency is continuing to roll
    out new pathways each year; however, specialties like urology do not
    yet have MVP options to participate. While we understand the
    constraints under the current payment system, we believe that
    collaboration with stakeholders will assist in creating more meaningful
    programs and reducing burden for providers.

    Additionally, the AUA recommends that quality payment incentives be
    large enough to cover the costs of the time and resources that are
    devoted to participating in a quality program while also rewarding
    physicians for their participation. This is important because it
    ensures that healthcare providers are adequately compensated for the
    efforts they put into improving patient care. Not only can financial
    incentives be used to improve patient care, but this can also be used
    to provide incentives to urologists and other physicians to practice in
    underserved areas. Therefore, Congress must ensure that quality payment
    incentives are commensurate with the investment of time and resources
    necessary for sustaining effective quality improvement efforts and
    ultimately enhancing the quality of care delivered to patients.

    The AUA appreciates your leadership and welcomes the opportunity to
    work with you to improve Medicare beneficiary access to care and ensure
    the care delivered by urologists and other physicians is reimbursed
    equitably. For any questions please contact paymentpolicy@auanet.org.

    Sincerely,

    Eugene Rhee, M.D., MBA
    Chair, Public Policy Council

                                     ______

                       Association for Clinical Oncology

                           2318 Mill Road, Suite 800

                              Alexandria, VA 22314

                                T: 571-483-1300

                                F: 571-366-9530

                               https://asco.org/

            Statement of Everett E. Vokes, M.D., FASCO, Board Chair

    The Association for Clinical Oncology (ASCO) is pleased to submit this
    statement for the record of the hearing entitled, ``Bolstering Chronic
    Care through Medicare Physician Payment.'' ASCO appreciates the
    Committee holding today's hearing to discuss a more sustainable
    Medicare physician reimbursement system that improves care for
    beneficiaries, including those with cancer. ASCO is a national
    organization representing nearly 50,000 physicians and other health
    care professionals who care for people with cancer. ASCO members are
    dedicated to conducting research that leads to improved patient
    outcomes and are also committed to ensuring that evidence-based
    practices for the prevention, diagnosis and treatment of cancer are
    available to all Americans, including Medicare beneficiaries.

    ASCO supported the passage of the Medicare Access and CHIP
    Reauthorization Act of 2015 (MACRA) as a replacement for the flawed
    Sustainable Growth Rate (SGR) formula for Medicare physician
    reimbursement. Since its enactment, ASCO has provided extensive
    education to its members as well as significant input to the Centers
    for Medicare and Medicaid Services (CMS) around necessary refinements
    to the program to ensure its efficacy in the agency and for Medicare
    beneficiaries they serve. Unfortunately, physicians still face the same
    uncertainty MACRA was intended to address--financial instability within
    the Medicare payment system.

    We are encouraged by the Committee's interest in addressing current
    challenges and look forward to collaborating on ways to ensure long-
    term stability in the Medicare payment system. ASCO offers to be an
    ongoing resource for you as you evaluate the financial sustainability
    and patient impact of the Medicare physician payment system, MACRA's
    effectiveness and the continued transition to a value-based payment
    system.

    ASCO's History of Quality Improvement

    Since its founding over 50 years ago, our affiliate organization, the
    American Society of Clinical Oncology (the Society), has been dedicated
    to the delivery of high-quality, high-value care for every patient with
    cancer--every day, everywhere. The Society has a wide range of
    resources and programs aimed at improving the standard of cancer care
    received by patients in the United States and around the world.

    Oncology care is entering a time of unprecedented progress in both the
    understanding and treatment of cancer. However, today's medical
    practice environment is facing significant disruption, which threatens
    oncologists' ability to deliver the high-quality cancer care that
    patients deserve. Ongoing consolidation of physician practices,
    escalating cost of care, workforce shortages and physician burnout are
    on the rise and administrative burden has never been greater. As cancer
    care professionals navigate these challenges, they are looking for
    models that enable the delivery of high-quality, high-value cancer care
    and a framework that supports success regardless of payment
    arrangements and other administrative policies.

    In response to this need,\1\ in July 2021, the Society launched its
    ASCO Patient-
    Centered Cancer Care Certification initiative. This program promotes
    the oncology medical home as an effective approach to assuring every
    patient with cancer achieves the best possible outcome for their
    disease. It offers oncology group practices and health systems a single
    set of comprehensive, expert-backed standards for patient-centered care
    delivery.
    ---------------------------------------------------------------------------
        \1\ https://practice.asco.org/quality-improvement/quality-programs/
    asco-certified.

    The now permanent program (ASCO Certified) is based on Oncology Medical
    Home (OMH) standards \2\ from the American Society of Clinical Oncology
    and the Community Oncology Alliance (COA). These standards establish
    core elements needed to deliver equitable, high-quality cancer care and
    offer all stakeholders clarity on elements they should expect to see
    from cancer care teams. The OMH standards focus on seven different
    domains of cancer care, including patient engagement; availability and
    access to care; evidence-based medicine; equitable and comprehensive
    team-based care; quality improvement; goals of care, palliative and
    end-of-life care discussions; and chemotherapy safety.
    ---------------------------------------------------------------------------
        \2\ https://ascopubs.org/doi/full/10.1200/OP.21.00167.

    The pilot included 95 cancer care sites and nearly 500 oncologists from
    12 participating practice groups and health systems in a variety of
    settings, including community, hospital, and academic settings. Two
    commercial insurers participated, and others expressed strong interest.
    Participating practices use the ASCO Quality Reporting Registry (AQRR)
    for ongoing measurement of quality, outcomes, and utilization measures.
    Performance data are derived from electronic health records, insurance
    ---------------------------------------------------------------------------
    claims, patient satisfaction surveys, and clinical pathways systems.

    Practices meeting the rigorous ASCO-COA Oncology Medical Home Standards
    are certified by the ASCO Certification Program. Certified practices
    are expected to sustain adherence to the ASCO-COA OMH standards
    demonstrated through ongoing assessment and improvement activities
    monitored and evaluated by the ASCO Certification Program.

    Additionally, ASCO's Quality Oncology Practice Initiative (QOPI)
    Certification Program \3\ provides a three-year certification
    recognizing high-quality care for outpatient hematology-oncology
    practices within the United States and certain other countries. Its
    primary focus is the safe delivery of chemotherapy in the outpatient
    setting. Practices receive QOPI Certification based on their full
    compliance with QOPI Certification Standards as assessed during an on-
    site survey.
    ---------------------------------------------------------------------------
        \3\ https://practice.asco.org/quality-improvement/quality-programs/
    qopi-certification-program.
    ---------------------------------------------------------------------------

    Enhancing Oncology Model

    In June 2022, the Center for Medicare and Medicaid Innovation (CMMI)
    announced a new, 5-year voluntary oncology payment model, the Enhancing
    Oncology Model (EOM),\4\ which began on July 1, 2023. Participating
    oncology practices are taking on financial and performance
    accountability for episodes of care surrounding systemic chemotherapy
    administration to patients with seven common cancer types: breast
    cancer, chronic leukemia, small intestine/colorectal cancer, lung
    cancer, lymphoma, multiple myeloma, and prostate cancer. EOM
    participants are responsible for the total cost of care during a 6-
    month episode and elect to participate in one of two, two-sided
    financial risk arrangements.
    ---------------------------------------------------------------------------
        \4\ https://www.cms.gov/priorities/innovation/innovation-models/
    enhancing-oncology-model.

    EOM employs specific design elements, including comprehensive,
    coordinated cancer care; data-driven continuous improvement; payment
    incentives, including a Monthly Enhanced Oncology Services (MEOS)
    payment and a performance-based payment (PBP) or a performance-based
    recoupment (PBR); an aligned multi-payer structure; and focused efforts
    ---------------------------------------------------------------------------
    to identify and address health disparities.

    EOM participants are required to implement participant redesign
    activities, including 24/7 access to care, patient navigation, care
    planning, use of evidence-based guidelines, use of electronic Patient
    Reported Outcomes (ePROs), screening for health-related social needs,
    use of data for quality improvement, and use of certified electronic
    health record technology. As part of the data reporting for quality
    improvement, EOM participants will submit health equity plans to CMS,
    where participants detail evidence-based strategies to mitigate health
    disparities identified within their beneficiary populations.

    ASCO is pleased that EOM is a voluntary model and that practices were
    able to choose to participate based on their level of readiness and
    ability to assume financial risk. We fully support CMMI's focus on
    equity and coordinated cancer care. The cancer care delivery
    requirements of the CMMI EOM have many similarities with ASCO-COA
    Oncology Medical Home Standards and ASCO Certified. Practices achieving
    ASCO Patient Centered Cancer Care Certification will be well positioned
    to succeed in the EOM.

    We are concerned, however, that CMMI significantly reduced MEOS
    payments compared to similar payments in the earlier Oncology Care
    Model (OCM). This is especially concerning given that there was a 1-
    year gap between the end of OCM and the start of EOM, during which time
    practices received no additional support for the mechanisms instituted
    during OCM to enhance patient access and care coordination that are
    continuing under EOM. The limited MEOS may not cover the practice
    redesign efforts needed in this model with financial risk.

    While OCM prompted practice changes that enhanced patient-centered
    care, those changes cannot be sustained or broadened to other practices
    without a regulatory and payment framework that supports them. We are
    eager to work with CMS and Congress to enable the practice
    transformation critical to practices surviving and thriving in the
    years ahead, so patients receive the care they need and deserve.

    Below are areas of improvement we believe are vital to achieving high-
    value, high-quality care for all patients with cancer.
    Medicare Physician Payment Reform
    In repealing the SGR, MACRA specified a 0% update to the Medicare
    Physician Fee Schedule (MPFS) Conversion Factor (CF) for a period of 6
    years, followed by a 0.25% annual increase for Merit Based Incentive
    Payments System (MIPS) participants and a 0.75% annual increase for
    Advanced Alternative Payment Model (APM) participants thereafter. While
    Congress provided temporary relief in 2021 and 2022, physician
    reimbursement was cut in 2023 and again in 2024. In the Consolidated
    Appropriations Act of 2024, passed on March 9, 2024, Congress included
    a +1.68% adjustment to the MPFS CF for the remainder of 2024. This
    increase resulted in a 1.68% reduction to the 3.37% CF. This did not
    apply retroactively, with claims with dates of service prior to March 9
    reimbursed using the original conversion factor.

    Failure of the MPFS to keep up with increasing labor, supplies, rent,
    and other practice expenses influences a growing site-of-service shift
    from independent physician practices to off-campus outpatient hospital
    departments paid for by the Outpatient Prospective Payment System
    (OPPS). Rather than addressing the lack of sufficient payment under the
    MPFS, Congress directed CMS to reduce payments to new off-campus
    outpatient hospital departments, thereby encouraging further shifts
    into on-campus departments. Instead of encouraging value-based care,
    this consolidation results in reduced beneficiary access to community-
    based healthcare services. Congress must ensure that future payment
    updates within the MPFS are sufficient to sustain beneficiary access to
    community-based physician care.

    While we appreciate Congress' efforts to help stabilize physician
    payment, ASCO hopes to see a longer-term solution. We strongly support
    and encourage lawmakers to support the Strengthening Medicare for
    Patients and Providers Act (H.R. 2474), not yet introduced in the
    Senate. This legislation aims to provide an annual update to a single
    conversion factor under the MPFS that is based on the Medicare Economic
    Index (MEI). This inflationary increase will help providers keep up
    with rising healthcare costs. Moreover, ASCO supports the Providing
    Relief and Stability for Medicare Patients Act of 2023 (H.R. 3674) and
    the Provider Reimbursement Stability Act of 2023 (H.R. 6371),
    legislation that would increase resources across all Medicare service
    codes. Following the initial increase, the fee schedule would see
    annual adjustments based on the MEI. ASCO appreciates the inclusion of
    the provision to update direct costs associated with practice expense
    relative value units (RVUs) once every 5 years. Lastly, both bills
    would address over- and under-utilization estimates, which impacts
    budget neutrality in the MFPS. These consistent investments in Medicare
    services are crucial to the vitality of our profession and the quality
    of care we provide.
    MIPS Budget Neutrality and the Exceptional Performance Bonus
    For performance year 2021, there were a total of 954,664 MIPS-eligible
    clinicians under the Quality Payment Program (QPP) MIPS track.6 Of that
    total number, 951,744 (99.7%) avoided a negative payment adjustment.
    Almost 84% achieved exceptional performance and earned positive payment
    adjustments ranging from +0.09% to +1.79%. Only those clinicians
    scoring high enough to earn an exceptional performance bonus actually
    received any positive payment adjustment. Clinicians who received a
    positive score, but did not reach the exceptional threshold, received a
    payment adjustment of 0% due to the budget neutrality requirement of
    MIPS as established by MACRA (i.e., absent the ``exceptional
    performance'' bonus, the number of negative adjustments equals the
    number of positive adjustments). As only 0.31% of clinicians received a
    score below the threshold (and received a 7% penalty), the only real
    source for a positive payment adjustment came from the $500 million
    annual ``exceptional performance'' bonus. With the sunsetting of the
    ability to earn this bonus in performance year 2022, it is very likely
    that high-scoring clinicians participating in MIPS going forward will
    receive little to no positive adjustment through MIPS; this is
    compounded by the 0% statutory update to the MIPS track until 2026 and
    the lack of an inflationary update to the MPFS.

    When the MIPS track of the QPP was originally envisioned, it was
    thought that a budget-neutral system would provide rewards to high
    performers, while penalizing low performers. Experience has shown us
    that small and rural practices disproportionately bear the burden of
    growing penalties, which in the aggregate are far too small to result
    in any meaningful distribution to higher performers. The budget-neutral
    nature of MIPS should be re-examined, as should the exceptional
    performance bonus. We urge the Subcommittee to consider legislation to
    not only address budget neutrality in the MPFS as outlined above but
    also in MIPS.
    Provider Participation in APMs
    MACRA provided for a time-limited, annual payment incentive to
    Qualifying APM Participants (QPs) equal to 5% of estimated aggregate
    payment amounts for covered professional services. The incentive
    payment was intended to encourage participation in advanced APMs and
    has been critical in assisting physicians to develop the infrastructure
    necessary for the transition to value-based payment models.

    Unfortunately, the combination of a lack of specialty-specific advanced
    APMs, financial uncertainty throughout the COVID-19 pandemic, and
    delays in the rollout of certain APMs (e.g., Oncology Care First, now
    named Enhancing Oncology Model) has resulted in many physicians being
    unable to qualify for this incentive. The payment incentive for
    advanced APMs was extended by 1.8% under the Consolidated
    Appropriations Act of 2024. While we appreciate Congress' efforts to
    ensure providers can successfully participate in value-based payment
    models in the short term, longer-term solutions are necessary to
    address the incentive gap we are nearing. Specifically, we encourage
    Congressional support for S. 3503/H.R. 5013 the Value in Health Care
    Act of 2023 to extend incentive payments for eligible APMs for an
    additional 2 years. Additionally, Congress should consider long-term
    solutions, beyond the 5-year cap outlined in the legislation to ensure
    financial stability in the program.

    Further, to qualify for the APM incentive, physicians must meet either
    the Medicare Payment Threshold Option or Medicare Patient Threshold
    Option. These thresholds are meant to ensure that physicians
    meaningfully participate in alternative payment models. Many specialty
    physicians will find it difficult to qualify under the currently
    specified thresholds. For example, oncologists who participate in a
    Medicare Shared Savings Program (MSSP) Accountable Care Organization
    (ACO) naturally have lower payment and patient threshold scores due to
    receiving referrals from primary care physicians outside of the ACO. As
    a result, many ACOs are considering whether to remove specialists from
    their participating physician lists so that the remaining physicians
    may be deemed QPs.

    Even within specialty-specific models, specialists may find that the
    limited scope of models--the EOM includes only seven cancer types--
    makes it difficult to meet the specified thresholds. Congress should
    extend the current 50% payment threshold and 35% patient threshold and
    should also direct CMS to remove barriers to participation in multiple
    APMs, such as allowing a single practice (identified by a Tax
    Identification Number) to participate in multiple ACOs.
    Conclusion
    Thank you for your commitment to improving the Medicare program and
    cancer care delivery. ASCO stands ready to serve as a resource as you
    continue this much needed dialogue around reforms to the physician
    reimbursement system. Please contact Kristine Rufener at
    Kristine.Rufener@asco.org with any questions.

                                     ______

                Letter Submitted by A. Joseph Borelli, Jr., M.D.
    April 11, 2024

    Senator Ron Wyden
    Chairman
    U.S. Senate
    Committee on Finance
    221 Dirksen Senate Office Building
    Washington, DC 20510

    Senator Mike Crapo
    Ranking Member
    U.S. Senate
    Committee on Finance
    239 Dirksen Senate Office Building
    Washington, DC 20510

            Subject: Revision of Medicare MRI Reimbursement Rates

    Dear Chairman Wyden and Ranking Member Crapo,

    Please accept this statement for the record regarding the U.S. Senate
    Finance Committee Hearing titled Bolstering Chronic Care through
    Medicare Physician Payment on April 11, 2024. Having served as the
    former Chair of the Committee on MRI Accreditation for the American
    College of Radiology, which established the MR Accreditation Program in
    2011--a program now integral to CMS's efforts to guarantee the quality
    and safety of MRI procedures to our seniors nationwide--I possess an
    in-depth understanding of the financial and operational challenges that
    MRI facilities encounter. This is particularly true for facilities like
    ours, operating in non-hospital, freestanding settings and serving a
    high volume of Medicare beneficiaries.

    Our current Medicare reimbursement structure does not adequately
    accommodate the operational costs of MRI facilities, especially those
    like ours that incur about $100,000 per month in fixed costs, including
    the lease and maintenance of a modern 3T MRI scanner of about $35,000
    per month. The cost of providing healthcare insurance for our employees
    has increased by 50% in the last 7 years, while Medicare reimbursement
    has been repeatedly cut. Currently, the typical technical reimbursement
    rate of approximately $100 per MRI procedure is insufficient to cover
    these expenses given the capacity limitations of MRI scanners, which
    typically perform about 300-500 scans per month. Hospitals, on the
    other hand, are reimbursed at nearly twice that amount.

    To address these challenges, I propose two key budget-neutral
    adjustments to the Medicare MRI reimbursement rates for independent,
    non-hospital-affiliated facilities:

        1.  Equipment-Based Reimbursement Scale: Establish a committee to
    annually adjust reimbursements in a budget-neutral manner based on the
    resale value of MRI equipment. This would ensure that facilities using
    higher-quality equipment receive a reimbursement rate that reflects
    their greater diagnostic capabilities and higher operational costs,
    while facilities with lesser equipment receive correspondingly adjusted
    rates. This would also eliminate the financial incentive to purchase
    the cheapest available equipment in the self-referred setting (e.g.,
    orthopedic offices).

        2.  Geographic and Demographic Considerations: Implement
    adjustments for facilities in regions with a high proportion of
    Medicare beneficiaries, like Beaufort County, South Carolina, where 75%
    of our patients are seniors. This would help facilities in high-demand
    areas maintain a high standard of care without financial strain.
    Regions with a lower proportion of Medicare beneficiaries would see
    reduced reimbursement, to maintain budget neutrality.

    These proposals aim to create a more equitable and sustainable
    reimbursement model that reflects both the quality of diagnostic
    equipment and the demographic realities of different regions. My
    extensive experience in developing MRI accreditation standards informs
    these recommendations, emphasizing a commitment to the quality, safety,
    and sustainability of diagnostic imaging services.

    I am eager to collaborate with your committee to refine and implement
    these proposals. Thank you for considering these urgent adjustments,
    and I look forward to your partnership in enhancing healthcare services
    for our senior population.

    Sincerely,

    A. Joseph Borelli, Jr., M.D.
    Former Chair
    Committee on MRI Accreditation
    American College of Radiology

    President and Medical Director
    3T MRI at Belfair

                                     ______

                 Coalition of State Rheumatology Organizations

                       555 East Wells Street, Suite 1100

                            Milwaukee, WI 53202 3823

                              Phone: 414-918-9825

                               https://csro.info/

    CSRO is comprised of over 40 state and regional professional
    rheumatology societies whose mission is to advocate for excellence in
    the field of rheumatology, ensuring access to the highest quality of
    care for the management of rheumatologic and musculoskeletal disease.
    Our coalition serves the practicing rheumatologist. We thank the
    Committee for its bipartisan interest in the topic of physician
    reimbursement. We offer several initial ideas for reform herein and
    would welcome the opportunity to discuss these in more detail.

    Rheumatologic disease is systemic and incurable, but innovations in
    medicine over the last several decades--primarily the development of
    biologics and biosimilars--have enabled rheumatologists to better
    manage these conditions. With access to the right treatment early in
    the disease, patients can generally delay or even avoid damage to their
    bones and joints, as well as reduce reliance on pain medications and
    other ancillary services, thus improving their quality of life.
    However, rheumatoid arthritis (RA) and other autoimmune conditions are
    extremely complex. Although rheumatology is beginning to benefit from
    more precise diagnostics, we still cannot predict with absolute
    accuracy which medication will work for a particular patient, because
    of RA's varied signaling pathways. Even where these tools are
    available, developing value-based care metrics or episode-based
    measures remains difficult. Within the confines created by these
    challenges, CSRO nonetheless continues to engage in efforts to define
    episodic care and appropriate cost measures.

    For rheumatology and every other Medicare-heavy specialty, a major
    barrier to the exploration of additional value-based care initiatives
    is reimbursement instability in the Medicare Physician Fee Schedule and
    its downstream effects on reimbursements from Medicare Advantage plans.
    Practices with high numbers of Medicare beneficiaries are faced with a
    large and growing gap between their reimbursement and their costs,
    which leaves little to no room to invest in the systems and
    infrastructure that modern medicine demands or to incur the financial
    risk that many value-driven models require. For that reason, we urge
    the Committee to focus congressional efforts on five policy areas that
    will provide immediate and long-term stability to the Fee Schedule, as
    described below.

    I. Inflation Update

    Unlike all other major Medicare payment systems, the Fee Schedule lacks
    a mechanism to incorporate inflationary increases into its
    reimbursement rates. That has created an ever-growing disconnect
    between the cost of providing care to Medicare beneficiaries and the
    program's reimbursement for that care. The medical community's
    endorsement of the Medicare Access and CHIP Reauthorization Act (MACRA)
    was rooted in the belief that it would replace the unpredictable
    Medicare payment landscape with a stable, quality-rewarding system.
    Unfortunately, this shift has not materialized as anticipated.
    According to the American Medical Association, reimbursement for
    Medicare physicians declined by 26% from 2001 to 2023, when one adjusts
    for inflation in practice costs. That is not a sustainable payment
    system and, inevitably, will lead to beneficiaries experiencing
    difficulty finding physicians who accept Medicare.

    The bipartisan Strengthening Medicare for Patients and Providers Act
    (H.R. 2474) would provide an annual Fee Schedule update based on the
    Medicare Economic Index (MEI), which is the most relevant inflation
    metric for medical practices. CSRO urges the Congress to enact this
    legislation.

    II. Budget Neutrality

    The Fee Schedule is subject to a statutory budget neutrality
    requirement, whereby increases in spending over a certain threshold
    must be offset by equivalent reductions in spending that same year.
    That threshold is $20 million, a level set by Congress in 1992 and
    never updated since. The Centers for Medicare and Medicaid Services
    (CMS) has no authority to change this statutory requirement, though its
    policy decisions have in the past ``triggered'' the threshold, thereby
    resulting in commensurate reimbursement reductions across the Fee
    Schedule. The concept of budget neutrality has turned the Fee Schedule
    into a fixed pie, while the outdated threshold amount will result in
    the threshold being triggered more and more as time goes by. The budget
    neutrality requirement is a main contributor to the annual pattern of
    Congress averting or mitigating reimbursement reductions at the last
    minute.

    CSRO urges the Congress to enact Section 5 of the bipartisan Physician
    Fee Schedule Update and Improvements Act (H.R. 6545), which would
    update the budget neutrality threshold to $53 million and establish
    inflationary indexing on a 5-year basis from there.

    III. Practice Expense Data Input Updates

    In 2022, CMS updated clinical labor practice expense (PE) inputs for
    the first time in two decades. Although that was a welcome update, the
    long delay meant that large increases were necessary to reflect twenty
    years of wage growth. That in turn triggered budget neutrality
    reductions once implemented.

    As part of long-term Fee Schedule stabilization, CMS must be directed
    to update data inputs on a more frequent and regular basis. CSRO urges
    the Congress to enact section 6 of the legislation mentioned above
    (H.R. 6545), which would require CMS to update direct costs to
    calculate PE RVUs every five years at a minimum.

    IV. Stop Extensions of Medicare Sequestration

    After a temporary reprieve during the public health emergency, the 2%
    Medicare sequestration was fully phased back in as of July 1, 2022.
    When the Medicare sequester was first created, it was scheduled to
    occur from FY 2013 through FY 2021. However, Congress has since
    extended Medicare sequestration to pay for other priorities, so that it
    currently extends through FY 2032--a full decade past its originally
    envisioned end date. Extending the Medicare sequester to offset new
    spending exacerbates the long-term underfunding of the Fee Schedule. We
    urge Congress to reject any further extensions of the Medicare
    sequester.

    V. Unique Situation of Buy-and-Bill Part B Clinicians

    The new Medicare Drug Price Negotiation Program (MDPNP) will become
    fully applicable to the pricing of selected Part B drugs in 2028, which
    is expected to result in large reductions to average sales prices
    (ASPs) for the selected medications. That in turn will result in
    reductions to reimbursement for the physicians who buy these
    medications at-risk for in-office administration, because reimbursement
    for selected drugs would be based on the maximum fair price (MFP)
    established via the MDPNP plus 6%, instead of the current ASP plus 6%.
    (Note that, in either scenario, the reimbursement amount would be
    subject to the 2% Medicare sequester.)

    In the legislative process leading up to enactment of the MDPNP,
    several provider groups expressed concern that this program could have
    unintended consequences on the financial stability of practices who
    acquire medication for in-office administration. The legislation tried
    to guarantee the MFP price point for provider acquisition, but that
    guarantee will be difficult to operationalize in the complex world of
    drug acquisition, which features several layers of middlemen. If MFP-
    based reimbursement drops below acquisition costs for selected drugs,
    medical practices will suffer financial instability and may have to
    stop offering the selected drugs until acquisition costs can meet
    reimbursement levels. There is also a lack of clarity on the extent of
    the impact that MFPs will have on commercial ASPs and on the additional
    administrative burden that practices will have to incur to manage the
    different reimbursement rates for the same medication.

    For these reasons, CSRO urges you to include the Protecting Patient
    Access to Cancer and Complex Therapies Act (S. 2764/H.R. 5391) as part
    of comprehensive physician payment reform. That legislation would leave
    intact the MDPNP process, but would make changes to the mechanics of
    how Medicare obtains its savings. More specifically, the bill would
    remove Part B providers from the middle by requiring the drug
    manufacturers of selected drugs to reimburse Medicare directly for the
    difference between ASP and MFP on their selected products. Notably, the
    bill keeps intact the two major goals of the MDPNP: Medicare would
    still obtain significant savings on Part B drugs and the bill would
    still guarantee beneficiaries access to MFP-based cost-sharing. This
    ``best of both worlds'' approach would keep in place the benefits of
    the MDPNP yet would also ensure that Part B providers are not
    inadvertently harmed in the process, ultimately protecting their
    Medicare patients' access to needed medication in the lowest-cost site
    of care.

    Thank you again for holding a hearing on Medicare physician
    reimbursement and for affording stakeholders the opportunity to provide
    input for the record. If you need additional information, please don't
    hesitate to contact us.

                                     ______

                        College of American Pathologists

                       1001 G Street, NW, Suite 425 West

                              Washington, DC 20001

                                  800-392-9994

                              https://www.cap.org/

    April 24, 2024

    Chairman Ron Wyden                  Ranking Member Mike Crapo
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Wyden and Ranking Member Crapo:

    The College of American Pathologists (CAP) appreciates the opportunity
    to share our views with the Senate Finance Committee regarding chronic
    care and the Medicare Physician Payment System. As the world's largest
    organization of board-certified pathologists and leading provider of
    laboratory accreditation and proficiency testing programs, the College
    of American Pathologists (CAP) serves patients, pathologists, and the
    public by fostering and advocating excellence in the practice of
    pathology and laboratory medicine worldwide.

    As you are aware, pathologists are physicians who specialize in the
    diagnosis of disease. On any given day, pathologists impact nearly all
    aspects of patient care, from diagnosing cancer to managing chronic
    diseases such as diabetes through accurate laboratory testing. Often,
    they guide primary care and other doctors, determining the right test,
    at the right time, for the right patient. Pathologists in hospitals and
    independent laboratories around the country are also responsible for
    developing and/or selecting new test methodologies, validating, and
    approving testing for patient use, and expanding the testing
    capabilities of the communities they serve to meet emergent needs.
    Pathologists assure compliance with laboratory regulatory and
    accreditation standards, while preventing overuse or improper
    application of tests. Although patients may never meet the pathologist
    on their care team, they can be assured that these experts deliver
    quality and care at every step. Indeed, the influence of pathology
    services on clinical decision-making is pervasive and constitutes a
    critical infrastructure and foundation of appropriate care.

    To help bolster the provision of chronic care services, the CAP
    recommends Congress work to stabilize the physician payment system,
    grow the health care workforce, increase oversight of insurer-imposed
    policies that impact patient care, and look at meaningful sources of
    health spending.

                         Sustainable Provider Financing

    Inflationary Update

    Over the last 5 years payments to pathologists have decreased by
    approximately 4.6 percent, while physician practice costs (medical
    supplies, lab personnel costs, professional liability insurance) have
    increased by nearly 13.8 percent. In 2024 alone, pathologists are
    anticipated to experience a net 5.7 percent reduction in Medicare
    Physician Fee Schedule reimbursement as payments are expected to fall
    by close to 1.1 percent while expenses are expected to increase by over
    4.6 percent. The lack of an annual inflationary update for
    pathologists, especially those that operate small businesses, compounds
    the wide range of shifting economic factors impacting the practice of
    pathology, such as increasing administrative burdens, staff salaries,
    office rent, and purchasing of essential technology when determining
    their ability to provide care to Medicare patients. The absence of an
    annual inflationary update, combined with the Physician Fee Schedule's
    statutory budget neutrality requirements and ongoing Medicare payment
    cuts, further compounds the difficulties pathologists face in managing
    resources to continue caring for patients in their communities.
    Therefore, the CAP requests that the Committee pass legislation to
    provide an inflationary update to the Medicare Physician Fee Schedule.

    [GRAPHIC] [TIFF OMITTED] T1124.010

    ----------------------------------------------------------------------------------------------------------------
                                                                                                   5-Year    Yearly
                                                 2020      2021      2022      2023      2024      Total     Average
    ----------------------------------------------------------------------------------------------------------------
    Pathology Medicare Payments                   0.03%    -1.75%    -0.65%    -1.16%    -1.11%     -4.64%    -0.93%
    ----------------------------------------------------------------------------------------------------------------
    Medicare Economic Index (MEI) for              1.9%      1.4%      2.1%      3.8%      4.6%     13.80%     2.76%
     Inflation
    ----------------------------------------------------------------------------------------------------------------
    Difference                                   -1.87%    -3.15%    -2.75%    -4.96%     -5.7%    -18.44%    -3.69%
    ----------------------------------------------------------------------------------------------------------------
    Since 2020, reimbursement rates for pathology services have gone down by approximately 4.6%, while physician
      practice costs (medical supplies, lab personnel, professional liability insurance) have increased by nearly
      13.8% over the same timeframe. In 2024 alone, pathologists are anticipated a net 5.7% reduction in Medicare
      Physician Fee Schedule reimbursement as payments are expected to fall by 1.1% while costs are expected to rise
      by 4.6%. Currently, it is too early to predict an MEI for 2025. Therefore, it is not included in above chart.

    Budget Neutrality

    Budget neutrality is another barrier to achieving high-quality, high-
    value health care. These requirements lead to arbitrary reductions in
    reimbursement unrelated to the cost of providing care, forcing
    physicians and other health care providers into adversarial roles,
    leading to an unpredictable reimbursement system from year to year. The
    CAP acknowledges that budget neutrality is a politically appealing
    option to control rising health care costs. However, the CAP urges
    Congress to think more creatively and expansively about ways to manage
    health care costs which do not generate such significant instability
    for health care providers, threatening beneficiary access to essential
    health care services.

    Because of the continuous reimbursement cuts caused by the Physician
    Fee Schedule's budget neutrality requirements and the lack of an
    inflationary update, the cost of providing patient care is becoming
    unsustainable. As costs exceed revenues, laboratory workforce shortages
    will worsen. The result: increased wait times in the emergency
    department, longer time before receiving a diagnosis of cancer,
    potential for increased errors in testing and delays in specimen
    collection and turnaround time for laboratory results. Therefore, the
    CAP requests that the Committee pass legislation to eliminate, revise,
    or replace the budget neutrality requirements in Medicare.

    Effectiveness of MACRA

    MACRA was originally passed to end a cycle of Medicare payment cuts and
    reward value-based care, yet today we are faced with continued
    financial instability within the Medicare physician payment system and
    value-based care that is not incentivized or attainable for most
    physicians.

    There has been a chorus of dissatisfaction with the Merit-based
    Incentive Payment System (MIPS). The Medicare Payment Advisory
    Commission (MedPAC) has questioned the value of the MIPS program due to
    its design and measurement methods. Indeed, the Government Accounting
    Office's (GAO) 2021 report on Provider Performance and Experiences
    under the Merit-based Incentive Payment System described many of the
    challenges physicians experience in the MIPS program, including the
    question of whether MIPS meaningfully improved quality of care or
    patient outcomes. It further indicated that the design of the program
    may incentivize reporting over quality improvement. CMS's response to
    the GAO report was that a new pathway in MIPS, called MIPS Value
    Pathways (MVPs) would address many of these challenges. Unfortunately,
    both the MIPS and MVP quality programs continue to pose challenges,
    including for the care of chronic conditions. Alternative payment
    models (APMs) have similar issues, while the burden of data entry and
    other administrative requirements continue to impede the effectiveness
    of MACRA instead of improving care for patients.

        1. Quality Programs

              The MIPS and MVP programs incentivize silos of care rather
            than rewarding integration of the care team. Because CMS scores
            individual clinicians on quality measures that apply only to
            individuals, there is no incentive to foster collaboration. The
            proposed future of MIPS, MIPS Value Pathways or MVPs,
            exacerbate this problem because most current and proposed MVPs
            are specialty-specific rather than condition or procedure-
            specific. For instance, instead of a Melanoma MVP that includes
            quality measures for the entire care team (primary care
            clinicians, pathologists, dermatologists, Mohs' surgeons,
            etc.), the Dermatological Care MVP includes quality measures
            for a variety of unrelated dermatological conditions. Thus,
            only dermatologists are eligible for this MVP and the disparate
            quality measures within it do not incentivize collaboration
            among dermatologists.

              This problem is even worse for patients with chronic
            conditions who may require ongoing and episodic care;
            integration among the care team is even more important for
            these beneficiaries. However, the MIPS program only permits
            quality measures that cover a single calendar year, which does
            not align with how patients with chronic conditions experience
            care.

              CMS should not remove or disincentivize process measures,
            especially for patients with chronic conditions. Since outcomes
            may be few and far between for these patients (e.g., diabetes
            will never be fully resolved for a patient), process measures
            are critical to ensure patients are receiving appropriate
            ongoing care. While we understand CMS' desire to measure
            outcomes, under the belief that is what matters most to
            patients, for chronic conditions especially, process measures
            are critical.

              Further, the CMS-proposed ``upsides'' of MIPS participation
            have not materialized, even for the highest performers. The
            seemingly promised 9 percent potential positive payment
            adjustments in return for flat PFS have not been realized and
            the cost and burden of participation in MIPS has been higher
            than anticipated. Thus, within MIPS, the administrative and
            financial burden of participating far outweighs any marginal
            improvements in cost and quality that could possibly be
            ascribed to MIPS participation.

        2. Advanced Alternative Payment Model (APM)

              Within the APM track, there is an equivalent lack of
            meaningful results, with increased and unnecessary complexity
            built into the system. CMS recently acknowledged in its own
            Synthesis of Evaluation Results across 21 Medicare Models,
            2012-2020 that most of the current models created by the Center
            for Medicare and Medicaid Innovation (CMMI) are not meeting
            quality and savings goals. In fact, according to the CMS report
            only two APMs on CMS's list of 21 improved the patient
            experience of care.

              Additionally, despite there being hundreds of APMs, there
            have been very limited options for physicians to participate,
            much less for them to receive Qualifying APM Participant status
            from meeting the Advanced APM participation threshold. Per the
            recently released MedPAC data book (July 2022), most clinicians
            participating in Advanced APMs were in accountable care
            organizations (ACOs) participating in the Medicare Shared
            Savings Program (MSSP). In fact, of the clinicians who
            qualified for the 5 percent Advanced APM bonus, over 75 percent
            were in MSSP. Four other Advanced APMs made up most of the rest
            of the eligible clinicians, while just 3.4 percent participated
            in an Advanced APM other than the top four or MSSP. One look at
            the CMS website for available APMs, their associated rules,
            dates for sign-up, data reporting and other requirements,
            demonstrates an extraordinary amount of complexity for models
            that are hardly being utilized.

              Further, many single-specialty practices are disenfranchised
            from being able to participate in APMs altogether. As currently
            envisioned by the CMS, APMs significantly favor multispecialty
            practices, including larger systems in urban settings. And
            while the CMS wants to see all Medicare beneficiaries and most
            Medicaid beneficiaries enrolled in an accountable care
            relationship by 2030, it is unclear how single-specialty,
            community-based practices can effectively participate in CMS's
            vision. The CMS has not explicitly articulated how this
            transition will occur, nor what they see as the primary
            accountable care relationship model for specialists. The CMS
            has acknowledged broad concerns among participants that the
            path to APMs remains unclear, particularly for specialties
            other than primary care. For example, of the Advanced APMs
            currently available, we believe pathologists are only able to
            participate in at most three models, and only to a very limited
            extent. Clearly, more opportunities are needed for specialty
            physicians to participate in Advanced APMs and incentives must
            recognize that high-value care is provided by both small
            practices and large systems, in both rural and urban settings.

        3. Reduce Health IT Administrative Burdens

              Another major barrier concerning implementation of MACRA is
            the associated administrative burden, particularly as it
            relates to the current state of health care data. While
            electronic health records are critical for advancing care
            accuracy, speed, and coordination, one size does not fit all
            with respect to health information technology (health IT). Even
            within a single specialty, different physician practices may
            have different levels of fluency with technology, and between
            specialties, maturity of health IT can vary widely. Therefore,
            when it comes to implementing the requirements of a system-wide
            program like MACRA, we suggest that regulations should
            acknowledge the varying states of data and encourage
            flexibility to accommodate different health IT readiness.
            Furthermore, rather than impose health IT requirements across
            the board, CMS and other agencies should work with stakeholders
            to move from the current state to an improved future state that
            promotes greater health data interoperability.

              Data entry remains a major burden to complete implementation
            of MACRA, as it requires significant time and effort on the
            part of physicians and/or administrative staff, an average of
            more than 200 hours a year in one study.\1\ However, one
            proposed alternative is quality measurement based on
            administrative claims. While these measures reduce data entry
            burden, they do not represent a complete fix; downsides of
            administrative-claims-based measurement include limited
            available data, retrospective evaluation, and oftentimes
            limited clinician control over the processes being measured.
            The CMS acknowledges the need for real-time evaluation and
            feedback, which cannot be accomplished with administrative-
            claims-based measurement.
    ---------------------------------------------------------------------------
        \1\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino LP.
    Time and Financial Costs for Physician Practices to Participate in the
    Medicare Merit-based Incentive Payment System: A Qualitative Study.
    JAMA Health Forum. 2021;2(5):e210527.

    The underlying PFS has created significant financial instability for
    physician practices, and dissatisfaction with MACRA may further
    discourage participation in value-based care models in the future. The
    long-term consequence of failing to avert the cuts and improve the
    effectiveness of MACRA is decreased patient access to care. The CAP
    urges the Committee to improve the provision of chronic care services
    to patients by minimizing physician administrative, financial, and
    technological burdens of participation in MACRA. To further improve the
    effectiveness of MACRA and provision of chronic care, the CAP asks the
    ---------------------------------------------------------------------------
    committee to take the following actions:

        1.  Pass legislation to maintain meaningful quality measures. The
    CMS is attempting to replace process measures: measures that look at
    whether the clinician did what he or she was supposed to do (example:
    annual hepatitis screening for active drug users) with outcome
    measures: what was the outcome of the procedure (example: decrease in
    lower back pain). This is an issue for pathologists because there are
    not relevant outcome measures for pathology. Pathologists do not have
    direct attributable control over the outcome of most procedures.
    Process measures have been and remain very important in all aspects of
    health care and efforts should be taken to protect them.

        2.  Pass legislation to improve stakeholder participation in the
    development of new payment models. The CAP remains concerned that
    models are being developed by CMMI that dramatically change providers'
    clinical decision-making without considering the input of those
    specialties impacted by the model. Thus, the CAP has sought to ensure
    physicians, especially the societies that represent physicians
    participating in and affected by new payment models, have input into
    new model development. Specifically, in carrying out its statutory
    duties of testing innovative health care payment and delivery models
    that lower costs while ``preserving or enhancing the quality of care,''
    CMMI is required to consult clinical and analytical experts with
    expertise in medicine and health care management. Amongst those
    clinical experts and those with expertise in medicine and health care
    management, CMMI should be required to include associations
    representing physician specialties whose services are impacted directly
    in both primary and supporting roles by the Center's models.
    Consultation with specialty associations will help ensure that models
    developed in a manner that is transparent and focused on the best
    interests of the patient consistent with sound clinical input and
    practices.

         Additionally, the fact that CMS has yet to take up any of the
    models recommended by the Physician Focused Payment Model Technical
    Advisory Committee (PTAC) demonstrates the complexity in creating
    appropriate physician-developed APMs as envisioned under MACRA. Having
    physician input and buy-in is critical to effective delivery system
    reform. More innovative health care payment and delivery models must be
    developed in an open and transparent fashion with the input of those
    specialties impacted by the models.

        3.  Pass legislation requiring PTAC model submitters to consult
    participating and affected specialties prior to model submission. The
    PTAC provides an important opportunity for specialists to develop their
    own models and submit them for review and recommendation to the
    Secretary. However, at least three models submitted to the PTAC have
    included pathology services, yet the CAP was not consulted or even
    aware they encompassed pathology services until the models were posted
    for public comment. Model submitters should be required to provide
    evidence of consultation and concurrence from specialties participating
    in their models prior to submission so that the PTAC can make
    recommendations on models that are truly physician-focused and enable
    meaningful contribution of their participants in enhancing the care of
    patients.

        4.  Pass legislation requiring that traditional MIPS options be
    maintained for single specialty practices to ensure that private/
    independent practices of all sizes remain a viable option for
    physicians. Traditional MIPS, though burdensome, allows single
    specialty pathology practices to be accurately measured on relevant
    quality activities and obtain full incentives without pressure to
    consolidate. Many pathologists in independent practice choose to stay
    in MIPS for that reason. The CAP believes the replacement of
    traditional MIPS with MVPs and Advanced APMs incentivizes larger,
    multispecialty practices, as the clinical alignment envisioned by these
    programs is often achieved via physician employment or practice
    consolidation. Indeed, consolidation among physician practices and
    between hospitals and physician practices has accelerated in the past
    decade, with participation in APMs cited as reasons for
    consolidation.\2\ This kind of consolidation is bad for ensuring access
    to quality care for patients in rural and underserved communities.
    ---------------------------------------------------------------------------
        \2\ Medicare Payment Advisory Commission. 2022. March 2022 Report
    to the Congress: Medicare Payment Policy; Ch 4. Washington, DC: MedPAC.
    ---------------------------------------------------------------------------

                 Addressing the Health Care Workforce Shortage

    As you know, older adult patients require higher levels of care due to
    greater incidence of chronic disease, which will increase the demand
    for physician services on a smaller pool of available physicians.
    Therefore, it is imperative to grow the physician workforce. The
    Association of American Medical Colleges (AAMC) is projecting that the
    United States will face a shortage of up to 124,000 physicians by 2034.
    The CAP appreciates that Congress made a critical initial investment in
    the physician workforce by providing 1,000 Medicare-supported graduate
    medical education (GME) positions in the Consolidated Appropriations
    Act of 2021 and 200 Medicare-supported GME positions in the
    Consolidated Appropriations Act of 2023. However, these should be
    viewed as a down payment for a much larger documented need.

    The demand for trained pathologists continues to far exceed the supply
    provided by the number of existing residency positions. Data from the
    CAP's 2021 Practice Leader Survey is suggestive of a nationwide demand
    of 1,000-1,200 pathologists to fill open positions in the United States
    in recent years, and these numbers are substantially lower than the
    demand that is being reported for 2022. In contrast, over the last
    decade or so, there have been approximately 620 pathologist residency
    positions available each year. To meet the increased demand for
    pathologists and other physicians, there must be a larger investment in
    training. As such, the CAP asks the Committee to support the following
    bills:

        1.  Pass S. 1302, The Resident Physician Shortage Reduction Act. S.
    1302 would provide 14,000 new Medicare-supported GME positions over 7
    years. While these 14,000 positions would not be enough to remedy the
    over 100,000 plus physician shortage, they are a critical step in the
    right direction. These positions would be targeted at hospitals with
    diverse needs, rural teaching hospitals, hospitals currently training
    over their Medicare caps, hospitals in states with new medical schools,
    and hospitals serving patients in health professional shortage areas.

        2.  Encourage committee members to support S. 665; the CAP supports
    the Conrad State 30 and Physician Access Reauthorization Act. S. 665
    will increase the number of waivers for a state from 30 to 35 and
    incentivize qualified IMGs who are citizens of other nations to work in
    underserved communities. For agreeing to these terms, physicians will
    not have to leave the U.S. for 2 years before they are eligible to
    apply for an immigrant visa or permanent residence, thus allowing them
    to begin to provide necessary patient care in rural and underserved
    areas upon finishing their residency. IMGs are an important part of our
    nation's health care system and currently represent 25% of the
    physician workforce.

                Insurer-Imposed Policies Impacting Patient Care

    Increasingly, our members are experiencing instances of improper
    practices by insurers, which has direct implications for patient care,
    including those with chronic conditions, and coverage. With the passage
    of federal legislation to address surprise billing, health insurance
    plans are increasingly relying on narrow and often inadequate networks
    of contracted physicians, hospitals, and other providers to shift
    medically necessary health care costs onto their enrollees, which can
    be especially burdensome to those with multiple chronic conditions. For
    example, although it has made changes to the program, in 2021
    UnitedHealthcare tried to roll out a ``benefit design'' that requires
    laboratories to meet UnitedHealthcare-determined efficiency and quality
    requirements to become a ``Designated Diagnostic Provider'' or DDP.
    Facilities that did not meet these requirements (non-DDP facilities)
    would ``remain in network,'' but UnitedHealthcare would not cover
    outpatient diagnostic laboratory services provided by these facilities,
    leaving patients ``liable for charges.'' Even with recent
    modifications, the CAP believes UnitedHealthcare policies that subject
    patients to an increased payment for services received at in-network,
    but non-DDP facilities, is counter to efforts to protect patients and
    eliminate surprise medical bills.

    Other insurers are keeping facilities in-network but imposing
    restrictive referral requirements that result in fractured care and
    added burden for patients and their physicians. For example, in
    situations where a biopsy leads to further hospital-based care,
    requiring patient samples to be sent outside the health system either
    prevents participation of the pathologist who is part of the
    multidisciplinary team or adds a second physician to the diagnosis, as
    the hospital-based pathologist will have to confirm the diagnosis and
    assume responsibility for the patient. There are also logistical
    challenges and risks in dividing diagnostic material for a single
    patient. Further, these kinds of requirements can adversely affect
    appropriate response to acute developments in a patient's care, and
    possibly cause significant delay in diagnosis. Some conditions may
    require rapid evaluation and treatment--not always possible when
    sending samples to outside laboratories--in order to prevent serious,
    even life-threatening complications. Additionally, for patients who
    live further away from the health system/hospital, returning to receive
    care after the results have been returned may be difficult and more
    likely to result in delayed care and poorer health outcomes.

    Finally, other health insurance plans are slashing reimbursement across
    the board--or ceasing reimbursement for critical services altogether--
    without any individual physician/practice consideration, leaving many
    pathologists in serious financial jeopardy across the nation. Blanket
    rate cuts that lower reimbursement below the cost to provide the
    services threaten the financial viability of many smaller and/or rural
    laboratories and pathology practices. And many pathologists have little
    leverage or ability to opt out-of-networks with powerful insurers
    because of consolidation and insurer control in their health systems
    and communities. Further, as the American Medical Association recently
    wrote to the FTC and Department of Justice, ``mergers of market power
    health insurers tend to result in lower than competitive payments to
    health care providers, but there is no evidence the cost savings are
    passed through to consumers in the form of lower premiums.'' Hindering
    access to high-quality pathology services through reduced rates or lack
    of payment for pathology and laboratory services, which adversely
    affects patient diagnosis, treatment, and outcomes.

    Insurers' increasing adoption of abusive practices and/or reliance on
    inadequate networks results in adverse consequences for access to
    quality patient care to benefit the financial interest of the payer.
    Now more than ever, patients--especially those with chronic
    conditions--and their treating physicians are relying on the expertise
    of pathologists and the availability of appropriate testing.

                   Meaningful Sources of Health Care Spending

    Finally, the CAP realizes that the policies we are advocating for cost
    money. However, the health of our country's citizenry, more than
    anything else, impacts all facets of our nation--from national security
    to its economic vitality, requiring significant financial investments.
    Therefore, we encourage the Committee look at waste and consolidation
    in the health care system as a source potential source of revenue to
    stabilize the payment system and grow the workforce in lieu of site
    neutral policies. For example, the largest source of health care
    spending in the U.S. is administrative, with over $265 billion a year
    in waste according to some studies.\3\ On the other hand, site neutral
    payment proposals fail to take into consideration the technical costs
    associated with specific individual codes and fail to recognize the
    distinct costs of physician services. Arbitrarily accepting hospital
    outpatient rates instead of the carefully reviewed inputs is a step
    backwards. The CMS has stated that comparisons between the Physician
    Fee Schedule (PFS) and the out-patient prospective payment system
    (OPPS) payments for services are inappropriate because of the different
    nature of the cost inputs and has explicitly refused to impose one
    payment system on the other.
    ---------------------------------------------------------------------------
        \3\ ``The Role of Administrative Waste in Excess U.S. Health
    Spending,'' Health Affairs Research Brief, October 6, 2022.

    OPPS data is hospital data and does not reflect the actual resource
    costs of physicians in their offices or laboratories. It reflects the
    average costs of ``buckets'' of services rather than resource costs for
    individual services performed by physicians. The monies are then
    distributed by case-mix. Complete accuracy of this data is practically
    impossible. OPPS rate setting allows for meaningful comparison of
    resource-intensiveness and costs of services within the OPPS system.
    But the methodology is not designed to allow for comparisons to
    services outside the OPPS. Current law requires physician services to
    be resource-based and ambulatory payment classifications are not
    resource-based. In short, site-neutral proposals could result in
    billions of dollars being shifted between sites of service, and
    potentially out of the health care system, resulting in major
    disruptions in health care revenue at a time when consolidation is on
    the rise and practices in rural and underserved areas are struggling or
    ---------------------------------------------------------------------------
    closing.

    In closing, the CAP appreciates the opportunity to provide these
    comments for the record. Please contact Darren Fenwick at
    dfenwic@cap.org or 202-354-7135 if you have any questions regarding
    these comments.

    Sincerely,

    Donald S. Karcher, M.D., FCAP
    President

                                     ______

              Emergency Department Practice Management Association

                      1660 International Drive, Suite 600

                                McLean, VA 22102

    The Emergency Department Practice Management Association (EDPMA) is the
    nation's only professional trade association focused on the delivery of
    high-quality, cost-effective care in the emergency department. EDPMA's
    membership includes emergency medicine physician groups of all sizes
    and billing, coding, and other professional support organizations that
    assist healthcare clinicians in our nation's emergency departments.
    Together, EDPMA members see or support approximately 60% of all annual
    emergency department visits in the country. For more info, please visit
    https://edpma.org/.

    Re-envisioning a plan for improving the quality of and access to
    physician services provided to Medicare beneficiaries can only occur
    after Congress first stabilizes the Medicare Physician Fee Schedule
    (MPFS) through two policies: (1) the creation of an annual inflationary
    update and (2) the modernization of budget neutrality requirements.
    Although there are additional substantive reforms that would benefit
    the MPFS, indexing the MPFS for inflation and modernizing the budget
    neutrality requirement are critically important, foundational steps
    that must be taken first. Each of these critical steps is described in
    turn below. However, we would first like to emphasize the unique impact
    that Medicare payment instability has on emergency medicine practices.

                 EMTALA's Unique Impact on Emergency Physicians

    Although Medicare reimbursement issues affect all clinicians in the
    program, emergency medicine providers are in a unique situation
    compared to nearly every other medical specialty, due to the
    longstanding federal law EMTALA (Emergency Medical Treatment and Labor
    Act). Since 1987, EMTALA has provided a statutory guarantee that every
    patient who presents to an emergency department must be evaluated and
    medically stabilized regardless of the patient's insurance status or
    ability to pay for their care. Essentially, 100% of all emergency
    patients benefit from EMTALA's protections and 100% of emergency care
    is provided under EMTALA before the physician knows what payment--if
    any--will be rendered for clinical care. EMTALA is a critical feature
    of our nation's safety net and emergency care system. EDPMA members are
    proud to be a pivotal part of that safety net.

    As a direct result of EMTALA, emergency physicians see a broad
    representation of patients, including uninsured, Medicaid, Medicare,
    and commercially insured patients (the average proportions are roughly
    25% for each payor). It is well established that the ultimate
    reimbursement for uninsured, Medicaid, and Medicare services is less
    than the actual cost of providing clinical care to these patients. As a
    result, on average, EMTALA's requirements create a significant unfunded
    gap for approximately 75% of the patients seen in our nation's
    emergency departments. Coupled with significant workforce challenges in
    recent years, this results in a substantial strain on emergency care
    practices.

    These dynamics also mean that emergency physician practices are highly
    sensitive to downward movements, fluctuations, and the absence of
    inflation adjustments for reimbursement rates of all payors, including
    Medicare. Emergency physician practices cannot adjust to reimbursement
    decreases in the same way that other specialties can. When
    reimbursement rates go down or are not adjusted for inflation, other
    specialties not subject to EMTALA have more flexibility to adjust
    processes for patient financial screening or patient scheduling to
    ensure the economic stability of their practices. For example, they can
    first inquire about patients' ability to pay, require insurance
    information or payments before care is delivered, or refuse to see
    patients at all in response to reductions or changes in reimbursement.
    Emergency physician practices have the unique opportunity, but also the
    affirmative challenge of providing clinical care first, and only
    afterwards collecting appropriate reimbursement to attempt to sustain
    patient access to care. This makes emergency care uniquely vulnerable
    to the downward trend in Medicare reimbursements. To avoid stretching
    the safety net beyond its breaking point, the emergency medicine
    community needs the MPFS to be on stable ground before enactment of
    additional substantive reforms.

                  Inflationary Update: Medicare Economic Index

    Unlike Medicare's other major payment systems, the MPFS lacks a
    mechanism to reflect annual inflation, leaving physicians to absorb
    annual increases in the cost of practice on top of any additional
    reimbursement reductions. Not surprisingly, this has resulted in
    physician reimbursement falling significantly behind inflation metrics,
    behind the reimbursement of all other providers, and well behind the
    reimbursement of other sectors of health care, as this graph by the
    American Medical Association illustrates:

    [GRAPHIC] [TIFF OMITTED] T1124.011

    .epsIt is imperative that Congress provide a mechanism for physician
    reimbursement to keep pace with the rising costs of providing medical
    care. The Medicare Economic Index (MEI) is specifically designed to
    measure annual increases in the cost of practice. It provides the most
    relevant inflation metric for the MPFS. For 2024, the MEI is +4.6%.
    Failure to do so will inevitably result in serious beneficiary access
    challenges, as noted in the Medicare Trustees' 2023 Report to
    Congress,\1\ which warned that access to Medicare physicians would
    become ``a significant issue in the long term,'' absent a change in the
    delivery system or in the level of update. The bipartisan Strengthening
    Medicare for Patients and Providers Act (H.R. 2474)\2\ would provide an
    annual inflationary update to the MPFS based on the MEI. This is a
    basic, foundational policy that will provide stability to the Medicare
    program. We urge the Congress to enact this legislation.
    ---------------------------------------------------------------------------
        \1\ https://www.cms.gov/oact/tr/2023.
        \2\ https://www.congress.gov/bill/118th-congress/house-bill/2474/
    text?s=1&r=1&q=%7B%22
    search%22%3A%22HR2474%22%7D.
    ---------------------------------------------------------------------------

                          Budget Neutrality Threshold

    The MPFS is subject to a budget neutrality requirement, by which
    payment changes over a certain threshold must be offset by reductions
    in spending that same year. Over the years, certain policy decisions by
    the Centers for Medicare and Medicaid Services (CMS) have added to
    reimbursement instability by triggering the statutory requirement for
    budget neutrality. Most recently, CMS' creation and implementation of a
    new add-on code (G2211) highlighted the ``winners versus losers''
    dynamic created by this policy: by triggering a Fee Schedule-wide
    budget neutrality adjustment, implementation of this code alone was
    responsible for a -2% reduction in Medicare payments for most
    physicians in 2024 relative to 2023.

    Although repeal of budget neutrality in its entirety may not be
    feasible due to budgetary and scoring implications, Congress must
    update the threshold at which budget neutrality is triggered. That
    threshold is set in statute at $20 million, a number that has never
    been updated since its enactment in the early 1990s. Unless this
    threshold is updated and then indexed from the updated level, budget
    neutrality will be triggered more and more frequently as time goes by.
    That not only creates instability for Medicare clinicians, but it will
    also make it more difficult for CMS to implement policies to keep pace
    with innovation, as even minor policy changes will begin to trigger the
    need for budget neutrality reductions. To avoid across-the-board
    reductions in the future, we urge Congress to modernize the threshold
    at which budget neutrality is triggered. Updating the threshold to $53
    million would reflect the three decades of inflation since the
    threshold was first created. Additionally, indexing the new level on a
    regular basis is a crucial long-term reform that will avoid recreation
    of the same problem in the future. To accomplish both of these goals,
    we urge Congress to enact section 5 of the bipartisan Physician Fee
    Schedule Update and Improvements Act (H.R.6545).\3\
    ---------------------------------------------------------------------------
        \3\ https://www.congress.gov/bill/118th-congress/house-bill/6545/
    text?s=3&r=1&q=%7B%22
    search%22%3A%22H.R.6545%22%7D.

    We hope this feedback is helpful to the Committee as it considers next
    ---------------------------------------------------------------------------
    steps for Medicare physician reimbursement.

                                     ______

                            Healthy Aging Coalition

                       4031 Aspen Grove Drive, Suite 250

                               Franklin, TN 37067

    The Healthy Aging Coalition appreciates the opportunity to provide this
    Statement for the Record in connection with the Senate Committee on
    Finance hearing entitled, ``Bolstering Chronic Care through Medicare
    Physician Payment.'' The Healthy Aging Coalition consists of multiple
    stakeholder organizations that are committed to ensuring that all older
    adults live their best lives with equity, vitality, dignity, and
    purpose, serving as a catalyst for education, action and change. We
    work to build national awareness around the key challenges and issues
    that impact aging adults with a focus on those in rural, underserved
    and minority communities and to identify opportunities for
    stakeholders, including policymakers, to advance equitable, evidence-
    based, and innovative solutions.

    We appreciate the Committee's commitment to examining revisions to
    physician reimbursement in traditional Medicare and Medicare Advantage
    (MA) to enhance support for older adults managing chronic conditions.
    One of the Healthy Aging Coalition's priorities is to support
    initiatives to reduce the prevalence of chronic conditions such as
    obesity, diabetes, heart disease, and Alzheimer's Disease that promote
    healthy longevity by promoting wellness and prevention programs. The
    U.S. cannot address chronic diseases without addressing drivers of
    chronic conditions, such as health disparities and social determinants
    of health (SDOH). We are concerned that current Medicare reimbursement
    does not provide adequate payment for the services and support provided
    by physicians along with those in communities that address these
    drivers and, in turn, address chronic conditions. It is also important
    to recognize the need to stabilize Medicare Advantage and the
    significant progress being made via supplemental benefits. These
    health-related services are important to chronic care as was recently
    issued by CMS for the Supplemental Benefits for the Chronically Ill.

    As the Committee explores changes to Medicare physician payment as a
    means of addressing chronic conditions, we urge that due consideration
    be given to ensuring reimbursement for the community services and
    supports that address and reduce chronic conditions. This would provide
    older adults a greater opportunity to achieve health and wellness.

    Thank you for your leadership in taking steps to support older adults
    managing chronic conditions. The Healthy Aging Coalition is committed
    to working with the Committee to reach this goal. Please contact Vicki
    Shepard at vicki.shepard
    @tivityhealthcom should you have questions or need more information.

    NAMES OF COALITION MEMBERS

    American College of Lifestyle Medicine
    American Society on Aging
    Ashtabula County YMCA (Ohio)
    Archelle Georgiou, MD
    Better Medicare Alliance
    Bitewell
    BloomingHealth
    Determined Health
    DoucetSolutions
    Debbie Witchey
    Gerontological Society of America
    Grantmakers in Aging
    Healthcare Leadership Council
    Health Policy Source
    Home Care Genie
    Jefferson College of Population Health
    Julianne Holt-Lunstad, PhD
    Lois Drapin, The Drapin Group LLC
    Medical Fitness Association
    Mercy Community Healthcare
    Milken Institute
    Motion Picture & Television Fund
    NashvilleHealth
    National Association of Nutrition and Aging Services Programs
    National Council on Aging
    National Minority Quality Forum
    Open Source Wellness
    PreferCare
    Sharecare
    Spark Living and Learning, LLC
    Tivity Health, SilverSneakers
    UsAgainstAlzhiemer's
    USAging
    YMCA of Portage (Indiana)
    Vivo

                                     ______

                     Infectious Diseases Society of America

                          4040 Wilson Blvd., Suite 300

                              Arlington, VA 22203

          Statement of Steven K. Schmitt, M.D., FIDSA, FACP, President

    On behalf of the Infectious Diseases Society of America (IDSA), which
    represents more than 13,000 physicians, scientists, public health
    practitioners and other clinicians specializing in infectious diseases
    prevention, care, research and education, I thank the Committee for its
    focus on physician payment issues, highlighting the needs of patients
    with chronic conditions. IDSA asks the Committee to recognize the link
    between chronic diseases and infectious diseases and the critical need
    to reform Medicare physician payment policies to support access to
    infectious diseases prevention, diagnosis and treatment that can
    especially impact patients with chronic diseases.

    The Connection Between Chronic Disease and Infectious Disease

    Chronic diseases and infectious diseases are inextricably linked. Some
    chronic diseases are caused by infections. Patients with chronic
    conditions are often at greater risk of contracting infectious diseases
    and suffering more serious illness from infections, as we saw with
    COVID-19. These issues demonstrate that infectious diseases (ID)
    physicians play a key role in caring for patients with chronic
    diseases. As the percentage of the U.S. population that is
    immunosuppressed (due to transplants, use of certain biologics,
    cancers, etc.) continues to grow, so will the need for a robust ID
    workforce and a payment system that enables ID recruitment and access
    to ID care.

    Recent research has shown that many chronic illnesses result from
    infectious agents and can be exacerbated by infectious pathogens.\1\
    For example, infectious agents such as viruses, bacteria and parasites
    can cause cancer or increase the risks of developing cancer. Certain
    viruses can also disturb the signals in the body that moderate cell
    growth and can lead to cancer developing. Cancer patients also have a
    much weaker immune system due to the spread of cancer to the bone
    marrow, thereby stopping the production of blood cells that can help in
    fighting infections. Furthermore, cancer treatments such as
    chemotherapy, steroids and radiation can weaken the immune system,
    making cancer patients more susceptible to infections.
    ---------------------------------------------------------------------------
        \1\ Knobler, S.L., O'Connor, S., Lemon, S.M., & Najafi, M. (2018).
    OVERVIEW. The Infectious Etiology of Chronic Diseases--NCBI Bookshelf.
    https://www.ncbi.nlm.nih.gov/books/NBK8
    3680/.

    The human immunodeficiency virus (HIV) is now regarded as a chronic
    disease that patients live with for multiple decades due to the use of
    antiretroviral therapy (ART).\2\ Health care systems across the country
    now treat HIV patients with chronic care management models. However,
    ART can cause multiple complications over time. Cumulative exposure
    over time to antiretroviral drugs has demonstrated that HIV-infected
    adults are at a much higher risk for the development of cardiovascular
    disease, kidney disease, osteoporosis and neurocognitive disease.
    Patients that have been diagnosed with viruses such as HIV have weaker
    immune systems and are less able to fight infections that may cause
    cancer. HIV patients are at a higher risk for many different forms of
    cancer, including Kaposi sarcoma, Hodgkin's lymphoma and liver and lung
    cancer.\3\
    ---------------------------------------------------------------------------
        \2\ Deeks, S.G., Lewin, S.R., and Havlir, D.V. (2013). ``The end of
    AIDS: HIV infection as a chronic disease,'' The Lancet, 382(9903), pp.
    1525-1533. doi:10.1016/s0140-6736(13)61809-7.
        \3\ Risk factors: infectious agents. (2019, March 4). National
    Cancer Institute. https://www.cancer.gov/about-cancer/causes-
    prevention/risk/infectious-agents.

    The number of immunosuppressed adults in the United States has been
    increasing over time due to wider use of new immunosuppressive
    treatments for a broad range of conditions that are immunocompromising,
    including cancer, organ transplants, autoimmune disorders, rheumatoid
    arthritis, psoriasis and more. Immunosuppression greatly increases the
    risks and severity of infections. A review of 2021 data found that 6.6%
    of U.S. adults are immunosuppressed, a significant increase from the
    2.7% reported in 2013.\4\, \5\ Additionally, the numbers of
    immunocompromised infants and children have also increased, and
    pediatric ID physicians provide care to a significant number of these
    patients who are at a much higher risk for developing serious
    infections.
    ---------------------------------------------------------------------------
        \4\ Martinson, Melissa L., and Lapham, J. ``Prevalence of
    immunosuppression among U.S. adults.'' JAMA, vol. 331, no. 10, 12 Mar.
    2024, p. 880, https://doi.org/10.1001/jama.2023.
    28019.
        \5\ Harpaz, R., Dahl, R., & Dooling, K. (2016). Prevalence of
    immunosuppression among U.S. adults, 2013. JAMA, 316(23), 2547. https:/
    /doi.org/10.1001/jama.2016.16477.

    Over the past 4 years, the medical community has seen an increase in
    hospitalizations and deaths due to COVID-19 in patients with chronic
    conditions, such as heart disease, diabetes and more.

    Antimicrobial Resistance and Risk of Complications

    The prevalence of antimicrobial resistance (AMR) is a growing threat to
    patients, including those with chronic diseases. Millions of Americans
    per year develop
    hospital-acquired infections due to antibiotic-resistant pathogens.\6\
    The inappropriate use of antibiotics over decades has resulted in
    antibiotic resistance rates that continue to rise, with recent progress
    hampered by the COVID-19 pandemic.
    ---------------------------------------------------------------------------
        \6\ Clinical Infectious Diseases, ciad428. ``AMR Guidance.'' IDSA
    Home, https://www.idsociety.
    org/practice-guideline/amr-guidance/.

    To address the threat of AMR, IDSA greatly appreciates the leadership
    of Senators Michael Bennet (D-CO) and Todd Young (R-IN) in sponsoring
    the bipartisan PASTEUR Act, which would strengthen the antibiotic and
    antifungal pipeline by changing the way the federal government pays for
    novel antibiotics and antifungals that address unmet needs--paying for
    value instead of volume used. Under PASTEUR, the federal government
    would enter into contracts with novel antibiotic/antifungal developers
    to pay a set fee for a supply of new drugs regardless of the quantity
    used. PASTEUR would also provide grants to hospitals to support
    antimicrobial stewardship programs, with priority given to rural,
    critical access and safety net hospitals (which may partner with
    academic institutions for stewardship). Successful implementation of
    PASTEUR would require more ID physicians to ensure patients with
    resistant infections receive optimal treatment, lead clinical trials
    for novel antimicrobials and ensure that new antimicrobials are used
    appropriately.

    Current Medicare Reimbursement Concerns

    Currently, nearly 80% of counties in the United States do not have a
    single ID physician, and this poses significant patient access
    problems.\7\ Recruitment within the specialty continues to decline. In
    last year's fellowship match, only about 51% of ID training programs
    filled (down from 56% the year before), whereas most specialties filled
    90%-100% of their training programs. These shortages are driven in part
    by reimbursement disparities that negatively impact infectious disease
    physicians.
    ---------------------------------------------------------------------------
        \7\ Walensky, Rochelle P., et al. ``Where is the ID in COVID-19?''
    Annals of Internal Medicine, vol. 173, no. 7, 6 Oct. 2020, pp. 587-589,
    https://doi.org/10.7326/m20-2684.

    Many medical students and residents are very interested in this field
    but cite financial reasons for pursuing specialties that have much
    higher reimbursement rates. Only three other medical specialties fall
    below ID in terms of compensation, according to Medscape. Two of
    those--pediatrics and public health--are primarily paid outside of the
    Medicare system. The shortage of ID physicians is very worrisome from a
    patient care and public health perspective, given the unique roles ID
    physicians play. ID is uniquely part of the foundation of modern health
    care. Cancer chemotherapy, organ transplants and other surgeries carry
    significant risk of infection and require ID expertise. Many hospital
    quality measures, conditions of participation (antimicrobial
    stewardship, infection prevention and control) and other metrics upon
    which hospital payments hinge (hospital readmissions, health care-
    associated infections) all fundamentally require ID physicians. ID
    physicians are at the forefront of leading preparedness and responses
    to outbreaks and pandemics. Patients with serious infections have
    better outcomes, shorter hospital stays and lower health care costs
    when cared for by an ID physician.\8\
    ---------------------------------------------------------------------------
        \8\ McQuillen, Daniel P., and MacIntyre, Ann T. ``The value that
    infectious diseases physicians bring to the healthcare system.'' The
    Journal of Infectious Diseases, vol. 216, no. suppl--5, 15 Sept. 2017,
    https://doi.org/10.1093/infdis/jix326.
    ---------------------------------------------------------------------------

    IDSA's Proposals to Improve ID Capacity and Reimbursement

    As the Finance Committee considers Medicare Physician Fee Schedule
    reforms, we strongly urge you to include provisions that target
    specialties, like ID, that are at the bottom of the payment scale and
    are experiencing recruitment challenges and workforce shortages
    directly linked to inadequate reimbursement. IDSA recommends a
    provision that would provide a temporary 10% incentive payment to ID
    physicians, modeled after similar previous efforts for primary care and
    general surgery. This approach would provide a critical, rapid boost
    that would impact the specialty decisions of current medical students
    and residents. It would also serve as a bridge to provide time to
    develop and implement longer-term solutions.

    Over the last several years, IDSA has repeatedly engaged with the
    Centers for Medicare & Medicaid Services (CMS) to ask for assistance in
    addressing the reimbursement challenges that are impeding recruitment
    of ID physicians. Initially, we focused on urging CMS to improve the
    values of inpatient evaluation and management (E/M) codes, the codes
    mainly used by ID physicians, to maintain their historic relativity
    with outpatient E/M codes (whose values were increased in 2021). The
    historic relativity was based upon the fact that inpatient care is
    inherently more complex than outpatient care. Patients with serious
    infections often have underlying chronic illnesses, require more
    complex medical decision making and are at greater risk of adverse
    outcomes. CMS has not accepted this recommendation.

    In January 2024, IDSA provided a list of services performed by ID
    physicians that are not adequately captured by existing E/M codes, in
    response to a request from CMS. At the end of February 2024, IDSA
    submitted to CMS draft code descriptors \9\ for infectious diseases
    complex prevention, infectious diseases, complex investigation/
    diagnosis, complex antimicrobial therapy and infectious diseases
    complex care management. IDSA also shared two draft code descriptors
    that refer more generally to complex care, to provide CMS with options
    that are not ID-specific: complex medication management and inpatient
    complex care management. The six code descriptors align with the six
    categories of activities routinely performed by ID physicians not
    adequately captured by current E/M codes. IDSA encouraged CMS to
    include these new codes and/or add-on codes in the upcoming CY 2025
    Medicare Physician Fee Schedule rulemaking.
    ---------------------------------------------------------------------------
        \9\ https://www.idsociety.org/globalassets/idsa/policy--advocacy/
    current_topics_and_issues/
    antimicrobial_resistance/strengthening_us_efforts/letters-manually-
    added/idsa-add-on-codes-letter-and-descriptors_feb2024.pdf.

    Several members of Congress are increasingly concerned about the ID
    physician workforce shortage and ID reimbursement issues. Last fall, a
    bipartisan group of representatives sent a letter \10\ to CMS asking
    for the agency to incentivize more medical students to enter the
    infectious diseases field by modifying its reimbursement policy.
    ---------------------------------------------------------------------------
        \10\ https://www.idsociety.org/contentassets/
    2b7de28c54ae43f098838c12b2783a1f/congressman-van-drews-letter-to-cms-
    on-infectious-diseases-medicare-reimbursement-final.pdf.

    Like many medical specialties, IDSA is supportive of broad reforms to
    the Medicare physician payment system, including tying payment updates
    to a measure of inflation, such as the Medicare Economic Index;
    revising budget neutrality requirements, including raising the budget
    neutrality threshold; and requiring ongoing updates to the practice
    expense inputs that inform the value of services. These reforms are
    essential to addressing some of the foundational challenges that
    persist in the physician payment mechanism. However, these reforms
    alone are not sufficient to address the significant payment disparities
    facing ID that are driving ID recruitment challenges.

    Conclusion

    Thank you for your attention to physician payment issues and for
    considering our requests regarding the need to bolster access to ID
    treatment and prevention of infectious diseases through Medicare
    reimbursement reforms. While Medicare primarily covers adults,
    pediatric ID physicians face similar reimbursement and recruitment
    challenges that we hope to discuss in the future. We look forward to
    working with the Committee on these critical topics.

    Should you have any questions or wish to discuss our requests further,
    please contact Amanda Jezek, IDSA's senior vice president for public
    policy & government relations, at ajezek@idsociety.org.

                                     ______

                      Medical Group Management Association

                        1717 Pennsylvania Ave., NW, #600

                              Washington, DC 20006

                                 T 202-293-3450

                                 F 202-293-2787

                                    mgma.org

    April 10, 2024

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chairman                            Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    215 Dirksen Senate Office Building  215 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Re: MGMA Statement for the Record--Senate Committee on Finance's April
    11th Hearing, ``Bolstering Chronic Care through Medicare Physician
    Payment''

    Dear Chairman Wyden and Ranking Member Crapo:

    On behalf of our member medical group practices, the Medical Group
    Management Association (MGMA) would like to thank the Committee for the
    opportunity to provide feedback on bolstering chronic care through
    Medicare physician payment. We appreciate your leadership in holding
    this important hearing as it is vital that Medicare adequately
    reimburse physicians for their chronic care services. Significant
    reforms are needed to the Medicare physician payment system to stop the
    harmful yearly cuts and support medical groups' ability to offer high-
    quality care to patients with chronic conditions.

    With a membership of more than 60,000 medical practice administrators,
    executives, and leaders, MGMA represents more than 15,000 group medical
    practices ranging from small private medical practices to large
    national health systems, representing more than 350,000 physicians.
    MGMA's diverse membership uniquely situates us to offer the following
    policy recommendations.

    The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was
    enacted to repeal the flawed Sustainable Growth Rate (SGR) formula,
    stabilize payment rates to physicians in Medicare fee-for-service, and
    incentivize physicians' transition to value-based care models. While
    well-intentioned, MACRA's methodology for updating the Medicare
    Physician Fee Schedule (PFS) does not keep pace with rising practice
    costs and inflation, and simultaneously cuts reimbursement for
    physicians.

    The Centers for Medicare & Medicaid Services (CMS) finalized a 3.37%
    cut to the Medicare conversion factor in its 2024 Medicare Physician
    Fee Schedule (PFS). From January 1st to March 8th of this year, medical
    groups absorbed a 3.37% reduction to reimbursement. Following
    congressional action to partially mitigate 1.68% of the cut in the
    Consolidated Appropriations Act of 2024 (CAA, 2024), physician
    practices are left with a 1.69% reduction for the rest of the year.

    Medicare physician reimbursement is on a dire trajectory, and these
    annual cuts continue to undermine the ability of medical group
    practices to keep their doors open and function effectively. MGMA
    offers the following recommendations to strengthen Medicare payment and
    sustainably support medical groups providing care to patients with
    chronic conditions.

                              Key Recommendations

          Pass legislation to implement an annual inflation-based
    physician payment update tied to the Medicare Economic Index (MEI) to
    ensure medical groups have a functioning reimbursement system moving
    forward that keeps pace with rising costs. Without providing an annual
    inflationary update for physicians--similar to other payment systems
    under Medicare--medical groups will continue to face financial barriers
    to providing access to care for patients with chronic conditions in
    their communities. The Strengthening Medicare for Patients and
    Providers Act would provide this long-needed annual MEI-based update to
    Medicare physician reimbursement.
          Reform the budget neutrality aspect of the Medicare Part B
    payment system to avoid continued across-the-board payment cuts harming
    medical groups' financial viability.
          Pass the Chronic Care Management Improvement Act of 2023 to
    ensure Medicare patients with chronic conditions are able to access
    high-
    quality care.
          Provide positive financial incentives to support practices
    transitioning into value-based care. The Value in Health Care Act of
    2023 would reinstate the advanced alterative payment model (APM)
    incentive payment at 5%, allow CMS to set the qualifying APM
    participant (QP) thresholds at an appropriate level, and institute
    additional polices to properly incentivize and assist practices
    transitioning to value-based care arrangements.

    Pass an Annual Medicare Inflationary Payment Update

    This year's cut to the conversion factor is entirely untenable as the
    cost of running a medical practice continues to rise--89% of MGMA
    members reported an increase in operating costs in 2023.\1\ According
    to MGMA data, physician practices saw total operating cost per FTE
    physician increase by over 63% from 2013-2022, while the Medicare
    conversion factor increased by only 1.7% over the same timeframe.
    ---------------------------------------------------------------------------
        \1\ MGMA Stat Poll, July 12, 2023. https://www.mgma.com/mgma-stat/
    higher-costs-persist-for-medical-groups-even-as-inflations-growth-
    slows.

    In our 2023 Annual Regulatory Burden Report, MGMA surveyed over 350
    medical groups and 87% of respondents reported that reimbursement not
    keeping up with inflation impacts current and future Medicare patient
    access.\2\ This aligns with what the Medicare Trustees recently said in
    their 2023 report:
    ---------------------------------------------------------------------------
        \2\ MGMA 2023 Annual Burden Report, November 13, 2023. https://
    www.mgma.com/federal-policy-resources/mgma-annual-regulatory-burden-
    report-2023.

            While the physician payment system put in place by MACRA
            avoided the significant short-range physician payment issues
            resulting from the SGR system approach, it nevertheless raises
            important long-range concerns that will almost certainly need
            to be addressed by future legislation. In particular,
            additional payments totaling $500 million per year and annual
            bonuses are scheduled to expire in 2025 and 2026, respectively,
            resulting in a payment reduction for most physicians. In
            addition, the law specifies the physician payment updates for
            all years in the future, and these updates do not vary based on
            underlying economic conditions, nor are they expected to keep
            pace with the average rate of physician cost increases. The
            specified rate updates could be an issue in years when levels
            of inflation are high and would be problematic when the
            cumulative gap between the price updates and physician costs
            becomes large. Absent a change in the delivery system or level
            of update by subsequent legislation, the Trustees expect access
            to Medicare-participating physicians to become a significant
            issue in the long term.\3\
    ---------------------------------------------------------------------------
        \3\ Medicare Board of Trustees, 2023 Annual Report of the Board of
    Trustees of the Federal Hospital Insurance and Federal Supplementary
    Medical Insurance Trust Funds, March 31, 2023. https://www.cms.gov/
    oact/tr/2023.

    Practices have seen significant cuts to Medicare physician payment over
    the past 4 years, which have a heightened impact in the face of
    inflationary pressures (CMS projected a 4.6% increase to the MEI for
    2024) and other economic factors such as staffing shortages. Failing to
    stop this downward spiral in physician payment will continue to
    threaten the financial viability of medical groups, hasten negative
    repercussions to this nation's healthcare system, and hurt group
    ---------------------------------------------------------------------------
    practices' ability to treat patients with chronic diseases.

    Other Medicare payment systems receive annual positive updates--even
    hospitals that received a 3.1% increase in the Medicare hospital
    outpatient prospective payment system (OPPS) for 2024 have decried the
    insufficient nature of their positive increase given financial
    constraints and thin margins in the current environment. How does the
    Committee expect physicians to keep their doors open in the same
    environment if Congress allows these cuts to continue?

    A permanent solution is critical to stabilize Medicare physician
    payment. The Strengthening Medicare for Patients and Providers Act,
    which was introduced by a bipartisan group of congressional doctors in
    the House of Representatives and currently has 127 cosponsors, would
    provide an annual Medicare physician payment update tied to inflation,
    as measured by the MEI. This commonsense policy is long overdue to
    bring physician payment in line with the costs of providing care and
    should be enacted as soon as possible.

    Modernize Medicare's Antiquated Budget Neutrality Policies

    Compounding the lack of an inflation-based update are the annual
    reimbursement cuts medical groups continue to face stemming from 2021
    Medicare PFS changes, the phase-in of the E/M complexity add-on code
    (G2211) that CMS implemented in 2024, and corresponding budget
    neutrality requirements. The Provider Reimbursement Stability Act of
    2023 would modernize many aspects of Medicare budget neutrality and
    would make significant changes to alleviate the adverse effects
    practices are experiencing. The legislation would increase the
    triggering threshold from $20 million to $53 million (while adding an
    update to keep pace with inflation), institute new utilization review
    requirements to better reflect the reality of providers using certain
    services compared to CMS' estimates, and more.

    MGMA urges Congress to make changes to budget neutrality in unison with
    the long-needed annual inflationary update. These policies work in
    concert to undermine the financial viability of medical practices, as
    medical groups will be facing another cut in 2025 absent congressional
    intervention. Addressing both problems would go a long way towards
    establishing an appropriate and sustainable Medicare reimbursement
    system.

     Support Patients With Chronic Conditions by Enacting the Chronic Care
                        Management Improvement Act of 2023

    Chronic care management (CCM) is an integral part of care coordination
    for patients with chronic conditions. Medicare started paying for CCM
    services in 2015 for primarily non-face-to-face CCM services. While we
    support this initiative to improve the ability to manage patients'
    chronic conditions, theses services created a beneficiary cost-sharing
    obligation.

    The 20% coinsurance requirement for CCM services is a barrier to care
    for beneficiaries who are not used to cost sharing for care management
    services. The Chronic Care Management Improvement Act of 2023 would
    waive this coinsurance requirement, thereby improving patients' ability
    to receive the chronic care they need. We urge the Committee to pass
    this important piece of legislation.

     Support Physician Practices Transitioning Into Value-Based Care
                        Arrangements

    Value-based care arrangements such as APMs can help physician practices
    successfully treat patients with complex and chronic conditions, but
    Congress needs to do more to ensure practices have adequate financial
    support to voluntarily make the transition from fee-for-service.
    Congress recently extended the APM incentive payment at 1.88% for
    2024--a decrease from 3.5% in 2023, and 5% in 2022. MGMA strongly urges
    Congress to reinstate the full 5% as this payment is necessary to cover
    costs, support investments, and safeguard the financial viability of
    medical groups in the program.

    Congress also froze the QP thresholds at the 2023 level for the 2024
    performance period in the CAA, 2024. This was a welcomed extension, as
    CMS' increase of these thresholds would have made it extremely
    difficult for many medical groups to reach QP status and qualify for
    the APM incentive bonus and avoid onerous reporting requirements under
    the Merit-based Incentive Payment System (MIPS). We suggest the
    Committee give CMS the ability to adjust these thresholds under statute
    to allow them to be set at reasonable levels, as drastic increases to
    QP thresholds will make it impossible for many practices to join or
    continue participating in APMs. The Value in Health Care Act of 2023
    includes language to this effect and would implement additional
    policies, such as extending the 5% APM incentive payment, to better
    assist practices transitioning into value-based care arrangements.

    Conclusion

    MGMA thanks the Committee for its leadership in examining Medicare
    payment for chronic care. We look forward to collaborating with the
    Committee and its colleagues to craft sensible payment policies that
    will reinforce practices' ability to offer high-quality care to
    patients with chronic conditions. If you have any questions, please
    contact James Haynes, Associate Director of Government Affairs, at
    jhaynes@mgma.org or 202-293-3450.

    Sincerely,

    Anders Gilberg
    Senior Vice President
    Government Affairs

                                     ______

                      National Academy of Neuropsychology

                      7555 East Hampden Avenue, Suite 420

                             Denver, Colorado 80231

                                PH: 303-691-3694

                                FX: 303-691-5983

    April 25, 2024

    The Honorable Ron Wyden             The Honorable Mike Crapo
    Chair                               Ranking Member
    U.S. Senate                         U.S. Senate
    Committee on Finance                Committee on Finance
    219 Dirksen Senate Office Building  219 Dirksen Senate Office Building
    Washington, DC 20510                Washington, DC 20510

    Dear Chairman Wyden and Ranking Member Crapo:

    On behalf of the National Academy of Neuropsychology (NAN), we are
    writing to share comments and recommendations for consideration as part
    of your committee's April 11th hearing, ``Bolstering Chronic Care
    through Medicare Physician Payment.'' NAN is an organization that
    represents neuropsychologists, who are doctoral experts in how brain
    injuries and conditions affect behavior and functional abilities.
    Neuropsychologists work closely with other medical specialists in the
    assessment and treatment of people with a variety of brain injuries and
    diseases, as well as promoting brain health.

    You have received similar comments from our colleagues at the American
    Psychological Association Services (APA Services), which we have
    modified to identify specific considerations related to the practice of
    neuropsychology.

    We applaud your committee's attention to improving Medicare healthcare
    provider reimbursement policies, as they are not adequately supporting
    high-quality, cost-
    effective health care for the program's beneficiaries. We share the
    concerns of the broad provider community regarding the consistent
    failure of payment updates for Part B providers to keep pace with
    inflation. Steadily eroding reimbursement rates are increasingly making
    Medicare participation unsustainable for psychologists and other
    providers. We strongly support proposals to raise the budget neutrality
    cap on adjustments to the Medicare Physician Fee Schedule (PFS), and to
    connect annual conversion factor increases to the Medicare Economic
    Index or similar measures of inflation. However, our comments today
    will focus on aspects of the Medicare fee schedule and proposed payment
    policies that specifically impact neuropsychological services.

    Because of their foundational importance, it is important for
    policymakers to understand that Medicare PFS payment formula
    methodologies for both work and practice expenses have consistently
    undervalued neuropsychologists' services. This situation has been
    exacerbated by the statutory requirement that annual updates to the PFS
    be made in a budget neutral manner.

    Work Valuation

    As the committee has recognized, the Medicare fee schedule tends to
    undervalue cognitively intensive services, and neuropsychologists'
    services are cognitively intensive. The Centers for Medicare and
    Medicaid Services (CMS) has recognized the need to set more appropriate
    work values for psychologists' services, and in the 2024 fee schedule
    CMS initiated a 19.1% increase in work relative value units (RVUs) for
    psychotherapy services over the next 4 years. However, CMS has not
    adopted a similar increase for psychological and neuropsychological
    testing and assessment services, which are as cognitively demanding as
    psychotherapy services.

    Psychological assessment is the process of systematically collecting
    reliable and valid information about behavior from multiple sources to
    inform decisions about a patient's mental or behavioral functioning,
    typically for the purpose of diagnoses, treatment planning, or
    treatment evaluation. Domains assessed in a psychological assessment
    typically consist of mood/emotional conditions and symptoms, mental
    status, adaptive functioning, and behavioral and interpersonal
    adjustment, with evaluation of acuteness vs. chronicity, severity,
    degree of functional impairment, comorbidity, and prognosis where
    information is available. Psychological testing has been shown to
    provide both clinical and financial benefit in treating psychiatric
    disorders.\1\
    ---------------------------------------------------------------------------
        \1\ Durosini, I., & Aschieri, F. (2021). Therapeutic assessment
    efficacy: A meta-analysis. Psychological Assessment, 33(10), 962-972.
    https://doi.org/10.1037/pas0001038.

    Neuropsychological assessments provide measurements of behavioral
    manifestations of central nervous system (CNS) disorders using
    techniques that provide objectivity, validity, and reliability.
    Information acquired from neuropsychological assessments can directly
    inform medical decisions by providing data relevant to diagnosis,
    progression or course of conditions, prognosis, and treatment of
    disorders. In addition, neuropsychological assessments can aid in
    making accurate predictions about functional abilities across a variety
    of disorders.\2\, \3\ Neuropsychological tests are
    administered in the context of a comprehensive evaluation that
    synthesizes data from clinical interviews, record review, medical
    history, and behavioral observations. Where appropriate, these
    evaluations consider neuroimaging, other neuro-diagnostic studies, and
    other lab/diagnostic studies to inform neuropsychologically oriented
    interventions.\4\
    ---------------------------------------------------------------------------
        \2\ Chaytor, N. & Schmitter-Edgecombe, M. (2003). The ecological
    validity of neuropsychological tests: A review of the literature on
    everyday cognitive skills. Neuropsychology Review, 13, 181-197.
        \3\ Gure, T. R., Kabeto, M. U., Plassman, B. L., Piette, J. D., &
    Langa, K. M. (2010). Differences in functional impairment across
    subtypes of dementia. Journals of Gerontology: Biological Sciences and
    Medical Sciences, 65, 434-441.
        \4\ Board of Directors. (2007). American Academy of Clinical
    Neuropsychology (AACN) practice guidelines for neuropsychological
    assessment and consultation. The Clinical Neuropsychologist, 21, 209-
    231.

    Neuropsychological evaluation remains the most sensitive cognitive
    testing method for discriminating pathophysiological dementia from age-
    related cognitive decline, cognitive difficulties that are depression-
    related, and other related disorders, and are the gold standard in both
    reliably establishing a diagnosis and developing treatment plans by
    clinically justifying relevant therapies and interventions.\5\ This is
    important in dementia care, as medications used to treat Alzheimer's
    disease have virtually no benefit for patients with other forms of
    dementia. An estimated 17% of Medicare beneficiaries with vascular
    dementia and 8% with Parkinson's disease are initially misdiagnosed
    with Alzheimer's disease, resulting in unnecessary treatment costs
    until they are accurately diagnosed.\6\
    ---------------------------------------------------------------------------
        \5\ Weintraub S. Neuropsychological Assessment in Dementia
    Diagnosis. Continuum (Minneapolis, Minn.). 2022 Jun 1;28(3):781-799.
    doi: 10.1212/CON.0000000000001135. PMID: 35678402; PMCID: PMC9492323.
        \6\ Hunter CA, Kirson NY, Desai U, Cummings AK, Faries DE, Birnbaum
    HG. Medical costs of Alzheimer's disease misdiagnosis among U.S.
    Medicare beneficiaries. Alzheimer's Dement. 2015 Aug;11(8):887-95. doi:
    10.1016/j.jalz.2015.06.1889. Epub 2015 Jul 21. PMID: 26206626.

    CMS stated in the CY 2024 proposed rule, ``because the physician/
    practitioner work RVU is developed based on the time and intensity of
    the service, the issues regarding the valuation of these types of
    services are particularly pronounced for services that are billed in
    time units (like psychotherapy codes) that directly reflect the
    practitioner time inputs used in developing work RVUs, compared to
    other services that are not billed in time units in which work RVUs are
    based on estimates of typical time, usually based on survey data.''\7\
    ---------------------------------------------------------------------------
        \7\ Medicare and Medicaid Programs; CY 2024 Payment Policies Under
    the Physician Fee Schedule and Other Changes to Part B Payment and
    Coverage Policies. 88 Fed. Reg. 52262. (proposed August 7, 2023).

    As with psychotherapy services and their corresponding codes, all
    psychological and neuropsychological testing services are time-based
    services and meet CMS' rationale for the proposed increase in value. We
    believe that parallel increases in the work RVUs for all psychological
    and neuropsychological testing and assessment services are warranted to
    maintain relativity across the current procedural terminology (CPT)
    codes, and to avoid disincentivizing provision of these services.

     Supporting Neuropsychology Integration in Alternative Payment Models

    In order to effectively respond to the needs of older adults with
    chronic conditions, it is imperative that new payment models and
    incentives adequately support integrated primary and behavioral/
    cognitive healthcare. For example, Integrated primary care, in which
    primary care and neuropsychologists work together as a team to assess
    and care for patients and their families, can improve patient outcomes
    and satisfaction with care and reduce overall treatment costs. It can
    also increase access to mental health treatment, since as many as 80%
    of patients with a mental illness visited a primary care provider
    within the last year, and up to 75% of primary care visits include
    mental or behavioral health components, including behavioral factors
    related to chronic disease management and patient health and well-
    being.\8\, \9\ In addition to improving the identification
    and treatment of individuals with behavioral disorders and care of
    patients' chronic conditions, research shows that integrated care can
    reduce treatment costs. One study found that integrating a psychologist
    into a primary care practice resulted in cost savings of $860 per
    member per year.\10\ We applaud the Committee's approval of the Better
    Mental Health Care, Lower-Cost Drugs, and Extenders Act, and its
    provisions in Sec. 104 to support adoption of evidence-based models of
    integrated care. We urge the Committee to continue to support
    integrated care in its development of new payment models and policies.
    ---------------------------------------------------------------------------
        \8\ https://www.cms.gov/priorities/innovation/innovation-models/
    guide.
        \9\ Guterman EL, Kiekhofer RE, Wood AJ, et al. Care Ecosystem
    Collaborative Model and Health Care Costs in Medicare Beneficiaries
    With Dementia: A Secondary Analysis of a Randomized Clinical Trial.
    (2023). JAMA Intern Med. 183(11):1222--1228. doi:10.1001/
    jamainternmed.2023.4764
        \10\ Robert John Sawyer et al. (2023). Making the Business Case for
    Value-Based Dementia Care, NEJM Catalyst. DOI: 10.1056/CAT.22.0304.

    Payment models, such as CPC+ were intended to incorporate care
    coordination and behavioral health integration as cost effective means
    of improving health outcomes. However, these models remain based in
    Medicare's fee for service structure and lack accountability for
    behavioral health outcomes and integration. The CMMI Primary Care First
    model builds on CPC+ and moves practices closer to taking on full risk,
    while focusing on high need, seriously ill patients. Yet, like CPC+ and
    Patient Centered Medical Homes, it focuses on physical health rather
    than behavioral health outcomes. Without adequate quality metrics,
    there is limited accountability and assessment of the value of
    ---------------------------------------------------------------------------
    integration.'' (p. 51)

    We were pleased to hear discussion of the CMS Innovation Center's
    Guiding an Improved Dementia Experience (GUIDE) Model8 during the
    hearing. The GUIDE model represents an innovative structure of care
    management that recognizes the critical role caregivers play in
    management of dementia and allows for provision of services that
    benefit an individual patient directly and indirectly via caregiver
    education, support, and respite services. As noted in the CMS
    description, ``dementia affects more than 6.7 million Americans in
    2023,'' and fragmentation in care leads to inaccurate or delayed
    diagnosis and increased contact with emergency services and hospital
    admissions, resulting in rising costs and poorer outcomes. Provider-
    based, fee-for-service models do not take into account the value of
    preventing unnecessary emergency and admission services. The GUIDE
    model builds upon existing care management programs, some of which were
    created by neuropsychologists.\9\ In the GUIDE model, the first
    recommendation in identifying beneficiaries is to utilize an
    interdisciplinary approach to the ``Initial Comprehensive Assessment
    Visit,'' which includes a cognitive assessment. Such programs add value
    via direct payments, improved diagnostic and risk specificity, and
    savings due to reduction in costly intervention through case management
    and caregiver support services.\10\

    We appreciate the opportunity to provide these comments on this
    critical issue, and we look forward to working with the committee to
    establish more effective Medicare payment policies for the benefit of
    the program's millions of beneficiaries.

    Sincerely,

    William Perry, Ph.D.
    Executive Director and Past-President

                                     ______

                          National Association of ACOs

                          2001 L Street, NW, Suite 500

                              Washington, DC 20036

                                  202-640-1985

                                 www.naacos.com

    The National Association of ACOs (NAACOS) appreciates the opportunity
    to submit a statement to the Senate Committee on Finance in response to
    the hearing ``Bolstering Chronic Care through Medicare Physician
    Payment.'' NAACOS represents more than 430 accountable care
    organizations (ACOs) in Medicare, Medicaid, and commercial insurance
    working on behalf of health systems and physician provider
    organizations across the nation to improve quality of care for patients
    and reduce health care cost. NAACOS members serve over 9 million
    beneficiaries in Medicare value-based payment models, including the
    Medicare Shared Savings Program (MSSP) and the ACO Realizing Equity,
    Access, and Community Health (REACH) Model, among other alternative
    payment models (APMs). NAACOS appreciates the committee's leadership
    and commitment towards improving the Medicare payment system. Our
    statement reflects the shared goal of our members to advance value-
    based care.

                       APMS ARE A PLATFORM FOR IMPROVING
                            CHRONIC CARE MANAGEMENT

    A key aim of health care should be keeping patients healthy and
    supporting them with getting the right services, at the right time, in
    the right place. Unfortunately, Medicare's fee-for-service (FFS)
    payment system can lead to care fragmentation that results in reactive,
    sickness-based care. This means higher costs and less coordinated care
    for patients. The current physician payment system also underinvests in
    primary care and care coordination and does not account for adequately
    paying providers as costs rise. As a result, physician practices have
    limited funding or tools to proactively manage complex patient care.
    Stabilizing Medicare's payment system and ensuring payment adequacy
    along with strong incentives to adopt infrastructure and staffing
    necessary for population health is needed to transition into payment
    models that focus on outcomes.

    APMs have proved to be the solution. Over the last 2 decades, the
    growth of APMs has enabled health care providers to work as a team and
    make necessary investments that result in better outcomes and reduced
    costs. APMs are becoming more rooted in our health care system but
    growth has been slower than Congress' original goal. It is essential to
    remove barriers to participation and give additional flexibility and
    tools to innovate care.

    ACOs Are the Largest APM Leading Medicare's Value Transformation

    The MSSP is the largest and most successful value-based care program in
    Medicare, and as such it should be utilized as an innovation platform.
    In 2024, there are 602 ACOs coordinating care for 13.4 million Medicare
    beneficiaries. ACOs are a voluntary alternative to the fragmented FFS
    system that gives doctors, hospitals, and other health care providers
    the flexibility to innovate care and holds them accountable for the
    clinical outcomes and cost of treating an entire population of
    patients.

    With primary care as the backbone, ACOs employ a team-based approach
    that allows clinicians to ensure patients receive high quality care in
    the right setting at the right time. ACOs improve quality while
    controlling costs through primary care-focused initiatives such as
    expanded primary care teams, care coordination strategies, and enhanced
    data and analytics tools for primary care practices.\1\ The ACO model
    also provides an opportunity for providers to work collaboratively
    along the continuum while remaining independent.
    ---------------------------------------------------------------------------
        \1\ https://journals.lww.com/hcmrjournal/Fulltext/2019/04000/
    Clinical_coordination_in_
    accountable_care.5.aspx.

    Importantly, ACOs provide shared savings opportunities and enhanced
    regulatory flexibility that allows clinicians to maintain financial
    security while practicing medicine more freely. For example, many
    primary care practices were financially harmed by the effects of the
    COVID-19 pandemic, and evidence showed that independent primary care
    practices participating in ACOs were better-equipped to respond to the
    crisis, supported by alternative revenue sources and workflow tools
    ---------------------------------------------------------------------------
    made available through ACO participation.

    It's clear these payment system reforms have been a good financial
    investment for the government. In the last decade, ACOs have generated
    more than $22.4 billion in savings with $8.8 billion being returned to
    the Medicare Trust Fund while maintaining high quality scores for their
    patients. The growth of APMs has also produced a ``spill-over'' effect
    on care delivery across the nation, slowing the overall rate of growth
    of health care spending. Providers in APMs also help make the Medicare
    program stronger by reducing improper payments. Using enhanced data and
    analytics, ACOs regularly identify and report instances of fraud,
    waste, and abuse.

     Develop Solutions to Improve Physician Payment and Encourage the
                        Movement to Value

    The Medicare Access and CHIP Reauthorization Act (MACRA) included
    advanced APM incentive payments to encourage providers to move into
    risk-based payment models while also providing funds that allow them to
    cover services not reimbursed by traditional Medicare (e.g., meals
    programs and transportation). These are the types of services that help
    address patients' social needs, keep patients healthier, and lower
    costs. MACRA also included a higher conversion factor update for
    clinicians in advanced APMs, however this does not adequately address
    inflation, creates more complexity for clinicians, and could make it
    harder for clinicians in APMs to successfully meet program financial
    targets.

    While NAACOS is pleased that Congress passed another short-term
    extension of MACRA's advanced APM incentives, it does not go far enough
    to drive long-term movement to value-based care. The next year when
    financial incentives favor clinicians that participate in risk based
    APMs, over those who remain in FFS, will be 2032 (see graph below).

    For clinicians in advanced APMs, the 1.88 percent incentive for 2024
    and higher conversion factor is a lower incentive than the maximum
    Merit-based Incentive Payment System (MIPS) adjustment, which is
    estimated to be just over 3 percent. As the incentive structure shifts,
    some clinicians may choose to voluntarily shift back to MIPS because
    the program will continue to offer opportunities for high performing
    clinicians in APMs to qualify for higher financial incentives.

    [GRAPHIC] [TIFF OMITTED] T1124.012

    .epsThe 1.88 percent advanced APM incentive will also expire at the end
    of 2024. The expiration of APM incentives will mean a significant
    incentive shift towards MIPS in the short term. APM adoption has been
    steadily growing but still falls below Congress' original goals of
    transitioning all clinicians into models with financial risk.

    Going forward the committee should:

        1.  Develop approaches that account for inflation in payment
    updates.
        2.  Maintain stronger financial incentives for physicians that move
    into APMs.
        3.  Ensure that incentives do not impact a clinician's ability to
    meet financial targets in APMs.

    Reduce Program Complexity & Improve Scaling of Innovation

    MACRA created nonfinancial incentives for clinicians in APMs by
    exempting them from regulatory burdens associated with the FFS payment
    system. Unfortunately, program complexity can lead to less
    participation in value models. Additionally, clinicians can be hesitant
    to participate in Innovation Center model tests because the models do
    not have a predictable pathway to permanence.

    Going forward the committee should:

          Reduce program complexity by ensuring that clinicians in APMs
    are not required to engage in duplicative quality reporting efforts.
          Emphasize that MIPS should prepare clinicians for and encourage
    adoption of APMs.
          Ensure that promising aspects of innovative models have a more
    predictable pathway for becoming permanent.

    While updating Medicare's payment system and incentive structure will
    take time, in the short term, the committee should advance the Value in
    Health Care Act (H.R. 5013/S. 3503). This bipartisan bill was
    introduced by Senators Sheldon Whitehouse (D-RI), John Barrasso, M.D.
    (R-WY), Peter Welch (D-VT), Thom Tillis (R-NC), Bill Cassidy, M.D. (R-
    LA), John Thune (R-SD), and Marsha Blackburn (R-TN). It makes several
    important reforms to ensure that APMs continue to provide high-quality
    care for Medicare beneficiaries, including:

        1.  Providing a multi-year commitment to reforming care delivery by
    extending MACRA's original 5 percent advanced APM incentive for 2 years
    to continue to encourage the movement to value.
        2.  Ensuring that qualifying thresholds remain attainable to
    promote program growth by freezing them at 50 percent for 2 years and
    giving the Centers for Medicare & Medicaid Services (CMS) authority to
    adjust thresholds through rulemaking and set varying thresholds for
    more targeted models where participants (e.g., specialists) cannot meet
    the existing one-size-fits-all thresholds.
        3.  Removing the revenue-based designation in MSSP that penalizes
    certain ACOs, especially those including rural and safety net
    providers.
        4.  Establishing guardrails for CMS to ensure that the process to
    set financial benchmarks is transparent and appropriately accounts for
    regional variations in spending, to prevent arbitrary winners and
    losers.
        5.  Directing CMS to establish a voluntary, full-risk track within
    programs like the MSSP and has the U.S. Department of Health and Human
    Services provide more technical assistance to new APM participants.
        6.  Directing the Government Accountability Office to evaluate the
    potential of parity between APMs and Medicare Advantage (MA), so
    policymakers can seek greater alignment between the programs to ensure
    that both models provide attractive, sustainable options for innovating
    care delivery, and to ensure that APMs do not face a competitive
    disadvantage.

    Build on the Innovation Center's Successes

    As the Center for Medicare and Medicaid Innovation (CMMI) tests new
    payment models, successful models, or key aspects of those models,
    should be embedded as permanent parts of Medicare via the MSSP. While
    the MSSP currently includes various participation options with
    increasing levels of risk and reward, there is currently no full-risk
    option for ACOs participating in MSSP. Congress should direct CMS to
    create a separate full-risk option within MSSP to serve as a better
    bridge between it and ACO REACH. This ``Enhanced Plus'' Track should
    include greater flexibility in payment design and available waivers. As
    the only permanent total cost of care model in Medicare, the MSSP
    should be adapted to remain a viable option for more advanced ACOs and
    further advance value-based care.

    Population-Based Payments for Primary Care

    More flexible payment mechanisms can support care delivery
    transformation, strengthen primary care, and increase participation in
    ACO initiatives. CMS recently launched the ACO Primary Care Flex model,
    which will allow MSSP ACOs to offer prospective population-based
    payments for primary care. NAACOS has been advocating for this
    approach, which will bolster primary care practices in ACOs. Shifting
    to prospective payments provides primary care practices with stable and
    predictable cash flow needed to transform care delivery and provide
    comprehensive, team-based care. For more than a decade, the ACO model
    has improved beneficiary outcomes, generated savings to Medicare and
    allowed practices to invest shared savings into innovation and patient
    care. This model builds on the success of MSSP while recognizing we
    must continue to evolve the program for growth to continue.

    While we are extremely pleased with the model, we are concerned that
    excluding high-revenue ACOs will prevent many independent primary care
    practices who have partnered with their local health systems from
    taking advantage of these much-needed innovations. The premise of ACOs
    is to bring together providers from across the continuum of care to
    provide improved care for beneficiaries. This is a primary example of
    why the committee should support removing the revenue-based designation
    in MSSP that continues to penalize certain ACOs.

    Expand Waivers for APMs

    Current law allows CMS to waive certain Medicare FFS requirements in
    MSSP and other APMs. This is a critical component of APMs as it allows
    providers to operate with fewer restrictions leading to a reduction in
    provider burden and increased care innovation. However, the waivers to
    date have been limited and can also be burdensome for providers. For
    example, MSSP only has waivers for telehealth and the 3-day rule for
    skilled nursing facility stays. Yet the ACO REACH model has access to
    many more waivers. We believe all APMs should have access to all
    available waivers and that those waivers shouldn't be limited to
    certain models. Congress should direct CMS to establish a common set of
    waivers for APMs.

    Chronic care management (CCM) is also a critical part of coordinated
    care. Unfortunately, Medicare's current CMM codes include a beneficiary
    cost-sharing obligation that creates barriers to care. While APMs offer
    opportunity to allow providers to reduce beneficiary cost sharing to
    ensure patients receive enhanced care management, we encourage the
    committee to look at legislative options to waive the beneficiary
    coinsurance related to CCM. This would help ensure that more
    chronically ill Medicare patients can receive access to high-quality
    care.

    Improve Approaches to Test and Scale Innovation

    While CMMI has been successful in testing innovative payment
    arrangements and increasing adoption of APMs, the success of these
    models is not captured within current evaluation approaches. Congress
    should work with CMS to ensure that promising models have a more
    predictable pathway for being implemented and becoming permanent and
    are not cut short due to overly stringent criteria. This includes
    broadening the criteria by which CMMI models qualify for Phase 2
    expansion and directing CMMI to engage stakeholder perspectives during
    APM development.

     Establish Parity Between APMs and Medicare Advantage Program
                        Requirements

    Recognizing ACOs' and MA's shared goals of improving the quality of
    care and cost savings to patients, it's imperative to build parity
    between the two programs. Misaligned incentives are harmful to
    advancing value as they increase provider burden, create confusion and
    disincentives for patients, and generate market distortions that favor
    one entity over another. Parity can be better provided in the programs'
    benchmark and risk adjustment policies, quality measurement, and
    marketing requirements. ACOs should be allowed to provide comparable
    benefits to those offered to MA patients, such as telehealth visits,
    transportation benefits, home visits, etc. Without parity, providers
    are forced to spend time managing the various program requirements
    rather than managing patient care. Congress should direct GAO to
    evaluate how to create more parity between APMs and MA. Additionally,
    Congress should explore opportunities to incentivize MA plans to enter
    risk-bearing arrangements with providers.

    We thank the committee for this opportunity to provide feedback on this
    important hearing. NAACOS and its members are committed to providing
    the highest quality care for patients while advancing population health
    goals for the communities they serve. We look forward to our continued
    engagement on bolstering CCM through payment system reforms. If you
    have any questions, please contact Aisha Pittman, senior vice
    president, government affairs at aisha--pittman@naacos.com

                                     ______

                         Obesity Care Advocacy Network

                       4511 North Himes Avenue, Suite 250

                                Tampa, FL 33614

    April 24, 2024

    U.S. Senate
    Committee on Finance
    Dirksen Senate Office Bldg.
    Washington, DC 20510-6200

    Dear Chair Wyden and Ranking Member Crapo,

    The Obesity Care Advocacy Network (OCAN) appreciates the opportunity to
    provide the following comments to the U.S. Senate Finance Committee in
    response to its April 11th hearing on ``Bolstering Chronic Care through
    Medicare Physician Payment.'' We are hopeful that the Committee will
    include payment reforms in any legislation being considering to address
    chronic disease care for Medicare beneficiaries, which promote greater
    access to comprehensive obesity care.

    Founded in 2015, OCAN is a diverse group of organizations focused on
    changing how we perceive and approach obesity in the United States.
    OCAN works to increase access to evidence-based obesity treatments by
    uniting key stakeholders and the broader obesity community around
    significant education, policy and legislative efforts. We aim to
    fundamentally change how the U.S. healthcare system treats obesity, and
    to shift the cultural mindset on obesity so that policymakers and the
    public address obesity as a serious chronic disease.

    Obesity is a progressive disease, and without treatment Medicare
    beneficiaries with overweight or obesity risk further health
    deterioration and an increased likelihood in the onset of related
    comorbid conditions including obesity-related cancers, diabetes, and
    end stage renal disease. Additionally, people with severe obesity have
    a 48% higher risk of physical injury including falls which lead to
    higher costs and mortality rates. Congress must take steps to address
    this crisis now.

     Medicare's Physician Payment System Must Recognize and Support
                        Coordinated Care for Patients Living with Obesity

    Medicare must issue guidance that obesity should be a recognized
    disease state for purposes of Medicare chronic care management codes.
    Medicare payments for non-face-to-face chronic care management services
    are traditionally not allowed for these services when they are utilized
    to treat and manage obesity because obesity is not listed in the
    Medicare Chronic Conditions Chartbook. The obesity community raised
    this issue more than a decade ago when CMS proposed establishing the
    chronic care management codes.

    The Chartbook highlights the prevalence of chronic conditions among
    Medicare beneficiaries and the impact of chronic conditions on Medicare
    service utilization and spending. Since 2013, the obesity community has
    argued that the Chartbook should include obesity especially given that
    13 of the 15 conditions listed (high blood pressure, high cholesterol,
    ischemic heart disease, arthritis, diabetes, heart failure, chronic
    kidney disease, depression, COPD, atrial fibrillation, certain cancers,
    asthma, and stroke) are commonly associated with obesity and/or are
    exacerbated by obesity.

    Obesity clearly meets the criteria CMS outlined in the proposed rule as
    the rational for selecting the 15 conditions eligible for the chronic
    care management payments. Specifically, (1) obesity is highly prevalent
    among the Medicare population; (2) obesity is chronic, i.e., typically
    lasts for more than 12 months; (3) obesity poses increased risk for
    death, acute exacerbation/decompensation, or functional decline; (4)
    obesity results in increased use of health care services; and (5)
    successful care management of obesity can improve outcomes/reduce
    costs.

    The prevalence of obesity in older adults is high.

    The obesity epidemic has had a negative impact on our nation's health
    and economy. Among older adults (aged 60+), the prevalence of obesity
    is 42.8%, similar to the level among younger and middle-aged adults.
    The prevalence of severe obesity among those aged 60+ is 5.8%. More
    than 20% of the population will be 65 years of age or older by 2030, up
    from 15% today, highlighting the importance of addressing obesity among
    older Americans.

    Obesity is a chronic disease, which typically lasts well longer than 12
    months.

    Obesity is a chronic disease that poses lifelong challenges for many
    individuals. In addition to the obesity community and the American
    Medical Association, numerous other healthcare professional
    organizations, such as the American Heart Association, American
    Diabetes Association, and the American Association of Clinical
    Endocrinologists define obesity as a chronic disease. Obesity is also
    recognized as a chronic disease in the NHLBI Clinical Guidelines on the
    Identification, Evaluation, and Treatment of Overweight and Obesity in
    Adults, which state, ``Obesity is a complex multifactorial chronic
    disease developing from interactive influences of numerous factors--
    social, behavioral, physiological, metabolic, cellular, and
    molecular.''

    It is also important to note the broad recognition of obesity as an
    independent, complex disease state by numerous federal agencies,
    including the Social Security Administration (SSA), National Institutes
    of Health (NIH), Food and Drug Administration (FDA), Veterans Affairs
    (VA), Centers for Disease Control and Prevention (CDC), and the
    Internal Revenue Service (IRS).

    Obesity poses increased risk for death, acute exacerbation/
    decompensation, or functional decline.

    Studies \1\ have demonstrated that obesity results in higher morbidity
    for a range of health conditions--including many on the list of 15
    chronic conditions proposed by CMS--hypertension, type 2 diabetes,
    coronary heart disease (CHD), stroke, gallbladder disease,
    osteoarthritis, sleep apnea and respiratory problems, and some types of
    cancer (endometrial, breast, prostate, and colon), among others.
    Approximately 75% \2\ of people with severe obesity have at least one
    co-morbid condition, often type 2 diabetes, hypertension or sleep
    apnea, which increases the risk of premature death.
    ---------------------------------------------------------------------------
        \1\ https://www.ncbi.nlm.nih.gov/books/NBK2003/.
        \2\ https://jamanetwork.com/journals/jama/fullarticle/192030.

    ---------------------------------------------------------------------------
    Obesity results in increased use of health care services.

    Adults with obesity in the United States compared with those with
    normal weight experienced higher annual medical care costs by $2,505 or
    100%, with costs increasing significantly with class of obesity, from
    68.4% for class 1 to 233.6% for class 3. The effects of obesity raised
    costs in every category of care: inpatient, outpatient, and
    prescription drugs. Increases in medical expenditures due to obesity
    were higher for adults covered by public health insurance programs
    ($2,868) than for those having private health insurance ($2,058). In
    2016, the aggregate medical cost due to obesity among adults in the
    United States was $260.6 billion.\3\
    ---------------------------------------------------------------------------
        \3\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10394178/.

    Successful care management of obesity can improve outcomes/reduce
    ---------------------------------------------------------------------------
    costs.

    The benefits of care management in individuals with obesity have been
    well documented. For example, a recent University of Southern
    California Schaeffer Center study on the ``Benefits of Medicare
    Coverage for Weight Loss Drugs''\4\ estimated the benefits of treating
    Americans living with obesity and the cost-offsets that Medicare and
    society could accrue if laws were changed to allow Medicare to cover
    AOMs. The study found that coverage for new obesity treatments could
    generate approximately $175 billion in cost offsets to Medicare in the
    first 10 years alone. By 30 years, cost offsets to Medicare could
    increase to $700 billion. The positive impacts extend beyond Medicare--
    with society possibly reaping as much as $100 billion per year (or $1
    trillion over 10 years) of social benefit in the form of reduced
    healthcare spending and improvements in quality of life from reduced
    disability and pain if all eligible Americans were treated.
    ---------------------------------------------------------------------------
        \4\ https://healthpolicy.usc.edu/research/benefits-of-medicare-
    coverage-for-weight-loss-drugs/.

    OCAN also remains concerned that coverage for services to prevent,
    manage, and/or treat chronic conditions such as diabetes, prediabetes,
    and obesity currently exists as a patchwork within CMS with persistent
    gaps and limitations related to the receipt of same-day service,
    ---------------------------------------------------------------------------
    referrals, coverage levels, payment, and sites of service.

    One prime example of these problems surrounds the 2011 National
    Coverage Determination for Intensive Behavioral Therapy for Obesity
    (210.12) (the ``2011 NCD'') to modify the limitations that this service
    only be delivered by primary care providers (physicians, nurse
    practitioners (NPs), physician associates (PAs)) in a primary care
    setting. CMS should reconsider the 2011 NCD to allow other qualified
    healthcare providers (i.e., registered dieticians, clinical
    psychologists, specialty physicians and specialty NPs and PAs) to
    independently provide and bill for this service upon referral from the
    primary care provider without limitation to the primary care setting.

    We appreciate the commitment made by the Biden Administration in its
    National Strategy on Hunger, Nutrition and Health to ``expand Medicare
    beneficiaries' access to . . . obesity counseling. We also appreciate
    the interest expressed in the CY 2023 Medicare Physician Fee Schedule
    to ``understand what existing services within current Medicare benefits
    may represent high value, potentially underutilized services'' and the
    request for information about ``obstacles to accessing these services
    and how specific potential policy, payment or procedural changes could
    reduce potential obstacles and facilitate better access to high value
    health services.'' The original IBT for Obesity benefit resulted in
    unintended administrative burdens and unnecessary expenses that could
    be remedied through a reconsideration of the benefit's 2011 NCD.

    Again, OCAN appreciates the opportunity to offer these recommendations
    to the Committee regarding potential reforms to the Medicare Physician
    Payment System to better address chronic disease care for Medicare
    beneficiaries. Should you have any questions or need additional
    information, please feel free to contact us.

    Sincerely,

    Christine Gallagher, MPAff
    OCAN Co-Chair
    Redstone Global Center for Prevention and Wellness
    George Washington University
    cqgallagher@gwu.edu

    Catherine Ferguson
    OCAN Co-Chair
    Vice President, Federal Advocacy
    American Diabetes Association
    cferguson@diabetes.org

    Anthony G. Comuzzie, Ph.D., FTOS
    OCAN Co-Chair
    Chief Executive Officer
    The Obesity Society
    tcomuzzie@obesity.org

                                     ______

               Primary Care Collaborative and Better Health--NOW

                       1101 Connecticut Ave., Suite 1150

                             Washington, DC, 20036

    The Primary Care Collaborative and our Better Health--NOW Campaign
    partners thank the Senate Finance Committee for convening the hearing
    and for this opportunity to submit a statement for the record. As it
    examines the sweep of issues related to Medicare payment, we urge the
    Finance Committee to put Medicare primary care at the center of its
    work.

    High-quality, whole-person primary care is an essential foundation for
    any proactive strategy to address chronic physical and mental health
    conditions and the increasingly unaffordable costs they generate. The
    National Academies of Sciences, Engineering and Medicine's (NASEM) 2021
    consensus report, Implementing High-
    Quality Primary Care, found that ``primary care is the only health care
    component where an increased supply is associated with better
    population health and more equitable outcomes.''\1\
    ---------------------------------------------------------------------------
        \1\ The National Academies of Sciences, Engineering and Medicine.
    (2021, May). Implementing High-Quality Primary Care: Rebuilding the
    Foundation of Health Care. Nationalacademies.org. https://
    www.nationalacademies.org/our-work/implementing-high-quality-primary-
    care.

    Primary care payment reform can unlock powerful improvements in quality
    and real cost savings, particularly in public programs that shape the
    entire marketplace Within the Medicare Shared Savings Program, primary
    care centric ACOs reduced preventable downstream costs compared to
    other ACOs and produced twice the shared savings as other, hospital-
    based ACOs.\2\ For certain practices, states and geographies, the CMS
    Innovation Center has also introduced new or re-tooled promising
    primary care models, including Making Care Primary, ACO Primary Care
    Flex and ACO REACH.
    ---------------------------------------------------------------------------
        \2\ Improve Care in Medicare by Growing Primary Care in ACOS.
    Primary Care Collaborative. (2024b, March). https://thepcc.org/
    resource/improve-care-medicare-growing-primary-care-acos.

    Despite these bright spots, our overall health care system's priorities
    remain out of balance, devoting less than five (4.7) cents of each
    dollar to primary care in 2021.\3\ Most primary care practices report
    no participation in either shared savings or
    population-based payment.\4\ In 2023, an estimated 1 in 4 (28.7%)
    Americans lack a usual source of care \5\ and rural and underserved
    communities, in particular, face widening gaps in access.\6\
    ---------------------------------------------------------------------------
        \3\ The health of US Primary Care: 2024 Scorecard Report--No One
    Can See You Now. Milbank Memorial Fund. (2024b, February 29). https://
    www.milbank.org/publications/the-health-of-us-primary-care-2024-
    scorecard-report-no-one-can-see-you-now/.
        \4\ Horstman, C., & Lewis, C. (2023, April 13). Engaging Primary
    Care in Value-Based Payment: New Findings from the 2022 Commonwealth
    Fund Survey of Primary Care Physicians. https://
    www.commonwealthfund.org/blog/2023/engaging-primary-care-value-based-
    payment-new-findings-2022-commonwealth-fund-survey.
        \5\ The Health of US Primary Care: 2024 Scorecard Report--No One
    Can See You Now. Milbank Memorial Fund. (2024b, February 29). https://
    www.milbank.org/publications/the-health-of-us-primary-care-2024-
    scorecard-report-no-one-can-see-you-now/.
        \6\ Rural-Urban Disparities in Health Care in Medicare--CMS.
    Centers for Medicare and Medicaid Services. (2023, November). https://
    www.cms.gov/files/document/rural-urban-disparities-health-care-
    medicare-national-report.pdf.
    ---------------------------------------------------------------------------

    Reorient Medicare Payment toward Primary Care and Prevention

    Over time, policy choices guiding Medicare Part B's fee-based payment
    structure have generated distortions that have systematically undercut
    investment in primary care \7\ and contributed to growing health
    disparities, based on geography, race and ethnicity.\8\ This persistent
    under-resourcing of primary care is an obstacle to the health of
    Medicare beneficiaries and the sustainability of the primary care
    workforce. Moreover, because all Medicare APMs and most private APMs
    are built upon the Medicare Physician Fee Schedule to one extent or
    another, shortcomings in Medicare's support for primary care are
    magnified throughout the nation's entire health care system.
    ---------------------------------------------------------------------------
        \7\ MedPAC (Medicare Payment Advisory Commission). 2006. Report to
    the Congress: Medicare payment policy. Washington, DC: Medicare Payment
    Advisory Commission.
        \8\ McNeely, L., Douglas Megan, Westfall, N., Greiner, A.,
    Gaglioti, A., & Mack, D. (2022). PRIMARY CARE: A Key Lever to Advance
    Health Equity. The Primary Care Collaborative. https://thepcc.org/
    sites/default/files/resources/PCCNCPC%20Health%20Equity%20Report.pdf.

    To address the rising tide of chronic disease discussed in the April
    11th hearing, policymakers must fix the underlying flaws in Medicare
    Part B's payment policies. Below, we detail our initial recommendations
    ---------------------------------------------------------------------------
    to the Committee in this regard.

    Enhance Transparency: As noted above, America's allocation of health
    care dollars is deeply unbalanced, devoting just 4.7 cents for each
    dollar spent to primary care. Congress should require HHS to follow the
    lead of more than twenty states \9\ and report primary care spending as
    a share of total spending. This requirement should apply to traditional
    Medicare, Medicare Part C and across federal programs.
    ---------------------------------------------------------------------------
        \9\ See PCC's State Primary Care Investment HUB for information on
    state based legislation measuring and reporting primary care spend,
    available at https://thepcc.org/primary-care-investment/legislation.

    Give Primary Care Practice a Choice: An Alternative to Fee-for-Service:
    Better Health--NOW supports efforts to rapidly transition primary care
    payment from a predominantly fee-for-service model to predominantly
    population-based prospective payment (hybrid) models. These new models
    must include up-front and ongoing investments, as well as guardrails to
    ---------------------------------------------------------------------------
    assure quality and access in rural and underserved communities.

    To that end, the Finance Committee should work with stakeholders toward
    legislative solutions that make a well-constructed primary care hybrid
    payment option broadly available. Under such an approach, payment would
    be provided to practices upfront each month to deliver primary care for
    patients with an ongoing relationship, coupled with FFS payment for
    other services. The design and implementation of hybrid payment should:

          invest in primary care capacity, support personalized, team-
    based care and pay for services tailored to the needs of the patient
    and the community;
          reduce or simplify the burdensome documentation associated with
    many FFS codes, which add to systemic costs and consume clinician time
    that could be better spent with patients; and
          allow for additional, higher payment tiers based on the scope of
    services included in such payments, such as greater behavioral health
    integration and ability to address health-related social needs.

    Enhance Primary Care Affordability in Medicare: As part of any Medicare
    payment reform legislation, Congress should remove financial barriers
    patients face in accessing the comprehensive, whole-person primary care
    necessary to manage their chronic conditions. We support

          authorizing patient cost-sharing waivers for the services
    provided prospectively as part of any hybrid primary care payment,
          eliminating cost-sharing for Medicare's behavioral health
    integration services (Section 102 of S. 923 the Better Mental Health
    Care for Americans Act) and
          removing cost-sharing requirements for Chronic Care Management
    codes (HR 2829, the Chronic Care Management Improvement Act).

    Accelerate Primary Care-Behavioral Health Integration: Research has
    shown that evidence-based, primary care integration models, like the
    Collaborative Care Model and Primary Care Behavioral Health, can
    successfully improve outcomes while making better use of an
    overstretched mental health workforce. In 2016, Medicare established
    payment codes to support the delivery of the collaborative care model
    and general behavioral health integration services. The Centers for
    Medicare and Medicaid Services and Congress have taken steps in the
    years since to further support integrated care. Unfortunately,
    availability of evidence-based, integrated primary care has been badly
    outpaced by patients' growing need for mental health and addiction
    services.

    To address the present crisis in behavioral health and strengthen the
    health of Medicare beneficiaries and their communities, Better Health--
    NOW supports S. 1378, the COMPLETE Care Act and S. 3157 the More
    Behavioral Health Providers Act. We appreciate the inclusion of these
    measures in the Better Mental Health Care, Lower Cost Drugs and
    Extenders Act of 2023, and urge all members of the Committee to press
    for enactment of these provisions this year. The More Behavioral Health
    Providers Act extends and expands the Health Professional Shortage Area
    program to help communities attract behavioral health clinicians needed
    to support integrated primary care teams. The COMPLETE Care Act
    provides for technical assistance and enhanced reimbursement for
    integrated care services.

    In light of the dual crises of mental health and addiction, we
    encourage the Committee to consider additional steps. One approach
    would be to remove expenditures on Collaborative Care Management (CoCM)
    and General Behavioral Health Integration codes from the expenditures
    compared against spending benchmarks in MSSP and other benchmark-based
    payment models. Accountable payment has the potential to support
    broader adoption of behavioral health-primary care integration. But
    because expenditures associated with delivering the services can
    increase spending over the short term, benchmark-based payment models
    like MSSP have a built-in disincentive to the delivery of and billing
    for integrated behavioral health. We encourage you to explore how to
    address this issue.

    (For more information, please see PCC/BHN responses to the Senate
    Finance Committee's bipartisan mental health legislative work here and
    here.)

    Support Private Sector and State Payment Innovation

    Primary care practices rarely serve only traditional Medicare enrollees
    and rely on other payers to remain viable and sustain services for all
    their patients, including Medicare beneficiaries. To succeed, Medicare
    primary care payment innovations should align with payment innovations
    by state Medicaid programs, as well as those advanced by private market
    payers and purchasers. In tandem with its Medicare payment reform work,
    the Finance Committee should pursue targeted policy steps this year
    that support constructive state Medicaid and private market primary
    care innovations, including the following.

     Strengthen Primary Care in Rural and Underserved Communities,
            Leveraging Medicaid and CHIP
    Strengthening primary care for Medicaid and CHIP beneficiaries is an
    essential complement to reforming Medicare payment. Medicaid and CHIP
    cover more than 80 million Americans, including a disproportionate
    percentage of rural people, low-income seniors, people with
    disabilities, and people of color. Yet, Medicaid primary care payment
    averages just 78% of Medicare's. Congressional leadership is necessary
    to ensure practices and clinics serving these communities can sustain
    primary care access. The following represent essential and immediate
    steps:

          Enact S. 2556 the Improving CARE for Youth Act, which eliminates
    payment restrictions on primary care and behavioral health services
    delivered on the same day for children in Medicaid/CHIP.
          Work with the Health, Education, Labor and Pensions Committee to
    provide longer-term funding for the Community Health Center Fund and
    increase the yearly outlay for the Fund to help Federally Qualified
    Health Centers reach more rural and underserved communities.

    (For more information on strengthening primary care in Medicaid, see
    PCC's report Access and Equity in Medicaid.)

    Encourage Primary Care Access Innovations in the Private Market:
    According to the Centers for Disease Control and Prevention (CDC), in
    2017 nearly a quarter of individuals with employer sponsored insurance
    were enrolled in high deductible plans without a health savings
    account.\10\ Over 50 percent of individuals with an HSA live in zip
    codes where the median income is below $75,000 annually.\11\ Yet HSA/
    HDHPs are barred from covering many primary care services until a
    patient meets their full deductible.
    ---------------------------------------------------------------------------
        \10\ Cohen, R.A., Zammitti, E.P. (2018). High-deductible Health
    Plan Enrollment Among Adults Aged 18-64 With Employment-based Insurance
    Coverage. 317. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
        \11\ Cohen, R.A., Zammitti, E.P. (2018). High-deductible Health
    Plan Enrollment Among Adults Aged 18-64 With Employment-based Insurance
    Coverage. 317. https://www.cdc.gov/nchs/products/databriefs/db317.htm.

    To address this barrier to primary care, Congress should broaden the
    preventive services safe harbor for High-Deductible Health Plans to
    facilitate pre-deductible access to comprehensive, whole-person primary
    ---------------------------------------------------------------------------
    care, inclusive of integrated behavioral health.

    Better Health--NOW supports the following legislation, introduced in
    the 118th Congress:

          H.R. 7681, The Primary and Virtual Care Affordability Act, which
    gives employers and health plan sponsors the flexibility to reduce or
    waive cost-sharing for primary care and extends the existing, waiver
    flexibility for telehealth services through 2026.
          S. 655, The Chronic Disease Management Act, which allows high-
    deductible health plans with HSAs to cover care for chronic conditions
    before exhausting the deductible.

    Within the U.S. health care system, primary care is the level of care
    best positioned to beat back the endemic rates of chronic disease and
    spiraling costs. The need for bold Congressional action to champion
    primary care could not be more urgent.

    We look forward to continuing to work with you to strengthen primary
    care. Please contact PCC's Director of Policy, Larry McNeely
    (lmcneely@thepcc.org) with any questions.

                                     ______

                      Society of General Internal Medicine

                            1500 King St., Suite 303

                              Alexandria, VA 22314

                                 (202) 887-5150

                              https://www.sgim.org

    The Society of General Internal Medicine (SGIM) thanks the Senate
    Finance Committee (``the Committee'') for holding this hearing on how
    to better reimburse physicians and the care teams who deliver chronic
    care to Medicare beneficiaries and for providing this opportunity to
    submit this statement for the record.

    SGIM is a member-based medical association of more than 3,300 of the
    world's leading academic general internal medicine physicians, who are
    dedicated to delivering high-quality clinical care, improving access
    for all populations, eliminating health care disparities, and enhancing
    medical education. Our members are committed to ensuring patients have
    equitable and affordable access to the highest quality of care
    possible.

    Primary care is the foundation of a strong health care system. Primary
    care physicians, including general internal medicine physicians,
    provide a broad range of clinical services and expertise, from
    preventative healthcare to treatment of multiple chronic medical
    conditions. In addition, primary care physicians also serve as the
    coordinator of their patients' overall care. In this role, they not
    only coordinate with other physicians, nurses, pharmacists, and social
    workers within their practice but also specialists, mental health
    professionals, and laboratories outside of them. They ensure that other
    care team members understand the patient's medical history and comorbid
    conditions and that the decisions being made are patient-centered. Our
    members take pride in cultivating enduring, trust-based relationships
    with patients that span decades. However, despite the robust evidence
    that coordinated primary care improves health outcomes and equity,
    incentives and infrastructure are not in place to allow primary care to
    deliver on its promise.

    This Committee must develop policies that will support the delivery of
    patient-
    centric care to Medicare beneficiaries and bolster the primary care
    workforce. The shortages of general internal medicine and other primary
    care physicians are well documented. The inadequate reimbursement for
    primary care generally and care coordination specifically has only
    perpetuated this shortage. SGIM members practice at the nation's
    medical schools and academic medical centers where they serve as
    educators and mentors. Therefore, we are ever mindful of the career
    choices made by students and residents and the influence compensation
    discrepancies between primary care and procedurally-oriented
    specialties have on those choices.

    Without meaningful change, more patients--regardless of where they
    live--will experience challenges accessing comprehensive primary care.
    Primary care practices have been operating on minimal or even negative
    profit margins in recent years. The financial challenges as well as the
    long hours and administrative burden associated with the practice of
    primary care has brought the United States to the point that there is a
    severe shortage of general internal medicine and other primary care
    physicians. Without action, these shortages will only grow and become
    more problematic as the Medicare population ages and their needs for
    coordinated comprehensive care grow.

    The overarching problems facing the Medicare Physician Fee Schedule
    (MPFS) are making it difficult to enact reforms to support primary care
    and chronic care delivery. As access to primary care services becomes
    more challenging, cognitive and procedural specialties are also being
    challenged by the downward pressure on Medicare physician payment,
    which has stagnated over the past 2 decades without receiving necessary
    increases or adjustments for inflation or to account for increased
    costs of providing comprehensive care in stark contrast to other
    Medicare fee schedules. According to an American Medical Association
    analysis of Medicare Trustees data, Medicare physician payment has
    declined by 30% percent when adjusted for inflation from 2001-2024.

    Congress enacted the Medicare Access and CHIP Reauthorization Act
    (MACRA) to enable Medicare to pay for high-quality care rather than the
    volume of services provided. However, this experiment failed. MACRA
    only authorized 0.5% updates to the conversion factor through 2019. For
    the last several years, the lack of positive updates and the MPFS'
    budget neutrality requirements have resulted in cuts to Medicare
    reimbursement, which Congress has mitigated. While SGIM appreciates
    Congressional actions to minimize these cuts, the downward pressure on
    Medicare reimbursement continues and is exacerbated by the MPFS' budget
    neutrality requirements, which have not been updated since 1992. The
    budget neutrality threshold, which remains $20 million, pits
    specialties against one another. As long as some specialties experience
    losses when new codes are added to the MPFS or positive updates are
    recommended for certain services, Congress and the Centers for Medicare
    & Medicaid Services (CMS) will not be able to transform the MPFS to
    support the delivery of high-quality coordinated primary and chronic
    care. Therefore, SGIM urges this Committee to make two structural
    reforms to the MPFS to support more equitable reimbursement: (1) an
    annual inflationary update to the conversion factor, and (2) an
    increase in the budget neutrality threshold to $53 million from $20
    million with the provision of inflationary updates every 5 years
    thereafter. These two changes will help reverse the downward pressure
    on Medicare physician payment. Making all physicians' reimbursement
    more sustainable will allow the Committee to make additional changes to
    support the delivery of high quality primary and chronic care.

    The significantly lower payment rates for primary care compared to
    those for procedural specialties discourage medical students from
    choosing primary care specialties, as they are attracted to higher-
    paying specialties particularly considering their growing amounts of
    medical school debt. As a result, many Americans do not have a primary
    care physician with whom they can schedule timely visits and receive
    longitudinal, comprehensive care; instead, they receive care from
    urgent care clinics and overcrowded emergency rooms. Even those with
    established primary care physicians have difficulty accessing the
    appropriate level of care, as primary care physicians are forced to see
    a higher volume of patients for shorter appointments. This leads to a
    viscous cycle of either less comprehensive care, or physicians being
    forced to work after-hours doing uncompensated but critical care
    coordination, leading to fatigue, burnout and erosion of the primary
    care workforce. Further, the persistent shortage of primary care
    physicians nationwide, particularly in rural communities, exacerbates
    existing disparities among vulnerable populations that are already
    facing significant healthcare challenges.

    CMS has taken steps in recent years to support primary care by creating
    new services, like those for chronic care management, and revising and
    revaluing evaluation and management (E/M) services. However, the lack
    of positive conversion factor increases and budget neutrality
    adjustments has eroded the value of these reimbursement increases for
    primary care. SGIM urges Congress to work with us to develop a set of
    reforms to support primary care and bring stability to the Medicare
    physician payment system. Specifically, Congress must improve
    reimbursement for the E/M services that are central to the
    comprehensive care of patients delivered by primary care physicians.
    Better reimbursement for these E/M services would also help to support
    the comprehensive care that many specialists deliver to patients with
    complex conditions such as diabetes mellitus, congestive heart failure,
    and kidney failure. Despite recent efforts to redefine and revalue E/M
    services, further improvements should be made to support patient-
    centered care, particularly for Medicare beneficiaries who have one or
    more chronic conditions.

    SGIM believes that establishing a technical advisory committee (TAC) to
    define and value E/M and other non-procedural work is critical to
    appropriately reimbursing for primary care services and supporting the
    delivery of high-quality comprehensive care as outlined in Senator
    Sheldon Whitehouse's primary care discussion draft. This has been a
    longstanding priority of our professional society. SGIM believes that
    Congress should codify CMS' responsibility to ensure that the MPFS is
    accurate, reliable, and publicly accountable. A TAC could assess the
    existing processes for service code development and valuation and
    propose solutions that are sustainable and evidence based.

    The TAC can begin making meaningful improvements to reimbursement for
    primary care now and ensure that the valuations of physician services
    provide reliable building blocks, which can be used in developing
    innovative alternative payment models like a hybrid payment system for
    primary care. Specifically, the TAC can determine how to base payments
    on the relative intensity of cognitive work by establishing a reliable
    process for defining services and assigning values. The existing
    mechanisms for valuing cognitive work are not evidence based and have
    helped perpetuate a system that has not prioritized primary care, while
    the volume and value of technical and procedural services has grown.
    SGIM believes that a TAC is critical to support primary care but
    recognizes that the existing mechanisms to value MPFS services may be
    better suited to be applied to procedures. This TAC does not have to
    replace the existing mechanisms for valuing all MPFS services.

    As the population ages, Medicare must lead the way in supporting
    primary care and other cognitive based care (e.g., addiction treatment
    and behavioral health). A TAC will incorporate evidence-based data into
    the valuation process of E/M service codes and be best equipped to
    ensure that these services are evaluated at more regular intervals. We
    believe that a regular, independent assessment of available data and
    data-driven policy recommendations will stabilize what has evolved to
    become an irregular process, which has been a major contributor to the
    declining primary care workforce. Even as hybrid and other alternative
    payment models expand, the importance of proper valuation of E/M
    services and the critical role of a TAC will remain. Alternative
    payment models continue to be based on the underlying MPFS, and any
    payment model must have a strong primary care system as the foundation.
    Appropriate valuation of primary care will remain critical to ensure
    resources are appropriately distributed to enable high quality,
    comprehensive, patient-centered care.

    Again, thank you for the opportunity to submit this statement for the
    record. SGIM looks forward to working with the Committee and the
    bipartisan working group on physician payment to meaningfully reform
    the MPFS.

                                     ______

                        Society of Gynecologic Oncology

                         1440 W Taylor St., Suite 4299

                               Chicago, IL 60607

                               P: (312) 235-4060

                              https://www.sgo.org

    The Society of Gynecologic Oncology (SGO) applauds the Senate Finance
    Committee for holding the recent hearing, Bolstering Chronic Care
    through Medicare Physician Payment. This is an important step in
    protecting Medicare beneficiaries' access to high-quality care.

    The SGO is the premier medical specialty society for health care
    professionals trained in the comprehensive management of gynecologic
    cancers. Our more than 2,800 members include physicians, advanced
    practice providers, nurses and patient advocates who collaborate with
    the Foundation for Women's Cancer to increase public awareness of
    gynecologic cancers and improve the care of those diagnosed with
    gynecologic cancers. Our primary mission focuses on supporting
    research, disseminating knowledge, raising the standards of practice in
    the prevention and treatment of gynecologic malignancies, and
    collaborating with other organizations dedicated to gynecologic cancers
    and related fields, all with the ultimate vision of eradicating
    gynecologic cancers.

    Gynecologic oncologists play a multifaceted role in providing care for
    women with gynecologic cancer. Gynecologic oncologists are involved in
    the diagnosis of gynecologic cancer, developing personalized treatment
    plans for patients, performing complex surgeries, overseeing the
    administration of chemotherapy, and monitoring patients to detect
    recurrence or complications. Unfortunately, Medicare reimbursement has
    not kept pace with the costs of delivering this complex care.

    The entire physician community continues to face unpredictable Medicare
    reimbursement rates and rising inflation--a perfect storm of financial
    instability that threatens SGO members' ability to care for patients.
    Therefore, SGO recommends that Congress work with physicians to
    implement long-term, systemic reforms that bring stability to the
    Medicare physician payment system ending this cycle of annual payment
    reductions and preserving beneficiary access to medical services.
    Specifically, we urge you to consider supporting the following
    legislative solutions:

          Annual Inflationary Adjustments: The Medicare Physician Fee
    Schedule (MPFS) does not receive necessary increases or adjustments for
    inflation, in contrast to other Medicare fee schedules. Not only does
    the MPFS not receive annual inflationary increases, the last statutory
    increase to the MPFS conversion factor of 0.5% was applied in 2019. SGO
    supports an annual inflationary adjustment, equal to the Medicare
    Economic Index (MEI) or some other inflationary factor. An annual
    inflation-based update to the MPFS will help practices cover the
    growing cost of clinical staff, rent, medical supplies and equipment,
    malpractice insurance, and other necessary expenses. Moreover, it will
    help to protect the supply of our nation's physicians and preserve
    patient access to care, particularly in areas where there may be a
    shortage of specialized providers, like gynecologic oncologists.

          Budget Neutrality: Current Medicare statute requires changes to
    the MPFS be implemented in a budget neutral manner, which means that
    policies that increase or decrease Medicare spending by more than $20
    million require that upward or downward adjustments be made by that
    excess amount to all physician services. This threshold has not changed
    since 1992. SGO recommends that Congress consider raising the budget
    neutrality threshold from $20 million to $53 million to accommodate
    changes in Medicare spending, allowing for more flexibility in
    adjusting physician payments. Congress should also provide for an
    increase every 5 years equal to the cumulative increase in MEI to
    ensure that physician payments keep pace with inflation and the cost of
    delivering care.

          Updates to Practice Expense: Medicare bases its payment rates
    under the MPFS in part on estimates of the resources used in furnishing
    each service to a typical Medicare patient. For each service, there is
    a valuation for practice expense (PE), which is composed of the direct
    and indirect practice resources involved in furnishing medical
    services. SGO recommends that the Secretary of Health and Human
    Services, no less than every 5 years, update prices and rates for
    direct cost inputs for PE relative value units which includes clinical
    wage rates, prices of medical supplies, and prices of equipment. PE
    data should be updated on a regular basis to account for the inevitable
    changes in technology, practice patterns, clinical labor rates, and
    other factors that influence these inputs. Updating the data more
    regularly will provide greater stability within the payment system.

    Moreover, SGO appreciates the Committee's interest in making
    improvements to the Centers for Medicare and Medicaid Services (CMS)
    Quality Payment Program (QPP), including simplifying the Merit-based
    Incentive Payment System (MIPS) and identifying strategies to bolster
    widespread adoption of alternative payment models (APMs).

    The purpose of value-based care programs is to drive down health care
    costs and improve patient outcomes, but those goals cannot be achieved
    without robust physician participation in these models. Unfortunately,
    there are challenges for physicians, such as financial risk and
    administrative burden. In an environment of stagnant Medicare
    reimbursement, physicians are even more averse to the financial risk
    posed by these programs. Additionally, physician practices vary by
    size, specialty, and location; therefore, it is important that APMs are
    developed in a way that is feasible and makes sense for different
    practices and patient populations. There are significant financial
    investments required to develop and implement an APM putting this
    option out of reach for many specialties or health systems. Congress
    should ensure that CMS is provided with the necessary resources to
    support measure and APM development allowing them to partner with
    interested stakeholders. It is critical that specialty physicians, like
    SGO members, are involved in designing APMs to ensure that alternative
    ways of delivering services are relevant to specialty practice, not
    overly burdensome, and support the needs of our patients.

    SGO believes value-based care delivery is critical in maximizing
    quality and cost effectiveness. Therefore, we are pleased that CMS
    continues to develop and test new models suitable for a wide range of
    practices of different sizes and specialties. Today, specialty
    physicians, like gynecologic oncologists, will find few physician-
    focused models available to them. We recognize that CMS intends to
    sunset traditional MIPS and move to MIPS Value Pathways (MVPs), and the
    agency is continuing to roll out new pathways each year. However,
    specialties like gynecologic oncology do not yet have MVP options to
    participate. Besides simplifying the MIPS program, the SGO strongly
    believes that all providers should have measures and MVPs that reflect
    the patient care they provide. Therefore, we encourage CMS to work with
    stakeholders like SGO to support and incentivize the development of
    specialty and subspecialty specific measures to make participation more
    meaningful for providers, Medicare beneficiaries, and the agency.

    The administrative requirements and reporting processes associated with
    CMS' quality programs can feel burdensome for providers. This comes at
    a time when providers are also experiencing burdensome prior
    authorization requirements in the Medicare Advantage (MA) program.
    Improving the program, which covers nearly half of all Medicare
    beneficiaries, is imperative to ensuring that seniors receive the
    highest quality of care. Prior authorization processes require
    practices to realign staff or hire additional staff for the sole
    purpose of doing this work. This comes at a time when there are
    staffing shortages throughout the health care system and funneling
    resources from direct patient care to prior authorization duties is not
    in the best use of limited resources, while taking away time and energy
    from direct patient care. Additionally, SGO members are concerned that
    this process leads to delays in patient care, which is particularly
    concerning when a patient has cancer and time is of the essence,
    leading to negative health outcomes. One study found that 25 percent of
    gynecologic oncology patients experienced prior authorization during
    their cancer care with patients experiencing over a 2-week delay in
    care when prior authorization occurred.\1\ Reform is needed to reduce
    the burden of prior authorization in gynecologic oncology and SGO
    encourages you to review the prior authorization policies within the MA
    program to protect patient access to timely care.
    ---------------------------------------------------------------------------
        \1\ Smith AJB, Mulugeta-Gordon L, Pena D, Kanter GP, Bekelman JE,
    Haggerty AE, Ko EM. Prior authorization in gynecologic oncology: An
    analysis of clinical impact. Gynecol Oncol. 2022 Dec;167(3):519-522.
    doi: 10.1016/j.ygyno.2022.10.002. Epub 2022 Oct 14. PMID: 36244827.

    Thank you for your leadership and interest in developing policy to
    stabilize the Medicare physician payment system to support providers
    and provide certainty for beneficiaries dependent on the program for
    their health care. We look forward to working with you to achieve these
    ---------------------------------------------------------------------------
    goals.

                                     ______

                              UsAgainstAlzheimer's

                        5614 Connecticut Ave., NW, #288

                           Washington, DC 20015-2604

                      https://www.usagainstalzheimers.org/

    UsAgainstAlzheimer's (UsA2) thanks the Finance Committee for holding
    this hearing on the vitally important topic ``Bolstering Chronic Care
    through Medicare Physician Payment'' and appreciates the opportunity to
    submit this Statement for the Record.

    UsA2 was founded in 2010 to disrupt and diversify the movement to end
    Alzheimer's. Through urgent and inclusive mobilization, UsA2 has worked
    to dramatically increase funding for Alzheimer's and dementia research.
    Our work to stop Alzheimer's now centers on prevention, early detection
    and diagnosis, and access to treatments for all regardless of gender,
    race, or ethnicity.

    Alzheimer's Is a Chronic Disease

    Alzheimer's disease and related dementia (ADRD) is a chronic condition
    whose death toll is outpacing other chronic conditions such as heart
    disease, stroke, and cancer. ADRD is included on the Centers for
    Medicare & Medicaid Services' (CMS) list of chronic conditions
    identified in its advisory on chronic care management codes
    (MLN909188--Chronic Care Management,\1\ page 6):
    ---------------------------------------------------------------------------
        \1\ https://www.cms.gov/outreach-and-education/medicare-learning-
    network-mln/mlnproducts/downloads/chroniccaremanagement.pdf.

    Alzheimer's disease and related dementia  Arthritis (osteoarthritis
    and rheumatoid)  Asthma  Atrial fibrillation  Autism spectrum
    disorders  Cancer
      Cardiovascular disease  Chronic Obstructive Pulmonary Disease
    (COPD)
    Depression  Diabetes  Hypertension  Infectious diseases like HIV and
    AIDS.

    The Risk and Prevalence of ADRD Can Be Reduced

    ADRD not only requires significant management, it is also
    interconnected to other chronic conditions and shares similar risk
    factors that if addressed could significantly reduce its prevalence by
    40% or more.

    Over the last decade, a growing and now undeniable body of evidence
    suggests that a significant percentage of dementia cases are, in fact,
    preventable or delayable, with the same strategies that can reduce the
    risk of other chronic diseases including cardiovascular disease,
    obesity, type 2 diabetes, chronic kidney disease, depression, and
    certain forms of cancer. These strategies include physical activity,
    proper nutrition, and sleep, and addressing other specific conditions
    that increase the risk of cognitive impairment including hypertension,
    hearing loss, and traumatic brain injury.

    Because the science is now clear, the Department of Health and Human
    Services (HHS) in 2022 updated the National Alzheimer's Plan to Address
    Alzheimer's Disease to add a sixth goal: ``Accelerate Action to Promote
    Healthy Aging and Reduce Risk Factors for Alzheimer's Disease and
    Related Dementias.''

    Achieving this goal means adopting strategies designed to combat
    chronic disease and promote a healthy aging agenda including
    interventions to encourage greater physical activity, a healthy diet,
    cognitive stimulation, hearing loss treatment, social engagement, and
    sleep hygiene. The evidence shows that the earlier people begin these
    activities the better opportunity they have to reduce their risk of
    ADRD. It is critical that Medicare reimbursement provides adequate
    payment for the services and supports provided by physicians to prevent
    and manage chronic conditions.

    Even a 5-year delay in the onset of Alzheimer's disease would reduce
    the population with the disease by 41% in 2050, which could reduce
    annual costs by $640 billion.\2\ The Risk Reduction Subcommittee of the
    National Alzheimer Project Act Advisory Council set a goal of reducing
    dementia risk factors \3\ by 15% by 2030. A 15% proportional reduction
    in risk factor prevalence would be associated with approximately
    427,000 fewer prevalent dementia cases \4\ in the U.S. population.
    ---------------------------------------------------------------------------
        \2\ https://www.degruyter.com/document/doi/10.1515/fhep-2014-0013/
    html.
        \3\ https://aspe.hhs.gov/sites/default/files/documents/
    18454de4f0f9ef42dacef6ef167b1933/napa-2021-public-member-
    recommendations.pdf.
        \4\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9260480/
    #::text=A%2015%25%20propor
    tional%20decrease%20in%20each%20risk%20factor%20would%20reduce,CI%2C%203
    .7%25%2
    D10.9%25).
    ---------------------------------------------------------------------------

    Early and Accurate Detection Is Essential

    One of the most important policies the Finance Committee can advance in
    the area of prevention and risk reduction is early and accurate
    detection of Mild Cognitive Impairment (MCI), so patients and their
    medical team have as much time as possible to implement strategies to
    slow the progression of the disease.

    The bicameral, bipartisan Concentrating on High-Value Alzheimer's Needs
    to Get to an End (CHANGE) Act (S. 2379/H.R. 4752) makes a point to
    strengthen dementia detection. The act directs CMS to require
    professionals providing the Medicare Annual Wellness Visit (AWV; 42
    U.S.C. Sec. 1395x [hhh]) and the Initial Preventive Physical
    Examination (also known as Welcome to Medicare Benefit, WMV; 42 U.S.C.
    Sec. 1395x[ww][1]) to use cognitive impairment detection tools
    identified by the National Institute on Aging (NIA).

    CMS currently encourages, but does not require, providers to use a
    brief validated structured cognitive assessment tool. Consequently,
    many providers use ``direct observation,'' rather than a validated
    tool, to assess patients' cognitive health. Direct observation is the
    least useful and least appropriate tool, all too often contributing to
    under-diagnosis, delayed diagnosis, misdiagnosis, and non-disclosure of
    diagnosis. Recent studies showed that among patients aged 70 years or
    older, seen in primary care settings, cognitive impairment goes
    unrecognized in more than 50% of cases.\5\ Underutilization of
    validated assessment tools delays detection and diagnosis, resulting in
    decreased opportunities for people to implement important lifestyle
    modifications, access timely treatment options, and participate in
    clinical research. Use of these tools will allow clinicians to better
    detect MCI and other early symptoms of Alzheimer's disease and related
    forms of dementia.
    ---------------------------------------------------------------------------
        \5\ https://www.nia.nih.gov/health/health-care-professionals-
    information/assessing-cognitive-impairment-older-patients.

    When people receive a timely and accurate diagnosis, they have improved
    opportunities to make informed and productive lifestyle, medical,
    financial, legal, and spiritual choices to strengthen both their own
    quality of life and that of their family caregivers. The CHANGE Act
    would help providers detect Alzheimer's sooner, which is increasingly
    important in light of new Food and Drug Administration (FDA)-
    approved and Medicare-covered therapies for use in early-stage
    Alzheimer's disease. It is also critically timed, as Medicare prepares
    ---------------------------------------------------------------------------
    to launch its nationwide comprehensive dementia care model.

    CMS could adopt this this pragmatic policy administratively, and the
    bill sponsors have long encouraged CMS to act. We are aware of CMS
    concerns about overburdening primary care doctors. In response, the
    bill sponsors significantly narrowed the bill, clarifying that
    clinicians can use any one of the NIA-identified tools, including brief
    assessments.\6\ Three of these tools can be filled out by the patient
    and caregivers before the visit, which means doctors would not bear
    added burdens. This small change puts patients concerns first.
    ---------------------------------------------------------------------------
        \6\ https://alz-journals.onlinelibrary.wiley.com/doi/full/10.1002/
    alz.13051.

    We urge the Committee to include the CHANGE Act in any package of
    policies designed to advance ``Bolstering Chronic Care through Medicare
    ---------------------------------------------------------------------------
    Physician Payment.''

    In conclusion, as the Committee considers policies designed to
    ``Bolster Chronic Care,'' ADRD should be included on the list of
    conditions it considers, alongside cardiovascular disease, type 2
    diabetes, hypertension, and other conditions that have more
    traditionally been seen as chronic conditions. For too long,
    Alzheimer's and Related Dementia has gone unaddressed, and we know now
    there is much we can do to reduce the risk, detect it early, manage the
    disease, and soon (we hope) effectively cure it.

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