Just under three hours. [background noises] [background noises] quick to subcommittee will come to order the chair will recognize for five minutes for Opening Statement. Also a lot of things happening in the whole house today between both sides. And so we are going to have to try to manage this hearing and thank you everyone who is testifying first and second for your patience and willingness to work with everyone. We appreciate that. The chart recognize mckay will recognize myself an Opening Statement. Today we are considering legislation to rewrite greater access to care for seniors with lower cost Prescription Drugs reducing unnecessary red tape for Healthcare Providers. We are also considering proposals design to make updates to our physician reimbursement bottles distract the critical balance between driving Higher Quality care while ensuring Medicare Programs remain solid for future generations. According to september 2023 report the centers for Medicare MedicaidServices Healthcare is expected gdp over the next decade. This is simply unsustainable especially for our Medicare Program for the data shows proportionate healthcare spending of those over 65 costs on average almost 2. 5 times more than the average working person spends with picking up much of the higher share of the spending. Their support only further underscores the need for hearing examiner policies and sustain and strengthen the Medicare Program. This is the first time in several years weve thoughtfully examine our reimbursement for physicians many of whom are providing specialized care for seniors with chronic conditions for these conditions also require coordinated care that spans across multiple providers and clinical staff requiring every targeted reimbursement incentivizing Higher Quality standards for these patients. These are complicated problems they require Serious Solutions and our goal is figure how to best access seniors in sustainable responsible manner with this boat require constructive work between stakeholders, regulators, and the subcommittee. Any changes we ultimate pursue will be fully offset and promote the highest quality of care for our seniors i want to thank our witnesses for being here today in the first panel i will yield my repainting to the vice committee. Correct think it mr. Chairmans hearing means a lot to me. As a provider myself many issues on todays agenda are pretties of mine. Ensuring patients have access to quality providers is the most fundamental reason why i came to congress in the first place. I want to talk for a moment about why this hearing is so important. Providers choose to work in healthcare because they care about people. They invest years often decades of their lives to treating then they work grueling hours many of them. They sacrificed time from themselves and their families to take care of patients. While they are working had the lives of others in their hands which can be incredibly stressful. We owe it to these providers and their patients to allow them to focus on patient care not worry about the massive amounts of paperwork waiting for them at the end of the day or about longterm ability to operate their practice. We note medicare is a single largest payer for Healthcare Services in this country and often shapes private plans approach coverage. It is critical we ensure medicare operates in a way that supports providers thereby ensuring the millions of seniors who rely on medicare continue to have access to the doctors. My passion for this issue is why i worked for many years to get the approving seniors timely access to care bill across the finish line to remove certain prior authorization restrictions from Medicare Advantage. That is why fears have led the charge in bipartisan efforts to ensure physicians are reimbursed appropriately including hr 2474 to provide them with inflationary updates to reimbursement levels. That it is why i believe strongly we must pass legislation to promote value based care as was intended when Congress Passed the medicare chip reauthorization act in 2015. I hope my colleagues will join me today and recognizing the importance of these issues and commit to working with me and others on this committee to ensure provider access for medicare patients. Mr. Chairman i yield back. A gentleman yields back. The chair will now recognize her gentle lady from california representative for five minutes for an Opening Statement. Thank you, mr. Chairman. I think i speak for all of us its good to be back in our hearing room doing our work. It is good to be with all of you. Last year my constituents in the present of the California Medical Association wrote a letter to me saying that quote within our Healthcare System a crisis of grave proportion is taking shape unquote. It was november 2022 while coving cases at ease healthcare workers were still struggling to keep up. For us in the patients we serve doctor hernadez wrote the crisis is far from over. California medical association surveyed its members about how medicare payments are impacting access to care. The response is really striking and i think highly instructive. 87 of physician said low medicare rates negatively impact their ability to recruit and retain physicians and 76 of physicians said medicare payments did not cover the cost of providing care. A few bills we are considering today attempt to stabilize doctor etiquette reimbursement although we are notably not considering doctor bruce on to provide a physician payment as it ties to inflation. That is a must on a bipartisan basis. I often hear from physicians in my district about Administrative Burdens for medicare and commercial health insurers. For example seven years ago Congress Passed macro the medicare access cheap reauthorization act the doctor said to finally end the annual need to pass to save doctors from cost of medicare reimbursement. That legislation created the meritbased incentive Payment System which the gao found added more administrative verdict while doing little to improve quality of care. I think our subcommittee should seriously consider recommendation to eliminate the meritbased incentive Payment System. While traditional medicare increased its paperwork Medicare Advantage plans also started burning doctors by overusing prior authorization. Prior authorization has morphed into a costly inefficient mechanism that prevents patients from receiving care and unnecessary burdens onto providers. It is why i support the improving seniors timely access to care act to reduce the overuse of prior authorization Medicare Advantage plan. While this hearing is focused on improving Patient Access to care and reducing burdens of physicians i am concerned my republican colleagues once again are not considered legislation to fund state Health Insurance programs in the area agencies on aging. These are two programs whose funding expired on september 30. As i said, not that you would remember it at our last hearing california state Health Insurance program is called hightail. This is a program that works and it works very, very well. Provide Stellar Services every day for seniors in my district to have medicare problems. We should not allow this to expire im also concerned our subcommittee is once again considering a huge slate of bills, 23 in total with nearly half either in discussion draft form or only formally introduced a week ago. I look forward to hearing from our witnesses today. Hunt how we can enhance a beneficiary access to care and reduce burdens on physicians. Without jeopardizing the Financial Sustainability of the Medicare Program. 10,000 americans age into medicare every single day. So if that is not reason enough to find a solution to these issues, i dont know what is. Thank you, mr. Chairman and i yield back. Her gentle lady yields back i will not recognize the chair full committee for five minutes for an Opening Statement for. Thank you chair guthrie good morning everyone. Our focus today it is to explore solutions to improve medicare payments to providers and ultimately help patients. Everyone has been hurt by inflation driven by President Biden the democrats record spending spree. Just last week we got two more pieces of bad news on inflation. First Medicare Part b premium are increasing by almost 6 next year. In fact since President Biden took over medicare premiums are up nearly 18 . Next we found out core inflation metrics show prices continuing to increase by 4 over last year. Inflation remains a huge problem everyone from patients to providers is feeling the pain of higher prices and higher interest rates. Patients have less money to spend on basic needs food, housing, healthcare and providers the cost of renting independent practice is growing as well this committee has heard testimony the whole Healthcare System becomes more expensive when providers cannot afford to stay independent. Todays hearing will focus on how we can eliminate unnecessary red tape and most importantly sustain access to care and lower costs for Medicare Beneficiaries. Regardless of where they live in and my doctor collects is that its important to let doctors do what they do best, spend time seeing patients and less time filling out paperwork. The balance the need to ensure patients and medicare are accurately paying for that care. While recognizing paperwork even if wellintentioned can limit time spent on providing healthcare increases costs. As we look to modernize our medicare Payment System wheat must be thoughtful and striking the best and right balance. Today we will consider a wide range of discussion drafts inflation aims to support medicare providers as they deal with raising paperwork, rising inflation and rising labor costs. For example if you discussion drafts address expired payment initiatives. If congress does not act before the end of the year doctors in certain rural areas and laboratories will see a pay cut for medicare starting january 1. In the short Term Congress should act to avert these cuts. We should consider why we are having the conversation every single year. If we did further proof government should not intervene in the economy look no further than the physician fee schedule and her efforts to create a more perfect price control congress is increase medicare payments to doctors seemingly every single year since 2003. Im not saying these are not worthy endeavors. I believe in supporting our doctors in 2015 this committee in Congress Passed to get us out of the cycle of the annual fixes. Yet here we are. With a system that again has underperformed those who rely on the Medicare Program. And still some of my colleagues across the aisle would expand such a system to cover every patient in the country. The fact is politicians and bureaucrats will always do a worse job than the market at determining the most efficient prices for an item or a service. Congress should spent its efforts on longterm reform to the program we have now so we are not back at this every one, two, or three years but its also important to recognize the greater context of this discussion. Parts of medicare are on pace to be insolvent or 2031. Solutions like the bipartisan lower cost more Transparency Act will save medicare money in the long run. But our resources are finite we must make sure we are examining every dollar medicare spends in andmaking sure its going to the right places before assuming Additional Resources are necessary. If Additional Resources are necessary we should Work Together to find ways to save medicare money and other areas. Again our goal today is to strengthen the Medicare Program and increasing access to care improving the way we reimburse providers and i think our witnesses for being here today and i look forward to the conversation. I yield back mr. Chairman progressive templating yields back. It is now date 17 of house being paralyzed without a speaker. We are 29 days away from another potential shutdown. This hearing comes at a time when House Republicans dysfunction is hurting the American People weakening our economy and undermining our national security. House republicans have caved to the extreme elements of his a party who has no interest in governing. They for severe cuts to critical programs in spite of the fighting agreements between the former speaker and President Biden they came dangerously close to a Government Shutdown that would have closer National Economy upwards of 13 billion a week and forced our troops to work without pay. I just think the American People deserve better democrats have repeatedly stopped the chaos and dysfunction from hurting every day americans but it is long past time for House Republicans to reject the extremists in their party. We should be working together to lower costs for American Family and grow our economy and the middleclass is time for the chaos to end. Now, turning to the topic of todays hearing medicare is played a Critical Role in the lives of our nation senior and disabled americans since its enactment. Medicare is the main source of healthcare for most of our nation seniors and disabled individuals. We must ensure it remains sustainable longterm delivers the highest quality care. I have Major Concerns about the process leading up to todays hearing. My republican colleagues the vast majority of the discussion will be discussing less than a week before the hearing. Many drafts are still halfbaked and given the broad array of topics and bills i am disappointed we do not have adequate time to fully event some of these policies and provide democratic input from the beginning. Republican majorities also put forward a long list of expensive republicanled bills that could collectively cost billions of dollars without any proposed way of paying for them. This is especially ironic given just yesterday his speech on the house for nominating jim jordan as a candidate for speaker republicans expressed concern with medicares finances and cited their support for jordan because of his desire to make devastating cuts to our nations social safety net healthcare program. It is unfortunately a pattern we see over and over again from republicans pushing forward policy changes and then demanding devastating spending cuts to medicare that white andd cruise costs for seniors the truth is medicare is not broke it does not need major changes and it certainly does not need terrible republican ideas to cut benefits, raise the retirement age are increasing your cost contribution. What we need is for republicans to stop their infighting so congress can come together to find Bipartisan Solutions for the American People. Nelson these policies before so they may have merit and dress addresscritical need above medie patients and providers of forcing my republican colleagues have thus far refused to engage with us constructively or proposed a path forward to move these bills on a bipartisan basis. Even the republicans unproductive track record on the house floor of this congress, i remain concerned were not going to bill to successfully move a bipartisan legislative package out of committee under the house floor and into the president s desk. Aerobic and codex also rejected Committee Democrats will request to include legislation in todays hearing that would directly expand access to care reduce healthcare costs for seniors. The majority refused to include hr 5630 the health low income seniors Affordable Care act led by representative craig for the bill would directly extend coverage for senior lower their outofpocket costs by extending coverage for outreach and Enrollment Programs. These programs help low income Medicare Beneficiaries enroll in medicare and access benefits at lower their outofpocket costs. Thanks to these programs about 3. 5 million Medicare Beneficiaries have received assistance and the number of seniors enrolled in the low Income Subsidy program increase of 11. 8 million in 2014 to 14point to million in 2020. Now let me just say i am concerned the totality of these proposals would result in significant funding cuts the Medicare Program raise healthcare costs for seniors to increase premiums. This will place additional undue burden on our nation seniors and raise their outofpocket costs. Democrats stand united in opposition to any republican efforts to cut medicare benefits, raise retirement age, or increase senior costsharing or premium we will continue the fight to protect the Medicare Program. I think all of our witnesses for being here today and i yield back mr. Chair. Correct a gentleman yields back will begin with you. So our first witness director centers for Medicare Medicaid services ms. Leslie gordon director of healthcare at the Government Accountability office mr. Paul massie executive director the medicare payment advisory commission. You are recognized for five minutes for Opening Statement. Thank you. Chair mark Rogers GuthrieRanking Members and members of the subcommittee thank you for the opportunity to discuss that medicare and Medicaid Services efforts to improve the Medicare Program. Before becoming the director of the center for medicare, i took care of patients as an ear, nose, throat physician. I saw firsthand a powerful impacts that help healthcare can have on health and wellbeing of individuals and their communities. Too my current role now. W our goals for medicare include quality person care improving access to coverage and care, advancing Health Equity and improving affordability and sustainability of the Medicare Trust fund. Through robust engagement with our partners and the communities we serve. Medicare payment policy is set in statute by congress. Cms works within the confines of the law to establish payment policies for physicians and other healthcare professionals. One area for us is transforming care through more holistic models for Healthcare Providers can care for people not just treat a disease. Over the last decade, medicare has accelerated participation and value based care models that reward better care, smarter spending and improved outcomes 2022 the Program Saved medicare roughly 1. 8 billion compared to spending targets of a year. This marks Consecutive Year of net savings. While the participating terror organizations or acos maintained higher ratings for quality care then similarly sized physician groups. In july of 2023 cms proposed changes in order to improve access to coordinated, efficient, highquality care for more people with medicare. Many changes were suggested by those providers currently participating in the program. By those who wanted to participate but felt they could not. Particularly providers and rural and underserved areas. Particularly in Behavioral Health and telehealth which is critical to improving the health and wellbeing of Medicare Beneficiaries. Following congressional action, cms has proposed procedures to allow marriage and family therapist and Mental Health counselors to enroll in medicare and be paid directly. Cms has proposed payments for intensive outpatient programs which are finalized both critical cap and the type of Behavioral HealthServices Covered by medicare. Following congressional action medicare also permit expanded access to telehealth for Behavioral Services including audio only for access or unable to use video. We note Telehealth Services have enabled individuals and rural and underserved areas to have improved access to care. Well continue to work within the confines of the law to ensure medicare properly covered these critical services. We remain concerned about the profound Health Equities that are persisted in the United States for generations. Cms is working to advance Health Equity by designing, implementing operationalizing policies and programs that support help for all people served by our programs. Bancorp rang the perspective of lived experiences and integrating safety net providers and communitybased organizations into our program. And finally cms is working to ensure medicare remains affordable for people and sustainable for future generations. The Inflation Reduction Act makes medicare by expanding benefits, lowering drug costs, and improving the sustainability for generations to come. The law provides meaningful Financial Relief for millions of people with medicare. Improving access to Affordable Treatment strengthening medicare both now and in the long run. Moving forward we aim to collaborate with congress and or other partners on areas where we can Work Together to drive meaningful change of Healthcare System. We are committed to ensuring we integrate the perspective of the communities that medicare serve as well as the providers and health plans that deliver healthcare into our policies. So thank you again for the opportunity to testify today. Im happy to address any questions you have. Thank you any thank you for the just money for the chair recognizes ms. Gordon for five minutes your Opening Statement. Good morning. Chair guthrie, rogers, Ranking Member and members of the subcommittee. I am pleased to be here today to discuss issues that affect physician payments and experiences in traditional feeforservice medicare. With the medicare enrollment and spending projected to increase, Controlling Program spending remains a serious longterm financial challenge. Physicians and other providers play an essential role in the growth of medicare expenditures alter the services they provide the services they order like diagnostic tests and referrals but my statement summarizes most of recent Research Reports examine the geographic payment for services under the physician fee schedule and physicians and other providers participation in and experiences with the merit bates Payment System in advance alternative payment models. First, in february 2022 geo reported on geographic adjustments to physician payments for physician time, skills and efforts focusing on geographic adjustment to the physicians work components under the fee schedule. The purpose of these adjustments is to account for differences in the cost of providing care across various geographic locations. Specifically medicare will pay more for a service and an area where approximate cost for a physicians time, skills, effort are higher than the National Average and less in an area where costs are lower. Geo reported in 2022 modeling for the geographic variations generally accounted for physician earning and 90 under the 19 localities to be examined. However in 14 localities the adjusted value was below the level needed to reflect the geographic variation in physician earning and in 15 localities the adjusted value was above. We also reported that removing the physician work geographic floor would decrease overall payments by about 440 million less than 1 of physician payments as of 2018 when we look at that. Most of the effected payment localities would seek less than 2 decrease. Turning my attention to the quality payment program, and 2021 we reported on physicians and other providers experience under the merit incentive Payment System. Looking at the years 2017 through 2019. The meritbased incentive Payment System allows eligible providers to earn performancebased payment adjustments. We found that at least 93 of providers qualify for a positive payment adjustments, less than 5 earned eight negative adjustment. And since a few funds were available to it spread out across a large number of providers who earn positive adjustments, those positive adjustments were less than 2 . November 2021 we reported on physicians providers participation in advance alternative payment models against 2017 2019. The advance alternative payment models encourage providers to share in the financial rewards and risks of caring for beneficiaries. We reported the proportion of eligible providers to participated was lower among providers and rural healthcare per shortage areas and others underserved areas compared to other providers. Most providers however who participated regardless of the area were eligible to earn the 5 incentive payment regardless of practice. But summarizes the highlevel notes from these issues in this concludes my prepared remarks so be very happy to answer the questions that you may have. Thank you i think if your testimony that your nonrecognition mr. Massie for five minutes for Opening Statement progress chair guthrie, chair rogers, Ranking Member pallone. Distinguished Committee Members my name is paul macey im in the executive director of the Medicare Payment Commission probe rifle for the opportunity to be with you today to discuss how to ensure Patient Access to care minimize burdens for providers. Does not take positions on proposed legislation but im happy to provide information about rules and Commission Work may be helpful the Committee Considers the issue. As you know, its a nonpartisan congressional support so our mission is to help you you must make each year. All point of a gao 10 commission a subclinical train including eight physicians, registered nurse and a pharmacist nine have high level executive experience with Healthcare Delivery organization plans eight commissioners or academic experts who publish frequently in peerreviewed journals with deep expertise in analyzing medicare issues payments, access, quality. On the commission has experienced different aspects of the Medicare Program the goal is to put the experience to bear to help congress improve the program for patients, taxpayers and providers. Just because we had that experience does not mean we have all the answers too. You can be assured our agenda as a commission is the same as yours. High quality care for Medicare Beneficiaries at the lowest cost for taxpayers. A core part of the Statutory Mission is assessing whether overall payments are adequate to ensure Medicare Beneficiaries have access to highquality care. And to advise congress on what when payments are too low or too high. Overall, meditech has found to privately insured vacation. We do several things to arrive at that finding. Our own nationally representative survey of beneficiaries we conduct focus groups in urban and rural areas and focus groups with clinicians. We analyze medicare data and compare all of our findings with other surveys and researchers. Based on that assessment for the last several years the Commission Recommended the amounts in current law or sufficient to support continued access to clinician services. However this march commission made two recommendations to congress how to update medicare payments under the sea schedule. First the Commission Recommended for 2024 medicare payments under the sea schedule should increase by one half of the medicare economic index which is a measure of inflation. That reflected concern for her w recent inflation has affected the cost of running a physicians practice. And second the Commission Recommended addon payment for clinicians to treat lowincome medicare patients. This recommendation would target Additional Resources to support access to the most vulnerable medicare patients in the providers who serve them. That was based on evidence those patients can face barriers to care and be more expensive to treat. This is one example of an important Commission Principal policy solution should be evidencebased and targeted to address specific problems to ensure medicare resources are used efficiently. Lastly the Commission Recognizes the importance of reducing red tape from providers. This time is best spent focusing on patient care. Reducing Administrative Burden was on the key reasons why marcn recommended that it be eliminated. It was burdensome for providers unlikely to collect meaningful information on quality it would make an equitable payment adjustments. That replace the sgr patient centered care delivery models. Looking ahead ongoing work on several of these issues. Our october schedule meeting in the future. Additionally in our december and january we will include update information with access to care and payment recommendations to ensure continued access. The commission is happy to have any resource to the committee at forger questions. Think if your test for that concludes all of our witness testified we will begin the question. I will recognize myself for five minutes for questions but first i want to say appreciate from my friend from new jersey were not proposing anywhere in their fake benefits await nor are we proposing to pay more. We were just as passionate what didnt happen last congress for the Inflation Reduction Act not only was the policy Medicare Part d innovation for our seniors. It also an onsite savings from cvo were spent upside all these issues were spent outside of medicare to enhance subsidies for insurance companies. We were just as passionate as he talked about. We need to come together with the baby boomers coming forward make sure its sustainable going forward. We spent the money on the enhanced subsidies for Health Insurance they knew this was coming and chose to spend that money there i want to make that point as passion as he made his. Ms. Gordon you are reporting is significantly more providers enrolled at that merit based atd incentive program. Versus enrollment advance alternative public models. What were the primary drivers whether such a big gap in the programs question rick in your estimation which program is more impactful from the perspective of driving more efficient spending and outcomes for patients . So, we reported it was a erra large number of priors enrolled in the program compared to the advanced apm. Structure the two programs are different. Clinicians are eligible and they are requested prior to participate or there are higher barriers or sort of more upfront costs and investment need to be made to enroll in the advanced apm. I would believe that might be why we see greater enrollment mitts compared to the apm which program is more impactful was spending . We have not evaluated that but we have heard from stakeholders with regards to both programs there were challenges. Challenges have to do with its driving quality improvement. The metrics reported were in the time we looked out from 2017 until 2019. Is not indicative that could be encompassed apm these awesome challenges upfront. Ask do you believe it rebates be considered for the net price . Thank you for your question. With the drug price program. Incorporating all that we have gotten and will continue to get through the robust engagement with all interested parties. We laid out inner guidance for the program that we will be looking at the factors that are laid out in the inflation. Courseware about the rebates . In the net price and the part deeply. The rebates be considered . In terms of how pbm and manufacturers negotiate with each other, the law is clear we are prohibited from interfering with that process. And we follow the law and implement consistent with the law in terms of the administration with the part b program. So there is some question how that toby implemented. Let me that something major address on our side of this hearing. So what are your primary goals in implementing the meritbased System Program . What more do you believe needs to be done to drive more enrollment in pbms . Thank you for that question. The meritbased investment system is administered by my colleagues in the clinic for standard and quality. What i can say is we are very interested in driving participation and value based care. Looking across our program to align Quality Metrics so we can really galvanize momentum to drive change on the ground up it will be interested in continuing to work with you on this issue. I would ask another question five seconds for a sick write to five will get as many people in his weekend. I will yield back at recognize Ranking Member from california for five minutes. Thank you, mr. Chairman. Thank you to each one of the witnesses. I am frustrated. There are two things that i deal with consistently in my Congressional District. I dont think my Congressional District is unique. Number one, doctors are not reimbursed as of a fair compensation. Therefore they drop out. They cannot be in the Medicare Program. The Medicare Beneficiaries in the district. They cannot find increasing the great difficulty find doctor that accepts medicare patients. I know we have the have a responsibilityin terms o. Certainly the funding mechanism. We are going to have to figure out we pay doctors fairly so that it is fair. But also the Public Interest the stay and medicare and treat patient. Most medicare patients are not very sick. It really is, i think for those who arent very sick. I am not so sure what you have studied. We need to measure what matters. I think those two bookends so to speak that i just raised are at the heart of what we need to address in our country. Because when push comes to shove if you dont have doctors in medicare than what can medicare mean to a medicare recipient . They are not receiving anything. We have got a serious work to do relative to the dollars and this. They that money and where were going to have to raise money. These areas can be uncomfortable. The length they look there. Im the march 23 report earlier this year medpac estimated medicare spend 6 more for medicare enrollees than those remained an original medicare. That translates into this is now what i am pursuing is the saving side. 27 billion. 27 billion in overpayments this year alone. So how first what is it taking what action is cms taking to reduce the overpayments . How does it recommend reducing the excess payments to the Medicare Advantage plan . We have got to look for saving money before we go out to consider where we raise other dollars. So it actually works for medicare recipients. Thank you for the question are absolute rights. Our Analysis Shows on average medicare pays more for Medicare Advantage relative to service. We have a number of recommendations to improve the value the program gets i will highlight two very quickly. One would change the Quality Program to budget neutral. And also restructure it to get more meaningful quality information. A number two recommendation to address coding on average plans coded more intensively. I did not hear you and im hanging on every word. You are talk about 27 billion in one year alone. Yes the second recommendation i would highlight it would be with address coding. Medicare advantage plan code more intensely than feeforservice. The increases Program Spending and increases part b premiums for beneficiaries. We have some ideas how to address that. Absolutely. Get the answer in writing so you can give me a lot of good information. Thank you. Lady yields back and recognizes the chairwoman of the committee. Its been four years since we had a provider hearing. Im anxious to get to work. Cbo released report projecting medical spending will double 813 billion in to 1. 5 trillion in 33 alone. 48 in 2021. I didnt see proposals in the president s fy2024 Medicare Part b to make sure theres access in rural areas or reduce red tape. Would you speak to whether or not the status we do is acceptable to seniors and ten years from now . I appreciate you raising this. Congress sets payment policy and we implement that consistent with the law and some of the areas that you raised are things that we have taken into consideration in our Regulatory Authority to do things about. For example, rural health. That is a priority for us. I personally in my prior role took care of people in a rural area. I also have traveled the country visiting providers in rural areas and i know how critical that we ensure access to care there. Thank you. Thank you. Ill be looking for the specifics, okay, and we will have to follow up. The medical trustees reporter hip and Knee ReplacementMedicare Part b instead of part a contribute today Medicare Part a projections being pushed out a few years. Are there other services cms thinks can safely be done in outpatient setting and what levs congress should take while maintaining quality appear and e thank you for that question. We will continue to analyze data and continue working with you. Okay, i hear from doctors in my district how rising inflation and red tape is making it harder for them to stay in independent practice. This Committee Heard testimony about spring consolidation in the Healthcare Systems being drivers of healthcare costs. My understanding is that hospitals get increases for inflation but doctors do not. Can you talk about why that is and how medicare payments differ . Thank you for the question. Thats correct. There are different differences between how medicare sets and updates payments for Physician Services and how medicare sets an update payments for hospitals. Part of the reason may have to do with the unit of payment is more disaggregated. Medicare will pay for more than 8,000 different items and services under c schedule and in the past congress has enacted policies that have tried to address underlying volume under the c schedule. Would you speak to how often those increases for inflation are calculated for hospitals versus doctors . Yes. So under impatient which updates payments for hospital, hospitals do receive inflation every year, in the past the Commission Part of monitoring access Medicare Beneficiary we tended to find that the updates have been sufficient to continue access but this year was different and we did recommend that payments under the fee schedule should be updated by a portion of inflation. What are your projections for the next ten years. More questions to come. I yield back. Thank you, mr. Chairman. Medicare is the main source of health care for nation seniors and individuals with disabilities and i will continue to fight to continue the Medicare Program. Im extremely disappointed that my colleagues rejected my sole request to include hr im sorry, sr360 today which would expand access to cover and lower healthcare costs for our nations most vulnerable lowincome seniors. The legislation would reauthorize and extend funding of critical outreach and Enrollment Programs including state which helps our nations seniors enroll in medicare and receive assistance for Prescription Drug coverage that lowers out of pocket costs. Many live on fixed income and struggle to afford lifesaving drugs. Can you briefly discuss outreach programs including chip and how they help lowincome seniors . Thank you for raising this. Outreach is so important because we want people to be able to navigate program and choose option that helps for their financial needs so they can take advantage of the benefits that are available and the chip program is one aspect of our overall and very important aspect of our overall outreach to include our medicare. Gov and 1800 medicare. Thank you, doctor. Millions of seniors qualify for Medicare Savings Program msp and the lowIncome Subsidy, lis program which directly lowers seniors outofpocket costs. So let me ask you, i understand that the lowincome outreach and enrollment activities help seniors enroll in lis and access assistance to help with out of pocket drug costs, is that correct . Yes, and thanks for the Inflation Reduction Act the Program Section up and downing starting january 1st, 2024 and this is a priority for us as we are in medicare open enrollment now to make sure that people know that they should find out if they could be eligible for that assistance. I understand that 3 million seniors qualify but are currently not enrolled, is that correct . It is correct that there are definitely across our programs people who are eligible who are not enrolled an that is why outreach is a priority for us. Well, thank you. I just think we have to expand and extend programs so lowincome seniors and individuals with disabilities would be able to access the help that they need. We know outreach and Enrollment Programs are successful as theyve already provided assistance to millions of seniors and have contributed to increased enrollment and im extremely disappointed that the republican majority refused to notice the important programs that have longstanding bipartisan support and have extended 11 times over the past 15 years. It is critical that we extend and hopefully we are able to accomplish that soon. Thank you, doctor, and i yield back. The gentleman yields back. Yeah, i have statements from the medical association and American Association of urologists in support of draft bills that i have including in todays hearings i have study of the institute detailing savings of more than a billion dollars a year for conditions and article from the Washington Post from september of this year how medicare spending has leveled off for more than a decade and i ask to be added to the record. I want to thank our witnesses for being here today. Ive been on this committee for a long time and i cannot remember having a hearing specifically on the concept of proposing a legislative change to budget neutrality. This mechanism leads to across the board for cuts and makes it harder for independent physicians, practices to survive and that, of course, threatens access to care. Three of us who are cochairs of the doctors caucus, dr. Murphy and winstrop plan to introduce, theres a draft of that as part of todays hearing. It would increase threshold allowing for corrections for overestimates and underestimates of budget neutrality and require timely updates to practice expense relative value units. Weve all seen whats happened to the cost of labor, california passed a minimum wage for healthcare workers for doctors who are in practice. They are competing for workers against the same pool of laborers and, again, the word unsustainable continues to creep in to the conversation. Ive worked with many people in this room on both side of the dias and i hope that we can get behind common sense solutions. Thank you for being here today. Thank you for the question. Its very important, practice expenses as well as work. One of the things thats come up today a lot is nips versus apms. I would have people recall as we were trying to get rid of the Sustainable Growth rate formula there was concern that all doctors would be driven into ac of courses and hmos because that would be the easy to approach the problem. But to allow small practices one, two, three Group Practices to continue practicing and to participate in a positive practice update that was the reason for the incentive program. Weve had one hearing in the last 4 and a half years in the implementation of macro. We didnt have any for four years fortunately with this committees leadership chairman griffin has had oversight hearing of macra, one of the things that came up from a harvard witness suggested it was not practicable to participate in acm. I seem to get from your testimony that perhaps thats a possibility . Thank you for the question. Give them opportunities to participate in apms. This is an area that the commission is working on. We discussed epm bonus and we will continue to work in the future to see how it can be restructured. I think it was suggested by ms. Gordon that enhancing payments so that the meeting the necessary informational structure infrastructure, so that would be possible, i mean, its a big expense for small practice, one or two doctor practice to provide the infrastructure is necessary to collect the data so is that something youre willing to look at . Yes, the commission is happy to work on this issue and support the committee. We do have to be concerned of consolidation of small practices. Consolidation in health care in general, this is one of the ways that we can tackle that. Thank you for yielding back. We are going to have one more set of questions but theres conferences and caucuses at 11 00. Theres maybe a schedule vote at noon. The witness will stay in contact with our staff, we will make sure that we move forward but we are going to recess after this question, so we are balancing both sides, so we have ms. Blunt rochester from delaware. Your recognized for five minutes. Thank you for the recognition and thank you to our witnesses for your testimony. Today we are considering Healthcare Provider policies including my bipartisan bilker increasing access to rehabilitation care act. Hr2583. I want to thank you my colleague adrian smith for tireless work on this bill and also acknowledge that he worked alongside our late colleague john louis and im proud to be taking on the mantle. Two lifesaving services by authorizing physician assistance, Nurse Practitioners and clinical Nurse Specialists to order them. These interventions are proven to reduce mortality rates, hospitalizations and costs. Unfortunately they have historically been underutilized due in part to lack of referrals from physicians and inadequate followup after referrals. Congress attempted to address this issue by authorizing certain additional providers to supervise pulmonary rehabilitation in the bipartisan budget act of 2018, however, cms has indicated that while this policy changes an important step forward they, quote, do not anticipate any significant increase in utilization of cardiac and pulmonary rehabilitation program. We know they reduce mortality rates and cost, can you describe why participation remains low in the programs despite the potential benefits . I appreciate you raising this. We agree that cardiac and pulmonary rehabilitation are important and beneficial for Medicare Beneficiaries. We look at literature and studies on utilization rates for the Impact Analysis of the proposed changes that would implement what you referred to with the bipartisan budget act of 2011 to allow pas and ps to supervise these programs and we will continue to monitor utilization of these programs after implementation of this new requirement and can continue to work with you on this issue. Can you describe how cms concluded to supervise the programs without the authority to the put in orders may not increase participation and what other potential solutions may increase access and utilization of cardiac and pulmonary rehab . This points to the need to examine utilization when these changes are made and we would be happy to continue working with you on this as we agree that cardiac and pulmonary rehabilitation is an Important Service for Medicare Beneficiaries to have access to. Yeah, i think whats important here they need the authority as well and so i want to switch to primary care where the minute 30 seconds i have left. Delaware like other places are experiencing shortage in primary care providers and thats why im sponsor to reauthorize the Community Healthcare center and why i serve as the one of the cochairs of the primary care caucus and delaware we have seen that physicians, primary care physicians are accepting new patients for medicare and medicaid its much lower and this is a big concern. Dr. Macy, in your testimony you describe certain financial pressures Healthcare Providers face including primary care providers that may influence their decision to see medicare patients, can you highlight some of those . Yes, thank you for your question. Every year we monitor access that beneficiaries have including clinician services. This year we recommended an add onpayment to target Additional Resources and the key thing to point out is that we structure the addon payment so it would be higher for primary clinicians when they provide services to lowincome medicare patients. Thats an important to target resources to sure up access. Thank you, im going to submit questions for the record but along that line of implementing g202211 and the addon its costly and duplicative and overpayment. We would like to follow up on your answers regarding that as well. Thank you so much, i yield back. The general lady yields back. I remind everyone we will stay in touch. I think theres unknown and exactly what the timing is going to be today. We appreciate that and appreciate you al being here and the second panel as well and now the subcommittee will stand in res subject to the call of the jair