Transcripts For CSPAN2 Health 20240703

The subcommittee will come to order, we will now resume with our second page, our witnesses for the second panel, i have to put my glasses on, sorry about that. Dr. Debra pat, texas oncology. Dr. Fer, youre recognized for 5 minutes for your opening. Program meant to do. I stayed there and continue today serve that community. Ive stayed therefore ever since. My training has allowed me to develop longterm relationships with my patients and deliver patient centered primary care. Were not called Family Medicine physicians just because we treat the whole family. We are called Family Medicine physicians because our patients are part of our extended family. Being a rural family physician is incredibly rewarding but in the last several years its gotten much more difficult. My patients have more chronic medical problems that require complex ongoing care management, more and more they are looking to our practice to help with the depression and anxiety, Meeting Basic Needs and navigating increasingly complex Healthcare System. But instead of providing primary care practices with support to meet the growing patient needs we are left struggling to stay afloat as payment shrink and administrative requirements multiply. Our failure to invest in framary care is being failed across the country in Patient Outcomes and repeated challenges trying to find a primary care physician. Data released just this week shows that over 16,000 primary care physicians have left the workforce over the past year but as country we have never needed primary care more than we do today. Despite much higher spending per person the u. S. Spends less on primary care has the highest rates of people with chronic conditions, the lawest Life Expectancy and highest preventible death rates compared to our peer countries. In other words, primary care is uniquely suited to help address the pressing healthcare problems we face today. Im leased to see subcommittees on ways to support physicians with patient centered work that we and do tangible reduction in administrative workload. We encourage by steps medicare has taken to more appropriately value Physician Office visits. In 2024 cms has proposed incremental step to better value primary care. The g 221st addon code would better account for time, resources and expertise involved with providing comprehensive primary care. Primary care Office Visits are more complex and g2211 is intended to recognize that. Opportunities meaningfully invest in primary care under our Current System are rare but this is one of the few of them that we can use. I urge congress to support implementation of this code. However, coding and billing challenges alone wont fix the broken physician medicare Payment System. We need congressional action. I strongly urge congress to reform budget and neutrality requirements, enact annual inflationary update for physician payments, support Physician Practices moving into valuebased payment models and pass the lower cost more transparency act. But strengthen medicare patients go beyond just improving payment. Congress mustards Administrative Burden which has become totally unmanageable. My staff and i spent hours every day navigating prior authorization and therapy requirements that prevent patients from being able to access evidencebased treatment in a timely manner. Thankfully the subcommittee has the opportunity to address some of these issues by first passing the seniors timely access to care act. Reforming step therapy in medicare and medicaid requiring Medicare Part b coverage of all recommended vaccines so that we can give all vaccines in our office and i have to go to the pharmacy for that. Standardizing quality measures across payers and programs. Primary care in this country is at a Tipping Point but congress can help to change that. Improving payment reduce the Administrative Burden would not only be investment in primary care but also in our patients and your constituents. Thank you for the opportunity to provide this testimony, i look forward to trying to answer your questions. Thank you for your testimony. Dr. Pat, youre recognized for 5 minutes for your testimony. I think your mic, hit the mic button. I appreciate for the opportunity to testify on the diagnosis of america. A large physicianowned private practice in the great state of texas. I serve as executive Vice President of oncology. As you consider policies in todays hearing i want you to envision consequences of inaction. Continued medicare fee schedule payment cuts pose real and serious threats to medicare fiduciaries accessing medical care, causes Chain Reaction that results in provider inadequacies and decrease quality of care for Medicare Beneficiaries. The disproportionate burden felt by nonhospital affiliated practices like mine, disparity reimbursement in Hospital Systems that are driving up the cost for medicare care for all americans. We face cuts can. Since 2014 medical inflation has increased every year yet medicare has only decreased, the ever widening gap can be seen in the graph including in my written testimony that shows medical inflation risen by 28. 4 since 2014. We have issues of network adequacy, quality of care and physician burnout. Cms is constantly cutting medicare reimbursements for physician as natural consequences that harm Medicare Beneficiaries as a result of decrease. I have to juggle and ask favors to be seen by primary care physicians or another specialists so i have to use my time. I have to refill primary care medications and frequently have gaps in care where no one is refilling their medications and they go without diabetes or hypertension medication. This causes fragmentation and delays in appropriate care. According to recent study 145,000 healthcare practitioners left the Healthcare Industry from 2020 through 2021 threatening access to medical care, 71,000 of these were physicians. This is alarming. We face staffing shortages. The burden of declinement reimbursement has been compassion herbated by National Crisis and shortage in healthcare staffing. Just last week you might have seen announcement after Kaiser Permanente increase payment. Only challenge further by inflation how would i pay for increases in staffing to continue to staff my clinics and be competitive . The natural consequence of this is brother and sister Cancer Patients arent able to get mammography. Cancer Infusion Centers and facilities arent able to open to capacity because we have staffing shortages. We are on a verge of major crisis in medical care. However, because respect systems receive inflation adjustment the physicians in private practice do not and gap between physicians and hospital reimbursement is resulting in consolidation of medical care. This is especially true with hospitals, top 40b hospitals showed that markup cancer drug unbelievable 5 times, if you have a cancer drug that costs the hospital 5,000 it can be marked up to 25,000. In addition by ignoring Hospital Survey data, cms is everpaying 340b hospitals close to 50 contributing to premium increase that they will pay in 2024. We need to pass meaningful legislation. I want to underscore that its critical for congress to fix the looming cut with much needed inflation update. Congress needs to make payments equitable in the hospital and private practice settings by passing site neutrality legislation and fix b340b. As doctor in private practice we need you to consider legislation and make meaningful change. Fragmented an disruptive medical care for beneficiaries. We need you to act now. Thank you for your time and im happy to take any questions. Thank you for your testimony. Yes. Youre recognized for five minutes for your testimony. Think tank dedicated to empowering patients an reforming programs. I want to thank you for inviting me here today to discus payment policy in medicare. My testimony today reflects my own views. Medicare payment policy should reflect 3 key goals, first, maintaining access to care, second, minimizing costs and third improving payment accuracy. We should all be committed to securing seniors access to health care. Fortunately 98 of physicians accept medicare rates and this pour cent and increased over time. Policies that increase Administrative Burden or underestimate physician pay could undermine this. These costs directly onto the shoulders of beneficiaries through cost sharing and premiums, just last week cms announced that part b premiums will increase by roughly 6 next year due the rising medicare spending, on average seniors already spend 28 of their Social Security checks on expenses in parts b, d alone. The fiscal sustainability of medicare itself is also crucial. Part b which covers Physician Services is the fastestgrow part of medicare. The Medicare Trustees project that this trust fund which is mostly financed by general revenues will consume over one fifth of federal income tax renew by the end of the decade. Rising costs will directly contribute to deficits which may result in benefit cuts, tax increases and economic harm in the future. Finally, medicare policy directly distorts decisions in the healthcare sector. Fee for Service Payment encourages higher volume of healthcare procedures regardless of quality. Both congress and cms have historically struggled with medicare policies. Under the Sustainable Growth rate before that, the per unit price of Physician Services is stagnated which help to control overall spending, however, the volume and intensity of such services on per enrollee basis grew. Maintaining lower payment rates may compromise participation by doctors. So far data by cms, access to Physician Services is stable or improving, however, congress could ebb act policies that would improve medicare payment policy on these dimensions for beth beneficiaries and taxpayers. First congress should offset with savings. Part b drugs and other areas have grown rapidly. Common sense policies like neutral payments or reducing statutory overpayments on drugs can save hundreds of billions of dollars without making any changes to benefit seniors benefit. Second, congress should adopt more marketbase pricing for doctors. The current process leads to absorbable errors in payment rates and disparities between specialties have reduced supply. Market competition to determine away the economic value of service. Gradual improvement is possible by tieing medicare policy to rates negotiated by Medicare Advantage plans. Third, congress should eliminate quality payment programs like mips and the financial incentives for advanced participation. These policies have been the clearest failure of macr ample and responsible for clinician burden without improving value. A recent cbo report that they have lost instead of saving money. It does not make stones subsidize in models that do not work. Quality metrics are best when they enable seniors to make informed choices between coverage and care options. This is already possible in Medicare Advantage which has become increasingly popular in recent years. Policymakers should ensure that it remains a vital option for seniors and encourage participation between ma and fee for service. Removing government distortions than adding new ones is a much more effective way to maintaining access to payment care and improving accuracy. Thank you, i look forward to answering your questions. My name is matthew and im Health Economist and senior fellow at the brookings institution. Im grateful for the chance to appear before you to discuss ways how medicare pays physician. I want to begin by discussing the tradeoff involved in deciding how much medicare pays physician. Broadly excuse me, first ensuring that medicare can access highquality physician care. The second is limiting the cost that higher payment rates imposed in taxpayer that bear Program Costs on beneficiaries who bear medicare premiums and cost sharing and even the privately ensured when medicare pays more. Data on how well Medicare Beneficiaries are able to access physician care can help policymakers if they were to balance access and cost and that saying i want to highlight two facts. First, survey data shows that most medicare fiduciaries do not currently report major problems accessing physician care. In 2022 around four fifths of beneficiaries searched for primary care provider said they had no problem or small problem finding one. Nine and ten that saw new specialist thought the same thing. Twothirds of beneficiaries reported never waiting longer than they want today to get an appointment and more than half said the same for routine care and along all of these dimensions Medicare Beneficiaries report comparable or slightly better access to physician care than the privately ensured. This could indicate the changes in medicare payments currently only have a modest affect or alternative Greater Alliance on nonphysician professionals and offsetting in physician payment rates. Looking ahead it is possible that the Delivery System might respond differently to future payment changes than it did to past one. Perhaps especially cost outpayment rates indefinitely. Additionally, under current law would outpay by more during the next year or two than they did during typical year in the past two decades. The data im speaking to here doesnt address outcomes other than access like quality. Nevertheless recent history does suggests theres some scope to grow more slowly than input costs in the years to come without decline in access. In the time i have left i want to briefly highlight four structural changes how medicare pays physicians that are word considering regardless of what policymakers decide on level of payment. The first is eliminating the meritbased incentive system which evidence suggests is failing of improving quality and efficiency of patient care and creating costs for clinicians. Since eliminating mips and second maintaining bonuses or apms rather than allowing to sharp. Well designed apms do appear to improve efficiency of patient care and current payment encourages model uptick and flexibility to improve their design. The third is insulating future physician payment rates from inflation shocks but in a budget neutral way. Physician payment updates are currently fixed in law to shocks can cause inflation adjusted payment, rates to be higher or lower than expected. This could be avoided without a large score card and payment updates should equal index minus an appropriate fixed percentage. The fourth which takes me beyond physician payment per se is adopting ambulatory services as subcommittee is considered and the benefits of neutral payment in terms of reducing cost and beneficiaries and removing incentives for consolidation are likely familiar so i will not repeat them but i will note that payment differences wily grow over time which will magnify the importance of sigh neutral payment. Thank you, again for the opportunity to testify, i look forward to your questions. Thank you very much. That conclude it is testimony. We will move to members questions. I will recognize myself for five minutes. I want you to clarify you said four fifths of people medicare patients dont have a trouble finding new primary care physician, that means a fifth of them do. You presented that kind of that was a positive number. From my perspective, thats awful. A fifth of medicare patients when they lose their primary care doctor or their doctors retire cant, are struggling to find a new physician, is that what you said . So thats correct, yes. I think that the question is relative to what, thats a far better number than we observed in private insurance and separate question to the extent to what extent would increase payments actually address that problem. Yeah, so the reality is then its a chicken or the egg, right because we have shortage of primary care physicians because of reimbursements. People cant find their doctor. Youre saying payment doesnt matter but im saying thats the root cause of the problem. Right, and i think it is possible that payment matters to some degree and those access measures are better for Specialty Care than primary care and so that might consistent that payment does matter at the margins. I think what is true is given as we have seen a large decline in payments without large, the question is how much does it matter. I think i mean, youre an economists but the economists need to take a tour through rural Southern Indiana and maybe it might change your view. You also said about about specialists twothirds of seniors and last number was just over 50 of seniors. Can you clarify those because, again, those are awful numbers. Twothirds is the number of people that reported never waiting longer than they want today for an appointment. So a third do. Many of the people are responding that they actually fair enough. Theres a tradeoff how much can you improve access for a given amount of yeah. Fair enough. Dr. Pat, i understand you run your own practice, many are facing 10 cut this year. As an independent physician, can you share what an 8 or 10 cut would mean to your ability to practice and what that might mean access for patients. In your patient you talk about that briefly but can you clarify that even more . Yes, sir. So when we have decreases in reimburse meant, you know, that has a trickledown effect to everyone that we employ. We employ 6,000 employees and its important for us to give appropriate compensation increases to stay competitive otherwise other that is have greater Funding Resources will take them away and will not be able to keep appropriate staffing. So the natural consequence of a cut is that we are not able to pay our staff appropriately the competitive rate to stay staffed appropriately. Yeah. You also talked about the pressure that independent practices feel to sell, to help systems, in fact, my medical practice we sold to the hospital in 2005. We got to the point where we couldnt sustain cardiology practice that and was almost 20 years towards today. In that context of physician payments, site neutral payments and other things, ive had conversations with hospitals, systems that dont really feel like this is have had an impact on the physician ability to stay independent and also has not been a major factor in consolidation. Can you talk about how that dynamic, the difference in payment, the payment disparity has impact on consolidation and physicians having a hard time staying independent. Absolutely. Thank you for the opportunity to answer the question. Its a very clear correlation, reimbursement is less and we cant pay staff as much. Theres a nursing shortage throughout the country. If the competing hospital is able to pay them large signing bonus and increase compensation, they take away our staff and we are not able to stay open and then we operate less efficiently and then if you are not able to stay financially viable theres always attractive offer to sell your practice to the Hospital System and thats how consolidation occurs. At some point it becomes more financially viable to transition and really its not a closure of the practice, its more just changing the shingle and all the insurance contracts to double. That consolidation is a natural increase in the cost of care. Its not in americas best interest to see that happen. Thank you very much. My time expired and recognize the Ranking Member for 5 minutes. Thank you, my friend, doctor. I listened very carefully to your comments, to mr. Field. It seems to me that and i might be wrong but my my takeaway from some of the things that you said was that youre not taking into consideration the the impacts and their lasting from covid. I mean, article after article after editorial speaks of physicians in our country that have just left their practice left their practice. We have heard different forums testimony here of professions being hall lowed out and, you know, explore what we can do to bring in a whole new wave of professionals. So you dont make mention of that. You say, well, twothirds, one thirds sounds rosy but i agree with doctor, theres something missing in this, in what you said. I dont know when you put the numbers together and they are all rosy, i dont think so. And you know, im a real common sense person and all of us here have heard testimony from professionals, we know whats going on in our own communities. We are not making this up. So maybe you can go back and take a look at it and come back and give us Something Else to take a look at. Now, weve heard a lot today about improving Patient Access to care, cms released data from a survey showing 92 and a half percent of Medicare Beneficiaries reporting no trouble accessing care. I dont know where they got this from but you get a different answer in my different. Dr. Furr and dr. Pat, you are both doctors. In your experience, tell the us how, you know, for the record how doctors are reacting to the decreasing medicare reimbursement . Are more doctors retiring, turning away from medicare patients. I really we really need to get this on the record here. Its not that i dont im asking you questions that i think i know the answer to but i want this on the record and mr. Fielder while most Medicare Beneficiaries report they are able to see their doctors, are there i dont know when this was survey whatever was taken, when was it . How current is it . The data im speaking to is from 2022. Well, thats almost two years old. At any rate how geographical differences come into this. How do they play into it. Is there that much of an effect as a result of them and how does reimbursement play a role in addressing the the access issues, so you can split up the time with minute and 36 seconds. Are the geographical floor, in a rural area not only are you in a rural area, usually taking care of lowincome patients and disadvantaged patients so you dont have the payer mix that balances that out. How often are those geographical designations reviewed . I remember many years ago i got into such a protracted battle because i had to because one of the counties in my Congressional District bore the designation of being rural except that was when medicare was established. Rural designation in 1966 and we were losing doctor after doctor after doctor and was pennies on a dollar. How often is that reviewed . I do know the floor is going to go away at the end of this year. Its critically important that congress act and keep that floor from going away. I can tell you from practicing rural area its not cheap to live in rural area particularly after covid. Gas is not cheap in rural area. I have a number of patient who is are travel nurses. I cant afford to have them because they are getting the money in cape cod in areas. Its not cheaper. We need to have the floor and not let it go away. Well, i think, mr. Chairman, that my time has expired. Thank you each one of you for being here today. I know the schedule has been rocky and not all that predictable but thank you for being here this afternoon and i yield back, mr. Chairman. I recognize mr. Bill for five minutes. Thank you, doctor, appreciate very much. I want to thank the panel their patience. Im particularly glad we have prioritized preventing additional consolidation in the healthcare sectors so far this congress and im pleased my bill providing relief and stability for medicare patients act was notice for todays hearing. My bill hr3674 which i lead with representative aims to prevent officebase specialty cuts that were adversely affected by the clinical pricing within the medicare physician fee schedule. I believe the cuts upwards of 25 have fueled closures of the Community Providers and worsened consolidation that ultimately hurt Patient Access as they end up in more expensive settings and i see this all over my district. I want to submit a letter for the record that would provide some relief and also submit a statement for the record from the society for surgery discussing its support for hr3674 and the need to avoid disruptions and care for Medicare Beneficiaries. I ask for unanimous consent that both be insert intoed the record, mr. Chairman. Without objection. Thank you, my question is for dr. Pat. Thank you for your testimony on behalf of the oncology community. Appreciate it. So you know the importance firsthand about maintaining communitybased settings for patients. Can you tell us what the impact on officebase providers would be if we dont work to alleviate these cumulative year over year cuts in the physician fee schedule and can you tell me what impact it would have on Patient Access, please, thank you . Thank you, congressman for the question. I think that it will have many implications if the costs are not alleviated. I think the natural consequence that private groups in Community Practice are not able to stay viable and and not able to have competitive staffing resources. When that happens we have to close treatment times the and not open to capacity and that decreases access and also furthers consolidation. So i think efforts to, you know, move reimbursement and your legislation, thank you for leading it would go a long way to to improve that and make Community Practice more sustainable. I also think that aside from individual changes that the side of service disparity poses continued challenge to the threat of consolidation and when you have consolidation happen, youre going to have access to care issues for Medicare Beneficiaries and all americans. I see that. And i know the patients in my District Community care for a lot of reasons. Beyond my bill, i also want to thank the chair for putting up legislation i colead with representative hudson and many of the bipartisan members of this committee, the saving access to the Laboratory Services, hr2377 which will provide the muchneeded permanent solution to the Clinical Laboratory reimbursement and medicare. I know the chairman here is a leader in that. We must prevent cuts to happen while prioritizing innovation. Lastly, i want to quickly thank the chair again for including the empower act to help the physician therapy workforce the fiscal therapy workforce in this case and i hope that we can go further by discussing my bill 1617, to prevent interruptions in fiscal therapy act as well. I look forward to working with the chairman and the committee on this important legislation and i hope so very important particularly for medicare patients. Thank you very much, mr. Chairman, i yield back. The gentleman yields back. I now recognize dr. Ruiz for 5 minutes. Thank you. Mr. Chairman, medicare is our nations promise to seniors. And medicare needs work we need to take action to protect the patients and we need to protect and strengthen medicare for our seniors. We need to address a major barrier to care for patients which is the physician reimbursement rates, the Medicare Participation for the physicians charged with providing these cares. For years physicians have been experiencing cuts to medicare reimbursements, year after year. Even while other medicare providers have experienced increases for inflation, you see from 2001 to 2023 inflation adjusted payments for physicians declined, declined by 26 even amid the rising costs of running a medical practice. So you see this widening gap, okay. That are going to reimburse them the most and they will drop medicare and that will leave our patients without a physician for them. This is about patients, not physicians. This is about putting patients first and ensuring that they they have thedoctors and medical professionals able to take care of them and keep their doors open especially in underserved areas so the physician fee schedule is broken and we cant afford for doctors to close their doors or take fewer patients because they cant afford to treat them. Medicare reimbursement rates to rising inflation will go a long way towards protecting physicians and ensuring reliable access to care for patients. Thats why my bipartisan bill with doctors miller meeks, doctor bushong was here earlier but miller meeks is still here, the hr 2474 strengthening medicare for patients and providers act will adjust medicare physician reimbursement rates based on inflation by tightening reimbursements to the medicare economic index. So considering the trending decline in physician payment rate, how do you see this access and quality of care in the future . As the saying goes especially about the future, i do think one of the striking features of the last two decades is that Patient Access and medicare has been remarkably stable even during a period where physician payment rates have lacked behind. And thats a testament to the physicians who care about their patients and will practice and take care of them and treat the Patient First and foremost. I appreciate that, but there have been challenges for them to do that and since we have limited time, i will ask you to answer that with my office in writing if you can because theres another bill that im a cosponsor of and i want to send a strong message to the chairman to please have a hearing on this bill and to please pass it through committee. I know that the Ranking Member as you is in support of this as well and we could pass a good bipartisan bill immediately to address this issue. But the hr by five to six seniors access to critical medications act of 2023, which i may cosponsor will allow physicians to help mail their medications to their patients. We have a lot of patience with mobility issues and this would help strengthen medicare by enabling seniors to receive their medication without the onerous barriers that it takes for them personally to go and get the medications themselves and with that i know i ran out of my time and i think you for your grace and yield back. The gentleman yields begin to the chair recognizes doctor burgess for five minutes. I do want to thank the witnesses for being here for your forbearance and what has been a sort of disjointed day. I dont know if you were here earlier in the hearing i talked about one of the bills thats the subject of this legislative hearing the provider reimbursement stability act of 2023, current medicare fee schedule over and over again is unsustainable and unpredictable. This is due in large measure to what is known as budget neutrality and often leads to acrosstheboard cuts and making it harder for practices to survive. So, with what youve heard about that this morning, can you speak to that legislation to stabilize and promote accuracy within the schedule . You would need to get to where the physicians are not going against each other and thats what the budget neutrality does. I think we definitely need to have that conversation because that definitely needs to change and part of what youve got in there where that changes is incredibly important. I think it would go a long way. That threshold is not changed since 1992 and the adjustment of the cost of dollars into the medicare spent currently would result in a significant increase in that threshold and that, you feel, would be beneficial to the practicing physician . Yes sir. I cant thank you enough for being here. I know you had to ride the train late last night and it was a lot for you to get here. We really do appreciate that. In your written testimony you mentioned examples of how consolidation leads to rising healthcare costs. Right now im working on a discussion draft of that would allow for physicians and hospitals 35 miles from an existing hospital or critical access hospital to open or expand and id like to remind everyone this is a draft im working on a few technical changes but let me just ask you the general question do you think physician ownership could be beneficial where healthcare is limited . I do. I would be very supportive of that idea. A very succinct answer. Let me ask you the same question. Physicians, most cant afford to run a hospital, but if they cant afford it and i have no problems with that. Who better to establish a facility in a rural area or underserved area then somebody that actually knows what a hospital is supposed to be and what a wellrun hospital looks like and at the fact we are precluded from that activity by virtue of our professional degree. People on the committee have heard me say it over and over again that a hospital can own a physician and a physician cant own a hospital. It makes no sense. In a free country it really should not be that way. I do know that there are concerns on both sides of the dais. I would say before i yield back i think the solution allows physicians to maintain activity in the business of healthcare while providing patients access to the care they need. It would allow doctors to continue to be able to afford to stay in practice when they have so many things working against them. In the interest of time i will yield back. The gentleman yields back into the chair will recognize mr. Cardin for five minutes of questions. Thank you mr. Chairman and Ranking Member for holding this important hearing. I agree somewhat with some of the comments my colleague made. It seems in this country you can be a lawyer and own the practice but if you are a doctor, you cant own a hospital. It sounds like we trust lawyers more than doctors in this country but hopefully we can get good policy on that. Really appreciate that. This congress im proud to colead the providing relief and stability for medicare patients act of 2023 along with my energy and commerce colleague. Get this, republican billy rakas. Im a democrat and hes republican and we are coleaving on the bill as well as representatives murphy and david. The bill would mitigate a significant cuts to offers space specialists by increasing nonfacility practice expenses relative to the valued units for procedures performed in office space settings that utilize hightech medical devices and equipment. I believe that this is important to ensure that we preserve access to office space care settings many of which face a possibility of closure or consolidation. Now by the Management Associates have found that office space specialists including cardiologists, radiation oncologists, vascular surgeons and radiologists have been subject to cumulative cuts under the physician fee schedule since 2006. This is simply not sustainable, and i worry patient care will suffer because of it. The focus should be on building robust systems that ensure the communities can access the care they need. I just spoke to an oncologist that owns a small practice and he was mentioning how difficult it is but i interrupted him and said if your practice were to close, how far would your patients have to go to be able to get your service . Use it to 60 miles in one direction, 95 and the other. That is america and i say that because i care about access for all americans. I represent part of los angeles. You could go a mile or two in any direction and youre going to going to doctors. A few more miles oncologists et cetera. So i want to point out please dont think if we represent a big city we dont care about Rural America and as well i dont think that my colleagues who represent Rural America dont care about people in big cities either. I just wanted to point that out. I have a question for doctor pat, deborah pat. Do you know that it causes a Chain Reaction that provides and the Provider Network inadequacy, decreased access to care, inability to manage staffing shortages and decreased quality of care for american seniors and both are Medicare Beneficiaries. Whats the impact of these sustained clinical cuts especially in medically underserved communities . Thank you for the question. I think that these cuts will result in doctors not being able to staff appropriately, which over burdens the doctor and makes them leave the workforce. Subject to close, others frequently consolidation of medical care and the natural consequence of that is that drives up healthcare cost. I think theres a number of factors that all influence access to care and the cost of care at the end of the day that will be harmed by not making change today. Thank you. Its important that we focus also on the workforce so we can get an adequate environment out there. Physician survey in my home state of california found 87 expressed that low medicare reimbursement and high cost of the practices in california are negatively impacting physician recruitment and retain mid and im sure thats not just for california. Its for the rest of the country. Congress must work collaboratively to ensure the workforce is equipped to address the communities they serve especially if we want to ensure that our Healthcare Workforce is diverse. In your testimony you mentioned evidence suggests that reductions in medicare physician payments rates potentially affects. Can you expand on this and what do you expect the impact will be on the Workforce Diversity . There is some evidence that particularly regarding specialty choice but we also ask how many total people are during the profession and into question than how large the effects are and how to balance the resulting increasing supply of the services. The gentleman yields back end of the chair recognizes mr. Karger for five minutes. Thank all of you for being here as we all know, we have a shortage in the state as well. Consulted pharmacists and Nursing Homes for many years Nursing Homes have been especially impacted by the shortage unit. Healthcare provider shortages is one of the biggest facing the Healthcare System and the nation right now. We all know that and there was a recent survey that said that u. S. Will face a shortage of up to 139,000 physicians and advanced practitioners by 2023 including sexual care. I would submit to you that more than any i would submit to you that more than any other agency, the ftc has failed the American Public by allowing consolidation and healthcare like they have. I would submit to you as a pharmacist that the primary reason for high drug costs is a consolidation, vertical integration that exists in the drug pricing chamber the Insurance Company that owns the group for purchasing organization, that owns the pharmacy, that owns the doctor, do you know who employs the most physicians in america right now . Not for sure but i would guess united healthcare. You are absolutely one hundred correct. United healthcare employs more physicians in america now than any other organization. It is not just pharmacy, its also in the Healthcare System, the hospitals. Now, look, im not opposed to anybody making money. I know we live in a capitalist society, i get it and i understand all that. We had a meeting with the energy and commerce committee. It wasnt a hearing, it was a meeting. We had the congressional budget office, the director, 20 staff members. I asked them that question, give me one example of where consolidation in healthcare has saved money. Crickets. Nothing. One example where consolidation and healthcare saved money, whether you are a democrat, republican or independent you all want the same thing in healthcare, accessibility, affordability and quality. Consolidation has done away with all of those i would submit to you. Im not saying we dont have quality healthcare, we have the best healthcare in america, in the world right here in america but the consolidation, i dont expect you to tell me but im going to tell you who i am voting for for president , thats going to be teddy roosevelt, we need somebody back here who will bust it up and he can do a better job dead than most of these people cannot live. Im just telling you. Let me ask you, what kind of misaligned incentives we have right now in healthcare causing these shortages. Many things we talk to our physicians, the biggest things Administrative Burden, as you know, working as a pharmacist, Administrative Burden started, taking high cost items, overusing pet scans and mobility devices and doing preauthorization for generic drugs so that just because they change their formula patients on diabetic hypertensive medicine for years in a wellcontrolled, i get a letter from the program, saying we will no longer covers that drug and they wont tell me what drug they will cover. So than ive got to call the pharmacist and say what drug to they cover, we dont know, you got to send it in and we will let you know if it goes through. They did that 2 or 3 times, theres no transparency. At least give me half a shot by telling me what you are going to cover, you might be doing it to save 2 or 0. 03 on the dollar and for what little savings they get, the patient might wind up in the emergency room, the patient might have to make 2 or 3 visits. Not only that but i will tell you when i still owned my business in the pharmacy, i had an employee totally dedicated to nothing but approvals, that is all they did, prior approvals. It decreases compliance because i get a prescription from the patient, from the doctor, sorry, cant fill it right now, i have to call and get a prior approval on this and it is 3 or 4 days and they dont come back, they go without for three or four days and a lot of times they dont come back period. I am telling you, teddy roosevelt, that is who we need to vote for. Mister chairman, i yield back. The gentleman yields back, the chair recognizes mister gill way for questions. Thank you for holding todays critically important hearing. The second Congressional District is one of the biggest districts in illinois covering a travel distance of approximately 3 hours from the northern part of chicago to southern boundaries and covers a diverse range of areas from urban, suburban neighborhoods to rural. I have approximately 2000 farms dotting the landscape of my district, and frequently receive feedback from constituents across the district, the challenges they face in healthcare, this concern is particularly pronounced for those living in rural corners of the district. Throughout todays testimony, access to physician care for medicare recipients has shown remarkable resilience in the face of challenges by the existing physician reimbursement model that remains well documented fact that individuals residing in rural areas, particularly those in communities of color frequently encounter obstacles when seeking highquality healthcare. These difficulties arise from a multitude of factors with workforce shortages especially the challenges in retaining physicians in those underserved regions, thats a prominent and persistent concern. Can you elaborate on how the proposed modifications to the physician Payment System, would you discuss during your testimony access to healthcare for Medicare Beneficiaries in Rural Communities . Excuse my voice. There are, in terms of Rural Communities in particular, broadly speaking, centers for medicare and medicaid is considering and is working on specific models that would provide more generous spending benchmarks to communities that are historically underserved, they will allow providers participating in these models to invest in care for those communities. I think those efforts are at the early stages. It remains to be seen if they will have the intended effect but thats an appropriate precaution. These provider side interventions are worth exploring and also looking at interventions that would target underserved beneficiaries, beneficiaries themselves. One specific opportunity is improving the medicare savings program. Thank you. Doctor patt, at the end of the Public Health emergency, the practice is no longer deliver cancer medications to patients. How has this impacted cancer Patient Access to treatment in Rural Communities . Thank you for the question. This is a really important one that happened at the conclusion of the pandemic. It is it is an amazing time in cancer care, not only are we able to frequently control cancer, cure cancer, but people are able to live their lives, sleep in their bed and eat dinner with their spouse and pick up their kids from soccer practice, they get to live and it is amazing. A lot of that is because therapies we give are chronic in nature, oral therapies. For patients especially rural patients like the patients that have to drive for healthcare are no longer able to receive mail order drugs from their doctor which means if you are on an oral on choleric or another drug that you take chronically to control your advanced cancer, you alone have to stop your daily life, drive three hours to a clinic to pick up your medication, drive three hours back and you still get to have your Cancer Control but dont get to live your life. If you are a rancher or housewife that lives in Rural America you have to drive and disrupt your daily life in order to receive care, in contrast to times before, during the pandemic and before the pandemic when patients could receive their oral medication delivered to their homes and that makes it a lot more convenient so this is a challenge and the particular burden on Rural Americans and it is growing because due to innovation and americas investment in innovation we have a lot of oral therapies that can scupper control cancer that operate 30 of the Cancer Therapy we get today but we think it will grow to 60 in the next few years. This will be an increase burden for rural recipients, healthcare and cancer care. It would go a long way for the healthcare of Rural Americans to make official policy to change that to allow patients to get their drugs by mail from their doctors. Thank you. I yield back. The gentle lady yields back, mr. Johnson for five minutes. Really appreciate this. We have a lot of pressing issues before us with deadlines coming up quickly, deadlines like 15 cut for approximately 800 tests under the medicare schedule that are set to take effect in january. Thanks to my friend, representative Richard Hudson for introducing hr 2377, the Laboratory Services act, that is a play on words, not the dance. This would create a sustainable path forward for the Laboratory Market protecting Patient Access for clinical, laboratory, infrastructure, fostering innovation for the next generation of lab services and im proud to sponsor this legislation and i will move this through a markup in short order. During the covid 19 pandemic patients were able to have medications mailed directly to them from their doctor for folks in rural ohio who i represent, this is a godsend, no longer did they have to drive to cleveland or pittsburgh to pick up cancer medications. That flex ability ended with the expiration of the covid 19 Public Health emergency. Now my constituents living in appalachia must make the hours long drive to pick up their lifesaving medications and this is insanity. Siors access to critical medications act introduced by my colleague from tennessee would make permanent those waivers from the pandemic allowing patients to receive medications through the mail or have a family number or caregiver pick those medications up at the doctors office, to increase access, save time and money and result in a better outcome. I. E. Eagerly joined as a cosponsor when a group of my constituents brought this to my attention and i look forward to helping progress this bill through this committee and onto the floor. Let me start my questions with you, doctor patt, if i could. Can you describe how this waiver i just spoke about helped Cancer Patients at your practice and how they have been impacted by cmss decision of the stark waiver following the Public Health emergency ending. Yes, thank you for your leadership in this. I think this is important for Cancer Patients especially in Rural America. Look at texas oncology, we are a large practice with many pharmacies throughout the state. Its difficult for them to come up to the practice and get medicine from the pharmacy. Only those that live in rural texas, that is the case across america when patients live a far distance from the clinic. Those patients are disproportionately burdened. It is so extreme, they cant send a loved one to pick up their medication for them. They have to either not work that day to go and pick up their medication. Usually medications are filled monthly, that something they would have to do every single month so it is a severe detriment that leads to delays in care because sometimes they cant come on the day they need to come. If we were able to mail order those drugs to patients, we can simply continue their cancer care or other care, than they wouldnt have delays and disruptions and get to live their life, get to be doctors and lawyers and teachers and housewives and ranchers and do the things they do in their communities. Is it safe to say, doctor patt, that this requirement once this waiver is reversed now that the waiver is reversed is it safe to say the requirement is hurting patients . It is absolutely hurting patients. I had an oncologist in my district. Part of what led me to be such a strong advocate, we got these waivers put in place, many of them during a pandemic, and i heard the Horror Stories from an oncologist who made the point, my family has a history of cancer too. I have several cancer survivors into deceased mother who was taken by cancer a few years ago, there are no more vulnerable patients in society than oncology patients going through chemotherapy and it is not just covid that could kill them in a matter of hours, its many other things in the critical stages of chemotherapy. I appreciate your testimony and i yield back. The gentleman yields back, the chair recognizes doctor scheier from washington for five minutes for questions. Thank you to our witnesses today, thank you for spending your entire day with us. In my districts in washington and throughout the country we are facing a shortage of doctors, resignations, the shortage is getting worse, deep cuts make it harder to see their patients and providing high value care. Congress has to act to make sure physicians can keep their doors open, and i am so eager to work with my colleagues on those issues. I am a little frustrated that this hearing is focused on so many partisan bills and the minority, it is an opportunity to work on these 2 together, and also frustrated that doctor reeses bill, inflation is not included, it has broad support from doctors in both parties. It is a bipartisan bill, increased participation and valuebased programs that include quality of care and Health Outcomes all while delivering costs and this bill would extend payments for advanced alternative payment models which help them transition to a model of care that focuses on patientss Health Outcomes. At this time i would like to ask for unanimous consent to enter into the record a letter asking for an extension of these incentives for 600 Health System, Hospital Physician groups that has great support. One of the bills the committee is considering would extend these incentive payments. The problem is it would be at a lower level, a 5 year retroactive. I am concerned about placing this on providers and limit the ability to help providers adapt and implement. According to the national association, the majority of providers would be negative impacted by this. The transition to alternative care models has been slower than anticipated, participation has been growing thanks to the program and we cant make it more difficult to adapt these. The representative from cms isnt here today but theres a bipartisan plan, so eager to work with mister dunn and his committee because of the shortfall being considered today. I request the committee reconsider these two bills to advance and strongly suggest the bipartisan bill sponsored by doctor bucshon. I also want to touch on seniors timely access to care. Higher authorization is a barrier for seniors. The higher authorization process to ensure between seniors and their care has been broadly bipartisan. I am happy it was brought up today. The house past the access to care act which would reform the process. Cms has issued a proposed rule with similar reforms and my ask today is not to any of you, to get those rules implemented to take care of our seniors as quickly as possible. One minute remaining if any of you would like to comment on these models, healthcare or access to care. Hopefully it will be passed and we need that immediately. Those burdens and priority embarrassments, physicians are leaving the practice and other types of practice, we very much support fee for service, we need to move to valuebased models. We do what we can, giving us a more accurate assessment of the cost of the program which makes it easier to get it through. Extending the 5 advanced alternative payment models does matter. Texas oncology participate in the oncology care model, over 134 million over 9 performance periods, decreased hospitalization and a lot of Strategic Investments that improved quality of care. This is the kind of program we should support. I yield back. The chair recognizes mr. Crenshaw from texas for five minutes. Thank you, everyone, for being here. Discussing matters of great importance. Okay, how about that . Great. The reimbursement is key to figuring out some hope that valuebased care would work better. It comes with some problems. A subjective way to figure out what the reimbursement is and it is hard to be dynamic. This is always going to be our problem. I would like us to also think about what the underlying drivers of additional costs are that are requiring us to keep coming up with Bandaid Solutions to make sure physicians are getting paid enough to maintain their operations. And administered of burden doctors face, and entertainment and medicare that mention the boarding requirements. The administrative barrier that practices in the network face when trying to participate in the alternative payment model. They face Administrative Burdens, and alternative payment models. And it is particularly challenging right now. As you know, ocn changed to eom, it is such that we who are participating is pretty low, reporting everything for eom, a duplicate of Administrative Burden. You have to hire extra staff to manage this. It is a huge physician burden in terms of cost, increasing staffing with staffing shortages. I will say going through the experience of texas oncology we made a lot of Strategic Investments that took time to make them but it did improve the quality of care we measured. They had been a straight of burden the admin strata version is steeper. More suggestions on what concrete steps we can take to remove unnecessary Administrative Burdens. Dont have a positive effect on Patient Outcomes, the committee would benefit greatly. All of you. The reporting we have in an alternative payment model is a huge reporting burden and anything we could do to lessen that, that Administrative Burden in terms of information we need to submit ourselves we would not have to staff up to participate especially, i can speak for my group, we are willing and able to participate in anything to improve quality of care but it has been a large Administrative Burden. I place that burden on you. Youve got to tell us the details. You have to give us that list of things that are very concrete, we benefit greatly from that. You want to take on the same subject . I would agree theres a lot of evidence of increased burden particularly, 13,000, 200 hours of increased time per physician from this alone where recent literature did not find any evidence that it actually improved the value of care but increased burden and lack of results on that front points to the very underwhelming record. Appreciate that, what about primary care, the texas oncology network, when we were i yield back. The gentleman yields back, the chair recognizes doctor joyce from pennsylvania for five minutes. I ask unanimous consent to enter their into the record a statement from the American Academy of dermatology in support of hr 2474. Thank you for being here today. Your impact and your discussion allows us to have better impact as we continue to legislate and look at the burdensome costs that occur with medicare, inadequate reimbursement for so many physicians throughout america. As a doctor who practiced in rural pennsylvania, i witnessed firsthand many unique barriers to care affecting rural and underserved communities. Unmet demand in rural areas for my subspecialty is on the rise. Hsa estimates 39 adequacy in nonmetro areas for dermatologists in the short timeframe by 2035. This raises the unfortunate question, what happens to americans who dont have access to care . One of the greatest threats in rural and underserved areas is arbitrary annual cuts to reimbursement for medicare Physician Services. Climbing reimbursement rates, especially those supported by rigid bureaucratic whims and not actual data are discouraging doctors from treating medicare patients. Let me say that again. That annual decrease in cost discourages doctors taking on medicare patients. If your doctors are available to treat medicare patients in underserved areas, there will be fewer opportunities for preventative screenings leading to delays, diagnosis and more Cancer Patients to see a doctor about. Doctor patt, can you tell me how the decrease impact your practice and the patients that you see . I was a lead arthur with doctor gordon and other members of the Community Oncology alliance during covid, the decrease incident screening is substantially down because of the pandemic. Out of the pandemic, people have engaged with healthcare. There are fewer doctors to see people because reimbursement is down. Its difficult for people to get the care they need during the pandemic because availability is less, demand outstrips supply leading to difficulty in getting in to see the doctor. This leads to a difficulty in getting a colonoscopy if you have bleeding. These natural consequences, pentup demand and decreased reimbursement, delays in patients getting care. I observed that when patients present with stage iii see Breast Cancer because they knew they had a breast mass, difficult to manage getting care. This has been a tremendous burden and exacerbated by the pandemic. A root cause with declining reimbursement to scale capacity of medical services to meet the demand. I also believe the current trend should be unsustainable all yield decrease access, and worse healthcare outcomes as you delineated. You acknowledged the need to offset increases in physician payments with savings from other areas of Medicare Part b. Neutral payments for services is one proposal that received a lot of attention at this committee and so has reform of the 340 b program. Can you please elaborate how these ideas can be advanced by this Committee Without exacerbating financial pressure particularly on rural hospitals and rural patients they serve. I would echo what others on the panel say about neutral payments and reducing disparity between payments for hospitals and physicians on Numerous Services like drug administration, imaging and clinic visits. With regards to 340 b this is a Discount Program or hospitals, with 40 in savings and pass the savings to patients. Medicare is required to pay the same amount as other drugs. Congress requiring or giving fema the authority to pay more accurate rates for these drugs would reveal savings for taxpayer. Thank you for your response and thank you for your witnesses for what has turned out to be a long day. I yield. The gentleman yields back, the chair of the full committee for five minutes. I too want to say thank you to our witnesses for being here as we are dealing with an unpredictable schedule. This has been a very important hearing, one that we have wanted to have for some time. As you heard, the theme of the healthcare discussions have been about the need to address healthcare consolidation. We are hearing from patients, employers, policy experts how consolidation is increasing prices without necessarily improving quality of care. This is directly relevant to the conversation we are having today as we want to ensure the healthcare economy and sustained private practice so you answered a lot of questions. I want to go back, doctor patt, you talk about the difficulty of maintaining a private practice in todays environment. For a private physician owned practice in the setting of declining reimbursement it is difficult to maintain competitive salaries for staff to staff your clinic and stay open. The natural consequence of not being able to staff appropriately and having declining reimbursement is theres an option to consolidate your practice at the hospital, that can be an attractive option for private practices because it is difficult to be financially viable independently so its a real challenge and i think many of the issues addressed in this Committee Hearing today can help fight neutrality, make physician reimbursement appropriate, would help that challenge. Talk about reforms you believe would reduce incentives to consolidate. I can expand a little bit on payments which are a major driver of consolidation. Hospitals have incentive to require Physician Offices to rebrand them as offcampus and charge higher rate for the same services that could be performed at a normal Physician Office so targeting those same Service Areas i mentioned before as well as removing exemptions to the bipartisan budget act of 2015 which set neutral rates for offcampus departments but exempted those that were already in operation could be another step towards that goal that was originally envisioned in that statute. By doing so it would help to remove this advantage to pay physicians as has been noted who have seen fewer pay increases over the years compared to hospital outpatient departments, one of the biggest, not the biggest growth in spending in part b. As a followup, to accomplish the goal of making medicare more sustainable for independent physicians. Yes. The committee for responsible federal budget estimated pursuing these reforms across ambulatory settings could save 280 billion over ten years and safe patients 140 billion in their own outofpocket costs as well. I would also like to ask you to discuss uses surrounding cost in the Medicare Program and if we are achieving goals related to a value. Share a few things, apms improve the value of care in medicare. It has been reinforced by a recent report, alternative payment models have not been promised. The First Operations expected 3 billion in savings in medicare savings and over that time it cost the Medicare Program one in 5 billion. In the second decade of operations in 20212030, the savings numbers would be almost 80 billion. Instead, net costs of 1 billion. Thats a pretty clear record that very few of the models save money at statutory only required to improve quality of care and on these fronts it has been a disappointment. Are there alternatives . I think in Medicare Advantage you see a structure thats very similar to valuebased care because they receive populationbased payments, required to pass along the savings they achieved to their beneficiaries in terms of lower cost sharing. The difference is they have proven to deliver core medicare benefits at 83 of the cost of traditional medicare and grown in popularity with half of Medicare Beneficiaries. Thank you, everyone, for being here. The chair yields back, and the chair recognizes the gentleman from tennessee for five minutes. Thank you all for being here. I will start with you. My background as a Community Pharmacist for 36 years, all use things get right into the model i have done my whole life. My question, do you think the differential payment gap between prospect of Payment System driven physicians out of business and empowered the Health System consolidation . Its a large part along with houses the physicians have to do in their practice. It encourages them to move in this direction, particularly the physician population getting older and hassle getting greater, easier to sell out, not have to deal with the hassles of employees cutting your personnel and losing money in your business, you cant run a business, and every year youre going to lose 3 to 4 . You tend to forget you are already losing 2 for sequestration. That was the biggest thing during covid, we got to back for primary care practice, that makes a huge difference. You have to have that dedicated person doing prior approval or figure out which met efforts the formulary to understand the pharmacy industry too. Doctor patt, thank you for being here. The bipartisan legislation, critical medication act, you thought you would have to create legislation for a patient who is could it lead dealing in most cases to be able to come to get a patient, a Family Member to pick up more it is nuts. What this legislation does is modernizes to make permanent that waiver, by cms, that allowed them to do that. If you look at it you could give me story after story where a patient missed a dose or reluctant to do the chemo initially and when they found out you couldnt mail it to them they just didnt get it. Part of the outcome on that would be detrimental. We spoke earlier about the burden to Rural Americans receiving Cancer Therapy but what we didnt speak about was all the disabled americans or americans that are ill because of their Cancer Therapy and not able to come in and get it and cant have a Family Member come in. Makes it better for them if you can mail it to them. It allows them to access care. It and that being an access to care issue the disproportionately burdens patients, disabled patients and rural patients. Thank you for your leadership. This would be a monumental improvement to cancer care in america if we successfully pass this legislation. If you look, we are just talking about part of the equation. If you look at what they are doing when you have shortterm changes in the therapy, they do a mailorder of three months, what is that costing . We need to do study on that. I encounter that every day in my practice as a cancer specialist. I booked our patients on and can blockade and the 4600 pill to control cancer and it really improves their progression for survival but has a lot of toxicity. I introduce that drug half the time. When they hung the back, i dont want them to have a refill because thats a multi thousand dollar loss. It happens half the time if they are filled with the pbm but if its still in the office and im able to check in with a patient before they get the refill, i am able to manage their dose in a timely fashion and that happens every day in clinics. Every day i am in clinic i make a dosage adjustment. Based on laboratory values, if they are getting it mailed to them from the pbm automatically without a doctor getting involved, they dont have that tight control. It is poorly characterized but we have so many stories. You need to get those stories because that is something they need to look at, whats the amount of money that is wasted . It is easy to fix it. Thats why they call it the art of practicing medicine. Are adjusting as you go and i only have five seconds left. I only have a little bit to the infusion side, my pleasure to introduce that bill. I have another cosigner. I yield back. My friend from california, recognized. Thank you, mr. Chairman. Medicare is not keeping pace with the cost of providing care and this gap is expected to keep growing under current law. How does the gap access quality care especially for traditionally underserved communities, and communities of color . 40 of my practice is africanamerican, those that are low income, their ability to go elsewhere for care is very limited. When those costs go up as far as care, increase Administrative Burden, less time to take care of our patients, thats when you see physicians dropping out of practice, their joy comes from taking care of patients and not clicking boxes. We need extra staff to do administrative stuff rather than doing the Administrative Burden. What is your percentage of africanamericans . 44. In addition to adjustments to the physician fee schedule, what are some ways that congress can support physicians to alleviate that . With quality measures, theres one thing we want to propose that there needs to be a standard for quality measures we plan to come up with quality measures, we jump through all these hoops trying to find out what the quality measure is for this plan. Some of the quality measures are automatically reported but some we have to manually report. Sometimes you dont need to know if they get the information or not. One plan tells me they get the bill data from labs so the diabetic is controlled. I found out another major plan doesnt look at the lab data so the only way to find out is to manually report its. That needs to be done manually. With that, the quality things held accountable for things we dont have control over. I can offer a patient a flu vaccine but cant make them take it. I can but be guilty of battery. I am not given credit for offerings that. I can put a code in and say i offered this and the patient refused it. Or their meaningful other refused it. It doesnt help me with my quality. More than anything else, being held accountable for things we cant control. I understand physicians face Administrative Burden for patients with complex chronic conditions like all timers disease. These patients usually need access to timely care from a variety of physicians. The application of the g 2211 code would reduce physician burden and allow for better care for these patients. How would implementation of the code impact overall care for patients like those with alzheimers . Things we talk about for primary care, talking about people with chronic problems. Primary care physicians are not the only ones who would benefit. A nephrologist who takes care of patients, and your chronologies takes care of diabetes, and a neurologist who takes care of dementia could use this code. The most important thing about this code, it covers a lot of areas, we take care of our sickest patients. The important thing is primary care, taking care of a lot of these problems. Then, they are overwhelmed. Taking care of primary care setting. Helping with primary care physicians. Matt fiedler, i want to talk about alterman and alternative payment designs. My district is a majority minority district. Increased barriers to access quality healthcare. Weve heard a lot of positives about alternative payment models. I am concerned that these payment models have the potential to exacerbate Health Disparities especially for underserved communities, and communities of color. If not designed with these communities in mind but alternative payment models designed in a way that recognize physicians working in underserved communities. There have been proposals in the center for medicare and medicaid innovations, the model that takes benchmarks that under the model are set higher in areas with large numbers of beneficiaries. The goal being to provide more generous payment environment and encourage greater investment in care for these beneficiaries. Those projects are in the early stages. That is one strategy. I yield back. The chair recognizes doctor miller meeks for questions. Our panelists are here today. A former nurse, current physician, currently licensed, 24 year military that, i also practiced in a community of 25,000 people and i traveled 30 miles to another community of 10,000 people to deliver care in addition to making home visits and picking up people and driving them to the main office in addition to driving the university of iowa so they could get access to care. Ive done academic medicine, especially private practice. Ive done military medicine and employed by a Hospital Physician which is why i was proud to cosponsor hr 2474, strengthening medicare for patient and providers act and you mentioned this legislation would provide annual inflationary updates and you mentioned it, based on medicare economic index, two physicians who support patients through Medicare Part b. I feel strongly about this legislation for the reasons you said so i am going to ask a simple question. Your organization supports this legislation on how they benefit from an annual inflationary update. Dont know any Physician Organization that supports that. Thank you. I would have questions for all of you. You stated Healthcare Providers incur substantial costs to interact with insurers totaling hundreds of billions of dollars per year, costs ultimately borne by consumers and taxpayers and i will say that i have done preauthorization therapy, everything i can to reduce the burden on physicians. How do you think physicians response ability to negotiate contracts, collect information about patients, Insurance Coverage and prior authorization, access to care. Would you believe the burden is higher for doctors and rural areas who operating independent practices. When we think about the ability of the Payment System, theres two sides of that equation, one side is the cost side. What does it cost to deliver that care. If we are imposing more on administered of costs, that means the payment rates need to be higher to achieve the same level of access. In terms of what we might, what we might do about that, in the context of medicare, there are particularly a better Payment System is a clear place to look. We are imposing substantial costs per position per year to comply with this program and very little evidence it is having the intended effect. Thank you for leading me to my next question. All tournament payment models have not lived up to our expectations. Furthermore, we have been focused on primary care and provided little opportunity for meaningful specialist participation. Clinical data registries drive healthcare improvements by providing feedback on Quality Performance and appropriate use metrics including Patient Outcomes. They can help physicians monitor and management Patient Population facilitating early interventions and Preventive Care which could lead to more successful disease management and less expensive care and participation in this proactive quality patient improvement and feedback tool, a congressional priority when it was originally and acted. Many specialties and subspecialties believe as implanted by cms, qualified Clinical Data registries are not being recognized to the fullest potential and only being used as an option for measures to cms and i wish cms had stayed for all the testimony and answers to questions. You believe cms has done enough to fulfill congressional intent when it comes to Clinical Data registry and improving healthcare . Access to the bonus by extension has been uneven among different specialties and geographic areas. With regards to mif s and many other quality programs across medicare, very siloed and dont take a comprehensive view of quality improvement, the incremental steps in this space have been slow in terms of yielding progress so it is important to have more Data Availability and allows meaningful measures for patients to compare qualities for doctors and providers without simply having government officials decide what their priorities are. Really quickly, doctor patt, do think congress paying entities will contribute for premiums. The natural consequence of 53. 7 billion Program Last Year being a reduction in cost, we think of it as a burden to manufacturers, selling 30 of their drugs to the 50 discount, ultimately that leads to an increase in drug prices which is a burden born on the back of american dollars. Thank you. I havent asked questions yet. Moving forward, you asked questions. I will recognize myself or five minutes. Doctor patt, did your practice participate in the oncology care model that was developed through cmi, and can you share specific results . Why do you think they chose not to continue and instead pivoted to the advanced oncology model . Texas oncology did participate in the program which was the alternative payment model for oncology. It was a Successful Program for texas oncology, we saved the Medicare Program 134 million over nine performance periods and reduced er visits and hospitalization, 9 , 6 , official numbers are in the written testimony but i will say we had Strategic Investments improving care quality that mattered for patients, content education, with compliance for therapies. The reported outcomes instruments, remote therapy monitoring allowed us to improve hospitalizations and er visits and lower costs in the subset of the whole population that we improved costs. And participating in eom and the reason it wasnt continued is overall the program was thought to be a failure because it failed to save medicare money overall. We need a similar dive to understand the Medicare Program, we as a private practice or lowercost service there might be winners and losers in that endeavor we might benefit from a better biopsy to understand better what three minutes, anybody would like to answer, it is important to get what you were just saying. When cmi was stood up it was estimated if we spent 10 billion it would take 30 billion in the same bill. Thats the way we do things. It didnt save the 20 billion. Or 30 billion, it actually cost money. How can cmi drive value, anybody else talk about the two minutes are up . Practices need to engage in real ways. We tested one model on oncology. There are other payment models that also might help practices transform, could be considered and that would be a reasonable way to think about how we study different models and the impact they have. One comment come one of the challenges has relied on primarily early volunteer models and that has forced them to to sign the models in such a way the federal government captures a small share of savings and may force them to make other changes that saved money under this. You couldnt think about making it a mandatory model or think about creating incentives in these models in the first place through existing bonuses. Thanks. I would say the evaluation of cbos assumption, the recent report provides an opportunity for congress to look at ways to provide oversight for the office and 10 billion appropriations it gets every decade are a major driver of those costs. It should be revisited and there should be more standards from congress and oversight on transparency for evaluation when models should be terminated, whether they should be meeting a net savings goal rather than budget neutrality goal, numerous ways congress can do this particularly because cmi has unprecedented power in terms of Government Agencies facing judicial review or administrative review and its ability to change medicare laws to stand up its models. It makes sense to provide counterweight to that. Any comments . The Incentive Program or advanced payment model, the government gives a small carrot and a big stick and 2 , you might have 9 down, the work is not worth the effort. Youve got to make the incentives worthwhile, they dont have the resources to do that. They are overwhelmed with other things. You talk about adding another level of work. There might be some savings. Ive got to do it. Thank you. I yield back. Seeing no other member present for questions, i will now conclude questions and ask unanimous consent and insert the documents on the staff and document work. Without objection, that will be in order. I remind members they have ten Business Days to submit questions for the record and ask the witness real respond promptly. Members should submit questions by the close of business on november 2nd and without objection, i will say thank you before we adjourn. Thanks so much. It is a fluid day, a fluid time, and unprecedented time in washington. Appreciate your willingness to travel, it means a lot, thanks for your patience. Without objection the subcommittee will be adjourned or is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] on capitol hill, the senate reaffirmed support for israel and condemned the hamas terrorist attack by a vote of 970. Dick durbin and tim scott were not present for the vote which comes on the heels of president bidens trip to israel where he met with Benjamin Netanyahu and pledge support and solidarity for the people of israel. The senate now done for the week, returning for legislive business on tuesday at 10 00 a. M. Eastern. Watch live coverage of the u. S. Senate on cspan2. Cspan is your unfiltered view of government funded by these Television Companies and more including comcast