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. Scholar to serve an underserved community. I went there, paid my deuce, did my time and i did what the 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 other agency the ftc has failed of the public by allowing healthcare as they have. I would submit as a pharmacist the primary reason for the vertical integration that exists with the insurance company. The group to the pharmacy. Do you know who employs the most physicians in america right now . I would guess united healthcare. You are correct. They have more physicians in america than any other organization. Its not just pharmacy. Its also in the Healthcare System, the hospitals. Look. I know we live in a capitalistic society. I get it and i understand all that. We had a meeting with the Energy Commerce committee. It wasnt hearing it was the meeting. We had the director and 20 staff members. I asked them that question. I said give me one example where consolidation healthcare has saved money. Crickets. Nothing. One example where the consolidation changed, you want to be accessibility, affordability and quality. Consolidation has done away with all of those i would submit to you. Now im not saying we dont have quality. But the consolidation i dont and i dont expect for you to tell me im okay with who im rooting for for president and thats going to be Teddy Roosevelt because we need somebody back here who could bust it up and he can do a better job than his people alive. What kind of symptoms do you think we should have right now in healthcare that is causing some of these shortages . Working as a pharmacist, the Administrative Burden get scans and now we are doing preauthorization for generic drugs so just because they changed the formulary the patients on the medicine for years is well controlled and i get a letter from the program and their plans say we are no longer going to cover the drug and they wont even tell me what drug they will cover so i have to call the pharmacist and they say you have to send it in and we will let you know. We had to do it two or three times. Theres no transparency. At least tell me what youre going to cover and they might be doing it to save two or three cents on the dollar and then whatever savings they give that person might end up in the emergency room. I had an employee totally dedicated but thats all they did was prior approvals. People in a decrease in compliance because i get a prescription from the doctor and ive got to call and get a prior approval and its three or four and a lot of times they dont come back period. Im telling you, Teddy Roosevelts who we need to boot for her. Mr. Chairman, i yield back. The chairman recognizes the gentlelady for questions. Thank you. They are covering a distance of approximately three hours on the northern part in chicago to southern boundaries. It encompasses a diverse range from urban. The 2,000 farms in the landscape of my district and frequently i receive feedback and the challenges in assisting healthcare. This concern is particularly pronounced for those in the corners of my district. Throughout today the testimony weve heard that access to physician care the medicare recipient has shown remarkable resilience in the face of challenges posed by the existing, the existing model however it remains we will document it but the fact that individuals are in rural areas particularly those in communities of color frequently encounter obstacles. Do these arrive in a multitude of factors with the workforce shortages especially the challenges is a prominent and persistent. Can you elaborate on how the proposed modifications. In terms of Rural Communities in particular, broadly speaking center for medicare and medicaid is considering and is working on specific models that would provide more generous spending benchmarks to communities that have been historically underserved and the hope is that it will allow them to participate in these models to invest in the care for those communities. I think those types of efforts are at the early stages and so it remains to be seen whether they will have the intense affects but that is a. Looking at interventions that help the beneficiaries themselves, so the opportunity for example is the medicare savings program. They decided cancer medication to patient, how is this impacting Cancer Patients to treatments thats fiscally again in the Rural Communities . Thank you for the question this is important with the conclusion of the pandemic. So you know, its amazing time not only are we able to frequently control or cure but people are able to live their lives and pick up their kids from soccer practice. For patients like those you mentioned in your district that have to drive for healthcare are no longer able to receive that you take a chronically to control your advanced cancer that you alone have to stop, drive the three hours into the clinic to pick up your medication, drive your three hours back. And in that you still get your Cancer Control but dont get to live your life because if you are a rancher in Rural America, you have to drive and disrupt your daily life in order to receive care. This is in contrast to the time. Before the pandemic where patients could receive. It represents about 30 of the Cancer Therapy do you think in the next few years. This is a burden for the recipients of healthcare particularly cancer care. I do think that it would go a long way to have the healthcare of Rural America to make official policies to change that to allow patients to get your answers and i yield back. The chair recognizes mr. Johnson for five minutes of questions. Thank you, mr. Chairman. I really appreciate this. You know, weve got a lot of pressing issues before deadlines like the 15 cut for approximately 800 to test some f the medicare clinical. In january, thanks to my friend, Richard Hobson for introducing hr 2377, the stating access to Laboratory Services act or salsa. Thats a play on words by the way. Its not the dance. This would create a sustainable path forward protecting Patient Access. For the next generation and im happy to cosponsor and look forward to moving this through a markup in short order. During the pandemic, patients were able to have medications mailed directly to them. Folks in rural ohio this was a godsend. No longer did they have to drive to cleveland or columbus or pittsburgh to pick up there cancer medications from their oncologist. The flexibility ended with the expiration of the Public Health emergency. Now my constituents in appalachia must make the drive to pick up the lifesaving medications and this is absolute insanity. Thankfully the seniors access to critical medications act octobey colleague of tennessee would make permanent those waivers from the pandemic allowing patients to receive medications through the mail or have a Family Member or caregiver pick the medications up and the Doctors Office will increase access. I 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 by questioning you if i could. Can you describe how this waiver that i just spoke about, how it helped Cancer Patients at your practice and how theyve been impacted by the waiver following the Public Health emergency . Thank you for your leadership. I think this is really important for Cancer Patients especially in Rural America. If you look at a place like texas oncology we have many pharmacies throughout the state and so its difficult for them to come up to the practice and get the medicine from the pharmacy or those that live in rural texas and i think that is the case across america when patients live a far distance from the clinic its those that are disproportionately burdened and is so extreme they cant even send a loved one to pick up their medication for them they have to either not work that day or do what they are doing for the day to go pick up the medication. Usually they are billed monthly so thats something they have to do every single month so it is a severe detriment because sometimes they cant come on the exact day. If we were able to mail order they would be able to seamlessly continue there cancer care or other care and they would attempt the delays and disruptions. They get to be doctors and lawyers and teachers and ranchers and do the things they do in their communities. Is it safe to say that this requirement once it is reversed is it safe to say it is hurting patients . Its absolutely hurting patients. I had an oncologist in my district and a part of what led me to be a strong advocate and thanks to my colleague we were the ones who got these waivers for telehealth and other things put in place many during the pandemic. I heard the Horror Stories and he made the point my family has a history of cancer. I have several cancer survivors into deceased mother taken by cancer, liver cancer a few years ago. There are no more vulnerable patients and society than oncology patients going through chemotherapy and its not just covid that could kill them in a matter of hours. Its many other things in the critical stages so i appreciate what youre doing and your testimony today. The gentleman yields back and we recognize the gentleman from washington. Thank you mr. Chairman and to the Witnesses Today for spending your entire day with us. In my district in washington and throughout the country we are facing a shortage of doctors early retirement resignations and shortage is getting worse as doctor space deep cuts that we get heard to see the patients on medicare while providing highvalue care. Congress has to act to make sure physicians can keep their doors open for medicare patients and so the patients can see their doctors and i am so eager to work with my colleagues on these issues. I am a little frustrated at the hearing is focused on so many partisan bills and has provided so little opportunity for us to work on these together especially when there are already Bipartisan Solutions that exist. And the tie to inflation has broad support in both parties. I was proud to help introduce the act with a number another member. Its a bipartisan bill that would help increase participation and valuebased programs to improve the quality of care and Health Outcomes while lowering costs and it would extend payments for advanced alternative payment models that help them focus on patient Health Outcomes. At this time id like to ask for unanimous consent for an extension of these incentives from 23 associations and over 23 health systems, hospital positions and groups that great support. One of the bills the committee is considering today would also have these payments. The problem is it would be at a lower level and with a fiveyear retroactive cap and im concerned about placing this kind of caps on providers and i think it would limit the ability to help providers adopt. According to the National Association of Accountable Care organizations, the majority of providers would be negatively impacted by this cap. So while the transition to alternative care models has been slower than it originally anticipated, participation has been growing thanks to this program and we just cant make it more difficult to adopt these. The representative isnt here today but i wanted to say theres a bipartisan planning so eager to work with this committee because of the bills considered today i would request the committee reconsider which of the two bills to advance and i would strongly suggest the bipartisan bills sponsored by the doctor. I also just wanted to touch on seniors timely access to care. Prior authorization has been a barrier for seniors. The effort to reform prior authorization process to ensure its not coming between seniors and their care has also been broadly bipartisan. Im happy its being brought up today. Last year the house passed the timely act to care act which would reform this process. Cms also issued a proposed rule with many similar reforms and my asked today and again its not to any of you, but would be to get the rules implemented so we can take care of our seniors as quickly as possible. I have one minute remaining if any of you would like to comment on these alternative payment models on the valuebased healthcare or timely access to care. Those embarrassments they go into others or they are just dropping out. We support feeforservice. Its going to be a thing of the past. Valuebased models. I think that it will give a more accurate assessment of the cost of the program that could make it easier. I think extending the 5 and alternative payment models does matter and we need peoples participation. They participated in the model and we say the Medicare Program over 134 million over nine performance period increased hospitalizations and weve made a lot of Strategic Investments that have clearly improved the quality of care. This is the kind of program we should support. Thank you and i yield back. The chair recognizes mr. Crenshaw from texas for five minutes. Thank you for being here. Great. Of the reimbursement is the key to any problem we deal with an medicare and figuring out because it is obviously important if there is some hope that valuebased care would work better. It also comes with some problems. Its a subjective way to figure out what the reimbursement is coming and its hard to be dynamic and subjective in a bureaucracy. I would like to think of the underlying factors that are requiring us to keep coming up with the Bandaid Solutions to make sure the physicians were getting paid enough. So when i talk about reporting requirements, the Administrative Burdens they face. Would you be able to describe some of these barriers practices and your network try to participate in the alternative payment model. I think in practice, thank you for the question. Its placed in Administrative Burden in the program both with reporting. They are both challenging. Do you have to staff appropriately to have them. Its particularly challenging right now and i cant speak for all the other payment models. And mycology has changed to eom a and. We are. So you have to hire extra staff in order to manage its huge physician in terms of cost and hours in addition to increasing staffing in the setting of a shortage. Growing. It took time to make them but it did improve the quality. The Administrative Burden. What can we do to remove the unnecessary burden. A positive effect on the Patient Outcomes. But the committee would benefit greatly. That Administrative Burden to the practices in terms of the information we need to submit ourselves we wouldnt have to staff up to be able to participate. And i think especially i can speak for my group who were very willing and able to participate in anything to improve the quality of care but this had been a large burden. In my 20 seconds left, do you want to take on the same subject . I would definitely agree, the burden particularly. The literature review didnt find any evidence that effectually improves the value of care so the increased burden and lack of results. Im going to point to a very underwhelming record. I appreciate that. I dont want to talk about primary care. Many. When we are i dont have any time. I will yield back. The chair recognizes doctor joyce from pennsylvania for five minutes. At this point i ask unanimous consent to enter a statement from the American Academy of dermatology. In support of hr 2474. Thank you for being here today. Your impact and discussion allows us to have. As we continue to legislate into look at the burdensome cost that occurs with medicare, if you inadequate have a reimbursement that occurs. As a doctor is practiced in rural pennsylvania, i witnessed firsthand many of the unique barriers to care affecting the communities. The unmet demand in rural areas reminds some dermatology is on the rise and not projected to improve. In fact, hsa estimates 39 adequacy in nonmetro areas for dermatologists in the short time period. This raises the question of what happens to americans who dont have access to care. One of the greatest is arbitrary annual codes to reimbursement for medicare Physician Services. The reimbursement rates especially those supported by the bureaucratic whimsy and not actual data are discouraging doctors from treating medicare patients. Let me say that again. The annual decrease in cost discourages doctors from taking on medicare patients. If doctors are available to treat medicare patients and already underserved areas then there will be fewer opportunities for preventative screenings leading to delayed diagnoses and ultimately more Cancer Patients. Doctor pat, you as a physician can you tell me how the decrease in medicare reimbursement impacts your practice and the patients that you see . We published, myself as the lead author. He even coming out of the pandemic we recognize people have had competing priorities as they engage with healthcare. There are fewer doctors to see people because reimbursement is down. Its more difficult for people to get the care they need that theyve delayed during the pandemic because availability is less and demand outstrips supply. This leads to difficulty getting into see a doctor and of getting a diagnostic mammogram and a difficulty in getting a colonoscopy if you have bleeding so these natural consequences in the reimbursement is that there are delays in patients getting care. I observed that when they present because they knew they had a mass but it was difficult to manage getting care then its harder to cure. The declining reimbursement hasnt allowed the capacity to meet the demand that we have. I also believe the trend should be unsustainable but its going to lead to decreased access and worse healthcare outcomes. You acknowledge the need to offset any increases in physician payments with savings from other areas. Mutual payments for the one proposal received a lot of attention at this committee and so has reform of the program. Could you please elaborate how these ideas could be advanced by the Committee Without exacerbating financial pressure particularly on the rural hospitals and the patients they serve . I would echo what others have said about the slight neutral payments and reducing the disparity between the payments for hospitals and physicians on numerous. With regards to 340b, this is a Discount Program where hospitals have been able to achieve 25 to 50 in savings and not required to pass the savings along to their patients. Medicare is required to be the same amount as others so congress requiring or giving the authority to pay accurate rates for the drugs would yield savings for taxpayers and patients. Thank you for your response and witnesses who turned out to be on a long day. I will yield. The chair recognizes chair rogers. I want to say thank you to the witnesses for being here dealing with an unpredictable schedule. This has been a very important hearing. One that we wanted to have for some time and as you heard of the healthcare discussions have been about the need to address healthcare consolidation. We are hearing from experts about the consolidation in so many cases increasing the price without improving the quality of care. This is relevant to the conversation today to ensure healthcare economies can sustain private practice. I know youve answered a lot of questions but i just want to go back you talk about the private practice in todays environment. The natural consequence of not being able to staff appropriately and having declining reimbursement is losing option to consolidate that can be an attractive option because its difficult to be financially viable. Many things can help fight neutrality and make the reimbursement appropriate that would help that challenge. Thank you. Would you speak to reforms. Hospitals have an incentive to acquire offices into charge a higher rate. Targeting the same Service Areas as i mentioned before or perhaps moving exemptions to the act in 2015 which sets my neutral rate. It would be another step towards that goal that was originally envisioned in the statute and by doing so it would help to remove this disadvantage to those that have as has been noted been seeing your pay increases as opposed to the hospital departments which is one of the biggest if not the biggest growing and spending. Is that to make it more sustainable for the independent positions . The committee estimated that pursuing these on ambulatory settings would save about 280 billion over ten years and save patients over 140 million in your own outofpocket costs as well. Id also like to add to discuss cost and the Medicare Program and. I think by their own admission into being and for us to a recent report, alternative payment models have not met the promise and optimism that has come with them. Over the first ten years, they had expected about 3 billion in savings whereas in reality over the time it costs the Medicare Program more than 5 billion. The second decade 2021 to 2030 for savings numbers would be almost 80 billion but instead its going to be the net cost of 1 million. So i think that is a clear record. Its required to save money or improve the quality of care. I think that in Medicare Advantage right now, you see a structure similar to 8 p. M. And valuable care because they received the payments and are passed along the savings they can achieve through bidding to their beneficiaries and their enrollees in terms of war benefits or lower cost sharing so these align with the same goal. The differences theyve proven to deliver core medicare benefits and theyve grown in popularity using to enroll in a plan. Thank you. Thank you everyone for being here. The chair yields and now recognizes ms. Harshbarger from tennessee for five minutes of questions. Thank you mr. Chairman. Thank you for being here. My background is a Community Pharmacist for over 36 years but ive done the [inaudible] the model ive done my whole life and i guess my question to you, sir, do you think the differential payment gap between the hospital and patient system is they are out of business and help the consolidation. Theres no doubt there is a large part of all the hassles physicians have to do in their practice so encouraging them to move in this direction and as the population is getting older and at the house was again greater and greater its easier to sell out and not have to deal with the hassles of employees and losing money on your business. I would note youre going to have. Thats the biggest thing we did, we got a big back. Three per 4 its here right now. Its dedicated doing your prior approval. Which ones manage the formulary. Understand, believe me and i that. Thank you for being here today because you all had been big. Who thought he would have to create legislation for a patient that is ill in most cases to be able to come pick their medicine up, get a Family Member to take you back or us to mail it. He just wants the union. If you look at it, you could give me story after story. Im sure the patient. A part of the outcomes on that are going to become detrimental. Absolutely. We spoke about the verdict to Rural Americans receiving Cancer Therapy. What we didnt speak about is all the disabled americans or. They are ill because of their Cancer Therapy and that they are not able to come in and get it and they cant have a Family Member in. It makes it so much better if you can mail it and it allows them to access care so it ends up and access to care issue. The disproportionately burdened disabled patients and rural patients so again thank you for your leadership. This would be a monumental improvement to cancer care in america. We were just talking about part of the equation. If you look at what some of them are doing when you have. Lets start patients on the different blockade and to control cancer it really improved the progression Free Survival but it has a lot of toxicity. To reduce it about half the time so when they come back i dont want them to have had a real because that is a multi thousand dollar loss. It happens half the time of the airfield. If it fills in before they get the refill, im able to manage the dose in a timely fashion and that happens every day and clinics. Thats why we see patients. Least on. They dont want to have the tight control and it leads to medical waste. Its poorly characterized, but we have so many stories about where documented. What is the amount of money that is wasted . Its easy to fix. Thats while. Theres a lot more on the infusion side, but its my pleasure to introduce the bill and ive got another cosigner and. This one is recognized for five minutes. Thank you, mr. Chairman. We heard that a physician reimbursement under medicare is not keeping pace with the increasing cost of providing care and the gap is expected to keep growing underground law. How does the gap impact accessibility to quality care especially for the traditionally underserved communities of color. 44 my practices. Their joy comes from taking care of patients. Its harder for tickets to the patients we need extra staff to do that. What did you see your say yor percentage was . 44. In addition to adjustments to the physician fee schedule what are some ways congress can better support physicians to help alleviate burnout . Theres a lot with the quality measures, there is one thing we really want to pose. Every plan. So you jump through these different hoops trying to find the quality manager of this brand. To some of them automatically reported, but some of them we have to manually report. Sometimes you dont even know whether they get the information are not so one plan tells me that they get to the bills data from the labs so that they know the diabetic is controlled. I recently found out another major planned theres a look at the data so the only way they can find that out is to support. If they will require that a lot of it needs to be done manually. We are held accountable for things we dont have control of. I can offer a vaccine but i cant make them take it. I would be guilty of battery. Im not giving credit for offering that. I can put a code and say i offered it and the patient received it. It doesnt help me any with my quality. One thing of the position is the being held and things we cant control. I understand physicians face Administrative Burden when working with patients with complex or comic conditions such as alzheimers disease. Do they usually need access to the physicians and specialties . Youve mentioned implementation of the g2211 code would reduce physician burden and allow for better care for these patients. How the implementation of the code impact overall care for patients like those with alzheimers . For primary care, but we are talking about people with chronic problems. So the primary care of the Family Physicians is in the only one that would benefit. Renal dialysis patients, chronically but also could use the code on endocrinologists who take care of diabetes could use this. A neurologist who takes care of a patient with parkinsons dementia. The most important thing about this code, it covers a lot of different areas but what we are trying to do is take care of our sickest patients with chronic problems to make sure physicians can afford to do that. I think the most important thing to do is we are able to take care of a lot of these problems and then especially as they are overwhelmed because they are getting too many patients with minor problems and the neurologist is seeing too many basic things taking care of the setting but theres not enough primary care physicians so we can hope some of the specialists by having more primary care physicians to take care of the problems up front. Thank you. I want to talk about alternative payment models because i know my district is a majority minority district into the communities typically experience barriers to access quality healthcare. Weve heard a lot of positives about alternative payment models today. However, im concerned about these payment models with a potential to exacerbate Health Disparities especially for underserved communities of color if not designed with of these in mind could alternative payment models be designed in a way to recognize physicians working in underserved communities . There have been proposals in the medicare and medicaid innovations currently testing the model that takes an approach with benchmarks set under the model that are set higher in areas with large numbers of traditionally underserved beneficiaries. Community of 25,000 people and i traveled 30 miles away, 10,000 people to deliver care in addition to making home visits in addition to going and picking up people and driving them to my main office in addition to draffing them to the university of iowa so that they could get access to care. Ive done military medicine and employed by a Hospital Physician which is why i was very proud to cosponsor 874, providers act. Dr. Pat, you also mentioned it. Based on medicare economic index two physicians that support patients through Medicare Part b, i feel very strongly about this legislation exactly for the reasons youve said and so im just going to ask a very simple question. Does your Organization Support this legislation and how could Family Physicians benefit from an annual inflationary update . I dont know any Physician Organization that does not support that. Thank you, and i would have questions for all of you, dr. Phil you stated that Healthcare Providers incur substantial costs to interact can fun . Ers likely totaling billions of dollars largely born by consumers and taxpayers and i will say that i have done preauthorization step therapy just about everything that i can to reduce burden on physicians. How do you think physicians responsibility to negotiate contracts collect information about patients Insurance Coverage and battle insurers impact quality and access to care and do you believe the burden is higher for doctors in rural areas and those who operate independent practices . So let me think about, you know, the ability of the Payment System to occur cost to care. What does it cost to deliver that care and so, you know, if we are imposing more in m costs whether quality reporting or other things, the payment rates need to be high the other achieve the same leverage of access. In terms of what we might, you know, what we might do about that, i think there are, you know, particularly in the con text of medicare i think particularly method and Payment System is a clear place to look. We are imposing substantial costs, thousands of dollars, per position per year to come play with this program and theres very little evidence unfortunately that its having effect and ruin quality of care. Thank you for giving me to my next question. Alternate payment models have not lived up to expectations and focused on primary care provider and provided little opportunity for specialist participation. Registries drive by providing feedback and appropriate use metrics including Patient Outcomes. They can help physicians monitor and manage populations, facilitating early interventions and Preventive Care which can lead to more successful disease management and less expensive care and participation in this proactive patient improvement and feedback tool was a congressional priority when it was originally enacted in macra. Many specialties and subspecialties believe that registries are not being recognized to fullest potential and only being used as an option for reporting measures to cms. I wish cms had stayed here to answer questions. Do you think cms has done enough for quality to health care . Extension has been uneven among geographic areas. Mifs and other programs dont take comprehensive Quality Improvement and the incremental steps that cms has announced in the space have been slow in terms of yielding progress, so i certainly think its important to try and have more Data Availability that allows meaningful measures for patients to compare quality between doctors and providers without simply having government officials decide what their priorities are going to be at the expense of patients. Thank you, dr. Pat really quickly, do you think congress overpaying entities through 340b program will contribute that Medicare Beneficiaries will expend on premiums . I do. I think the natural consequence of 53. 7 billion Program Last Year being a reduction in cost is, you know, what we think of it as a burden to manufacturers, if manufacturers are selling 30 of their drugs at 50 discount that ultimately that leads to an increase in drug prices which is a burden born on the backs of american dollars. Thank you, i havent asked questions yet. We typically go in order. I wanted to make sure with this fluid moving forward. Dr. Burgess. I will recognize myself for 5 minutes for questions. Dr. Patt first for you, did you practice the oncology care model cm that was developed through cmmi and can you share specific results and why do you think cms chose not to continue and instead pivoted to enhanced oncology model . Thank you for the question. Texas oncology did participate in the ocm program which was alternative payment model from oncology. We saved it was a Successful Program for texas oncology and for medicare, for us we saved the Medicare Program 134 million over nine performance periods, we substantially reduced er visits and hospitalizations. I think 9 and 6 but official numbers are in my written testimony but i will say that differently than that, we had Strategic Investments and improving care quality that mattered for patients. For example, content education about their specific cancer and therapy, i think, improved Health Literacy for patients that lead to compliance with oral therapies. And that kind of remote therapy monitoring allowed us to improve hospitalizations and er visits and lower costs within that subset of the whole population that we improved er visit hospitalizations and reduced costs. So i think that for us thats been a success, such a success we chose to implement initiatives for the entire practice and we have chosen to continue them. We are participating in eom. I think that the reason why ocm wasnt continued was because overall the program was felt to be a failure because it failed to save medicare money overall. I think that we need to do deeper dive into that data to understand who is saving money to the Medicare Program and who is not. I know since we as a private practice are a lower cost side of service that there may be some some winners and losers and that endeavor that we might benefit from a better buyout fee of that to try to understand better what we are winning from ocm. I have 3 minutes left. I want to direct this question to you. Anybody that would like to answer from the panel. I think its important and it gets exactly to what you were just saying. When cmmi was stood up, it was estimated if we spend 10 million to create the agency it would save 30 billion before you could book 20 and spend in the same bill. That was the way we do things. Here unfortunately but despite that, cbl came out and said its it didnt save the 20 billion. It actually or 30 billion which is the net 20 but it actually cost money. How how can cmi cm mi make sure they are driving value, drl the two minutes are up. One thing i would say that practices need to participate and engage in real ways, we tested one model in oncology. There are other alternative payment models proposed to ptac that might help practices transform that i think could be considered and that would be a reasonable way to think about how we study different models and what impact they have on medical care and cost. Whichever would like to go first . See one comment is, i think one of the challenges cmmi has faced it has relied on primarily on purely volunteer models and that has forced cmii to design models in such a way that the federal government captured the small share of savings from the models and also made forced them to make other choices that save money under the structures. Cmii could think of making models or one create incentives for participation in the models in the first place through things lick existing apm bonus. Thanks. I would say that the reevaluation of cbo assumptions and recent report provides an opportunity for congress to lack at ways to provide oversight of the committee, of the office, particularly the 10 billiondollar appropriations that it gets every decade are a major driver of those costs. That funding should be revisited and there should be more standards from congress and more oversight on transparency for its evaluations when models should be terminated rather than revised and when they should be expanded whether they should be meeting a net savings goal rather than just a budget neutrality goal. Theres numerous ways that congress could do this particularly because cmii has unprecedented power in terms of Government Agencies not facing judicial review or administrative review in terms of its ability to change medicare law and waive medicare law in order to stand up its models. I think it makes sense to try and provide some counterweight to that. Thank you, dr. Furr, do you have any comments. The Consumer Incentive Program or advanced payment model is often the government gives a small care and big stick so that you have to limit upside but you have downside. You might get 2 , you might have 9 down, so i think i have talked to physicians that tried, often the work is not worth the effort. So i think you have to make the incentives worthwhile and the other problem for smaller practices, they just dont have the resources to do that. They are overwhelmed with all the other things so even to talk about adding another level of work, you know, there might be some savings. If it gets done in my practice, i have to do it. Thank you. I yield back. Seeing no other member presenting themselves for questions, i will now conclude questions and ask unanimous consent to insert in the record the documents. Without objection, that will be in order and i will remind members that they have ten Business Days to submit questions for the record and act that the witness will respond promptly to the questions. Members should submit questions by the close of business on november the second. And without objection, thanks so much, its a fluid day, its a fluid time. This is unprecedented time here in washington and we appreciate your patience, your willingness to travel as far as you have and some more local than others and without objection, the subcommittee will be adjourned or is adjourned. [inaudible conversations]