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tv   Politics and Public Policy Today  CSPAN  May 26, 2016 5:00pm-7:01pm EDT

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no health insurance? raise your hands how many people here are is high deductibles and high co-payments in their insurance policy. what you are seeing is a failed health care system. the affordable care act has done some good things but it has not done enough. so let me be very honest with you and tell you what i have said many times and it gets me criticized many times, but i'll say it again. and this is in my view health care is a right of all people, not a privilege. [ cheers and applause ] i want every american to be able to go to the doctor when they need to go to the doctor
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[ cheers and applause ] we are losing thousands of people every single year who by the time they get into a doctor's office their situation has become terminal. that is unacceptable. first more not only today do we have so many people uninsured, 29 million, every one of us is getting ripped off by the unconscionable greed of the pharmaceutical industry [ boos ] . there are people in america dying and there are people getting much sicker than they should because they can not afford the astronomical high prices that the drug industry is charging us today. it is crazy that one out of five americans cannot afford the medicine they need and it is
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equally crazy that the top five drug companies last year made $50 billion in profit. [ boos ] if elected president, the drug companies will not continue ripping off the people of this country. [ cheers and applause ] brothers and sisters, everyone here knows that real change in america has never taken place from the top on down, but always from the bottom on up. [ cheers and applause ] you know, it's never about some guy up there saying, oh, you know, i think it would be a good idea to do this or that. it always occurs throughout our history when people by the millions stand up and fight back and demand dig any tie. [ cheers and applause ]
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you all know that 100 plus years ago many workers in america were working seven days a week, 12 hours a day, kids of 12 years of age were working in factories, losing their fingers because they were around machinery they should not have been around. and what working people said 100 plus years ago, they said we're not animals, we're not beasts of burden, we're human beings, we want dignity, we pe're going to form trade unions and negotiate fair contracts. [ cheers and applause ] 150 years ago amidst the abomination of slavery and racism, african-americans and their allies looked at the future and they stood up and they fight back to end racism in america and we'll never know, we will never know how many of
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these heroes and heroines were killed in that struggle, how many went to jail, how many were beaten, how many lost their jobs, but they had the courage to stand up and to demand a country which rid itself of racism and bigotry. people don't know this or have forgotten. 100 years ago, not a long time in human history. women in america did not have the right to vote or the get the jobs or education they wanted. [ boos ] what the establishment said to women your job is to stay home and have babies. that's what you're supposed to do. but women said you will not
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define us, we will define ourselves. [ cheers and applause ] and women and their male allies stood up, fought back, and said women in america will not be second class citizens. [ cheers and applause ] if you think -- not 100 years ago, think back 10 years ago. if i were to tell you or you were to tell me ten years ago, somebody jumps up and says "you know, bernie, i think gay marriage will be legal in every state in this country by the year 2015." the person next to her would have said "you're crazy. there is too much bigotry, too much homophobia, it will not happen." but the gay community and their straight allies stood up, fought
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back. [ cheers and applause ] and said loudly and proudly noo that in america people should have the right to love whoever they wanted regardless their gender. [ cheers and applause ] if we were here five years ago, no time at all and somebody were to jump up and say bernie, this $7.25 federal minimum wage is ridiculous, we've got to raise it to 15 bucks an hour, the person next to him would have said 15 bucks an hour? you're crazy, you're dreaming, you're too radical, you're an extremist, can't happen, you're canning for too much but three years ago workers in the fast food industry in mcdonald's, in burger king, in windies, they went out on strike and they
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stood up and they told america they can not make it on starvation wages, they need $15 an hour. [ cheers and applause ] and few years ago in seattle 15 bucks an hour. in san francisco, in los angeles, 15 bucks an hour. [ cheers and applause ] in california, new york state, 15 bucks an hour. what is my point? my point is that the establishment always wants you to believe that real change is impossible that your dreams are so radical they can not be achieved and you've got to accept minor changes at best. and what this campaign is about is rejecting that entire
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approach. [ cheers and applause ] no, my republican friends think we have to cut social security and benefits for veterans [ boos ] no, we're not going to do that, we're going increase social security and benefits for veterans. and what i am seeing all over this country, literally from coast to coast, from maine to california is people are beginning to understand that something is fundamentally wrong. they are asking themselves why is it that i am working longer hours for lower wages and almost all new income and wealth is going to the top 1%. why is it that we're seeing a proliferation of billionaires and yet half of the children in america ain public schools are n
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free and reduced lunches. why is it that kids are graduating school $90,000 or more in debt? why is it that women are making 79 cents on the dollar compared to men? why is it that we are the only major country on earth that doesn't gar tee paid family and medical leave? why are we the only country, major country not to guarantee health care for all? why is our infrastructure -- our roads and our bridges -- collapsing at the same time as millions of people desperately need jobs. why are we firing teachers when we need more teachers to better educate our children? [ cheers and applause ] why haven't we been more aggressive in taking on the fossil fuel industry and
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transforming our energy system? [ cheers and applause ] why do we pay the highest prices in the world for prescription drugs? why does wall street continue to rip off the american people every single day? those are the questions that the american people are beginning to ask answer the answer is that when people come together by the millions, when people stand up and say that our government has got to represent all of us, not just a few -- [ cheers and applause ] when this country brings about a political revolution so that real power rests in the hands of working families not wealthy
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campaign contributors, that's when we bring real change to this country. [ cheers and applause ] on june 7 there will be in california the most important primary in the whole nominating process. [ cheers and applause ] there are 475 delegates at stake here in california. what i have learned throughout this campaign is when voter turnout is high, when working people and young people come out in large numbers, we win. [ cheers and applause ] and if we can win here in california and win in the other five states that have primaries on june 7, we're going go
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marching into the democratic convention with enormous momentum [ cheers and applause ] and that i believe we'll be marching out of that convention as the democratic nominee. [ cheers and applause ] and if i am the democratic nominee, donald trump is toast. [ cheers and applause ] [ crowd chanting "bernie" ] so on june 7 here in california, let us see the largest voter turnout in democratic primary history. let this great state, one of the most progressive states in
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america go on record in saying yes to the political revolution. thank you all. [ cheers and applause ] ♪ ♪ this week en, road to the white house coverage of the libertarian convention in orlando, florida. on saturday we'll have a debate with the presidential candidates live at 8:00 p.m. eastern and on sunday beginning at 9:45 a.m. eastern, live coverage of the nomination process, delegate
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votes for the candidate, and victory speeches. that's all this weekend on c-spa c-span. >> madam secretary, we proudly give 72 of our delegate votes the next president of the united states. [ cheers and applause ] last year, congress passed the medical access and can chip
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reimbursement act through value based health care rather than a fee for service payment system. the acting administrators for medicare and medicaid services appeared before a house panel to discuss the proposed rules for implementing the new law and how the changes will impact doctors as well as patients. this is about 90 minutes. >> subcommittee will come to order. good afternoon, everybody, so
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we're going to begin, i'm excited to be having this hearing, when i came to congress back in 2001 the sustainable growth rate, or sgr, as we all know it by a provision there the balance budget act in the provision of 1997 was being implemented and under this payment formula any yearly increase for beneficiary spending that exceeded growth in gdp could result in negative adjustment for physician payment in medicare. dr. price was really well aware of that. clearly his policy and the math didn't work and for the next 15 years we had almost yearly struggles over what was aptly named the doc fix. 17 of these doc fixes later takes us to last march when we came together in a bipartisan fashion with stakeholder input and cms technical support to pass med the medicare access and chip reauthorization act of 2015. now commonly known as macra.
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this legislation put an end to the sustainable growth rate so doctors could focus on patient care and not worry about unpredictable payments. we've called this hearing today to take our first look at the regulations released by cms on april 27. we'll look at how these regulations match up with congressional intent and what our members and cms are hearing from stakeholders as they digest 950 plus pages of regulations that's the scope of the hearing to discuss the implementation of this truly his store ij legislative feat and there's a lot to discuss. i know on a bipartisan basis we'll dive in in a deep way. i'd like to take a moment to encourage members of both sides of the aisle as you hear from stakeholders and constituents regarding concerns or thoughts about the proposed rule, please bring them to the attention of the bipartisan committee staff so we can continue to do robust
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oversight and keep cms up to date on the information as they formulate their final regulation. the passage of macra last year confirmed our commitment to keep medicare strong for america's seniors. this is particularly important to me as well as many of you especially after we just se celebrated mother's day as both my parents depend on this important medicare program. by replacing the way physicians are paid and consolidated the separate quality measurement systems we have taken a great step toward the ultimate goal of fully entry grated value-based care through the incent i ha havization of high quality care. it's how this new law will work for clinicians and provider groups. we need to answer how this rule will affect individual and small group providers versus larger
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groups. how will this rule affect specialty groups? how will the timing work for implementation under potentially tight timelines? these are questions i hope to get clarity on today going forward. as we move forward with implementation i want to make sure that we as congress recognize very important facts regarding the law that we passed. the merit based incentive payment system is created as a budget neutral program, high quality value based care will take effort but as i said before such efforts must be recognized within the environmental and timing factors based in reality. additionally, the threshold for providers to qualify as advanced alternative payment models are high and are set in statute. working on a bipartisan basis with stakeholders from every corner of our country and an open dialogue and cooperation from cms will allow us to follow
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macra into the next generation of value-based health care. now we can go to work with that i would like to yield to the distinguished ranking member dr. mcdermott for the purposes of an opening statement. >> thank you. medicare was put in place some 50 years ago, a critical decision was made by the medical association in order to have them join in the effort, they demanded that they be paid their usual and customary fees and we on this committee have been since that time trying to get back the keys to the treasury. this is another effort here. now the proposal by -- the macra rule from cms is really as a result of our efforts as mr.
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tibury said 15 years didn't work. it took us 15 years to figure out we needed to do something different. i hope this is the beginning of a constructive bipartisan conversation about how to advance our shared goal of improving delivery of health care in the country. passing macra was a tremendous bipartisan accomplishment in that it put an end to a cycle of dysfunction. we had the same thing happen every year, we're going to have a 20% cut in doctor's pay so there would be a big rush around here and we'd put a patch on it then go on for another year and next year it would be a 24% cut in doctors' pay and we did that again and again. for years we lurched from crisis to crisis to avoid what were draconian cuts in the p s is in physicians payments. we ended up spending more on the temporary delays than it would have cost to do away with isgr
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in the beginning. last year we put an end to the cycle once and for all bypassings macra. macra is much more than a simple reveal, it's the most significant payment reform medicare program has seen in years thanks to macra we've set medicare on a sustainable course that will allow us to pay for value in health care rather than volume. the law modern sizes and streamlines physicians' payment. instead of a patchwork of incentives and alternative payment models it consolidates various programs into a single framework, it will allow flexibility for providers, allow them to practice medicine independent independently while holding them accountable accountab accountable. we are still in the early stages of digesting this proposed rule. it's big enough. it will take a while.
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the administration has worked to implement the law as intended through a process that is responsive to the needs of the public. the proposed rule is consistent with the goals of macra. it provides flex tonight participate in the merit-based incentive payment program or alternative payment methods that reward high value care. this will make sure providers do not end up in one size fits all approaches that doesn't make sense for them or their patients. it's the product of an open and transparent process that began months ago through active outreach, consideration of extensive comments and public workshops with stakeholders the agency has heard from a range of view points and the proposal reflects careful consideration of that input. i'm confident the administration will continue to be responsive to the needs of the public as it develops the final rule. this is an ongoing conversation, we still have much more to learn
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as we work toward our shared goal of making the implementation of this landmark law a success. getting people covered by health care is one thing. controlling the costs is another thing and this is about controlling the costs and i don't believe we've got our arms around it yet but we're in the process and we welcome you here to make this presentation. thank you. >> thank you, dr. mcdermott. without objection, other members opening statements will be made part of the record. today's witness panel includes one expert and we're lucky to have him. andy slavitt, acting administrator at the centers for medicare and medicaid services along with his colleagues have a daunting task of implementing this important law. on a personal note thank you for having me at your office yesterday. it was nice to get to know you and members of your team and look forward to continuing dialogue in the future. with that mr. slavitt, please proceed with your testimony, we appreciate you being hear today.
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>> thank you chairman tiberi and thank you for the opportunity to discuss cms' work to implement the medicare access and chip reauthorization act of 2015. we greatly appreciate your leadership in passing this important law which gives us a unique opportunity to move away from the annual uncertainty created by the sustainable growth rate to a new system that promotes quality, coordinated care for patients and sets the medicare program on a sustainable path, our number one priority is patient care and thanks to congress macra streamlined the patchwork of programs that currently measure value and quality into a singing framework called the quality payment program where every physician and clinician has the opportunity to be paid more for providing better care for their patients. in recognition of the diversity of physician practices congress created two paths. the first allows physicians and
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other clinicians the new flexment to participate in a single simplified program with lower reporting burden and new flixability in delivering quality care. it will second path recognizes that physicians and clinicians who choose to take a further step towards care coordination by participating in more advanced models like medical homes. our goal is to make both of these paths flexible, transparent and simple so physicians can focus on patient care not reporting or score keeping. we've approached the implementation with a belief that physicians know best how to provide high quality care to our beneficiaries, we've taken an unprecedented effort to draft a proposal that is based directly on input from those in the front line of care delivery. we've reached out and listened to over 6,000 stakeholders including state medical societies, physician groups and patient groups to understand how
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the changes were we're proposing may positively impact care and how to avoid unintended consequences, the feedback we received shaped our proposal in important ways and the dialogue is continuing. based on what we learned our approach to implementation has been guided by three principles -- first, patients are and must remain the key focus, financial incentives should work in the background to support physician and clinician efforts to provide the highest quality care and create incentives for coordinated care. second, we're focused on adopting approaches that can be driven at the practice level not one size fits all from washington. it will be important to allow physicians to define the measures of care most fitting with their patients. third we must aim for simplicity in everything we do. physician practices are already busy and we are seeking every opportunity point to minimize
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distractions by reducing, automating and freedom lining existing programs, among the many places we seek feedback during the comment period, this is among the most important as the burdens on small and rural practices in particular have increased over the last several years. one of the important opportunities will be for physicians to define and propose new payment models so we can create an array of customized approaches that reflects the diversity of care across the country and particularly as it relates to the various specialties that provide care. congress had the foresight to create a formal vice foice thro the physician payment model technical advisory committee. i had the opportunity to meet with them last week and can tell you they are very eager to move forward with their important work and we are eager to work with them. with all the work that went into this proposal, it's critical that we receive direct feedback from physicians and other
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stakeholders and oare undertakig significant outreach efforts. our proposed rule is the first step in the process. we look forward to receiving and reviewing comments to refine and improve our approach. in may alone we have 35 scheduled events and listening sessions to hear from a wide range of stakeholders and this outreach will remain an important part of our work i personally have been meeting regularly with physician groups, including smaller and rural practices and have spoken to physicians in different parts of the country about their work, the opportunities and challenges they face and what this proposal means for them and their patients. throughout this, i have appreciated the open dialogue with this subcommittee and the larger committee. it's clear we share the goals of creating a more sustainable system, smarter spending that keeps people healthier, we're striving to do just that in the implementation of macra but it will take word and broad
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participation to getting it right. i look forward to hearing your further thoughts and answering your questions. thank you. >> thank you, mr. slavitt, as you know in my district i represent urban, suburban, rural. and most of the concerns i've heard with respect to macra and the future implementation of macra is from small and rural providers. so the proposed regulation assigned three levels of risk for entities participating in alternative payment models and what i've not seen are tear tiers or variabilities in the amount of risk for participation between an individual and small group clinician and large group clinician clinicians. have you heard concern from providers about this? >> i think -- thank you for the question. i think the topic, particularly small practices and making sure
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they can succeed is of utmost importance. and our data shows that physicians that are in small and solo practices, so long as they report, can do just as well as physicians in larger-sized practices. so we know, however, that there is a burden on us to make the reporting as easy as possible. we also know there are a number of other steps that we need to be looking for and looking out for to make sure we make things as easy as possible and accommodate smaller practices. so we are looking for additional steps and ideas as people review the rules but i will say people are focusing on technical assistance, providing access through medical home models, opportunities to report in groups and using a reporting process that automatically feeds data, reduces the number of measures and overall lowers the burden for small practices. >> so in a followup to that, in
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reading through the regulation, there are several areas that seem to allow a little more flexibility for individual and small group practices. if you outline the major differences in reporting for individual and small group practices versus the larger groups that could maybe ease the burden or send that message to the smaller groups that there's sensitivity there? >> sure, absolutely. at the question of the physicians -- we met with a lot of physician groups and small practices in this process. one of their key requests was that if they're already participating in something like a clinical registry or some other way of getting data across, maybe an accountable care organization or clinical registry, that we use the that information rather than requiring them to send them again and our proposal does indeed allow this multiple ways for us to get information. secondly we're required to measure the cost of care and we
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are able to do that automatically by getting a claims fee that requires physicians to send us no information whatsoever and there are a number of areas where they need to attest to whether they're doing a certain activity which we think will reduce the burden and we're looking more broadly at the overall experience for physicians. small physician cans report in groups in many categories where they hadn't been able to before and finally i would say there are a large number of physicians who won't have to report at all because they'll be underneath the minimum threshold and congress put forward that iffy sigss don't see enough medicare patients or enough amount through medicare that they don't have to report at all so all of those things i think are there and, again, we also look for additional steps if there are some we can take. >> just a final thought, i don't mean to put you on the spot on this. but you think there's any more that we can do, those of us on
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this side of the dais and you and your team at cms that we could do to ensure that as we lay the foundation for macra going forward and there's bye in, complete buy-in from the community the system is not built with an inherent fairness or fairness issues? again going back to the rural provider or the two person provider group that has a bunch of anxious right now as this has begun to unfold is there any more we can do or you can do or we can work together on? >> i think it's got to be a vital continuous effort. i met with small physician practices from southern arkansas, southern oregon, new jersey, we have a meeting on friday with rural health association at their annual meeting. we went out to kansas city last
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week to meet with a family practice association and we hear a lot from small physicians who are concerned if people in washington are making centralized decisions that are going to impact their quality of care and what they tell us over and over again and we need to keep talking and getting more feedback is give us the freedom to take care of these patients, we know how to do it, let us define quality and select measures that are right for our practice, give us flexibility and don't make us focus on reporting, let us focus on patient care and it's really critical, i think, as we work together and adds you hear input that you get this to us and this we hold ourselves very much to that stan dhard physicians across the country are holding us to. >> thank you, sir, with that i recognize dr. mcdermott for five minutes. >> thank you. one of the issues that the question mr. tiberi is raising about small practices leads me
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to the question of consolidation and driving doctors together in larger and larger groups. the question then comes in my mind -- i practiced both as an individual and in the military and in a group practice so i've been in all sorts of forums. one of the things that strikes me that is going to be difficult to deal with here is the whole questionover whether what is the best care. if you have a large organization and they have an mri and they don't want to use it -- or they want to use it, they can crank a lot of people through with an mri for everything or they can say don't use an mri and there will be patients out there who do not benefit from what they could find. i can give you an example of a young woman, 34 years old who had pain in her back and was
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told you're riding a bicycle and there's reasons why, you're young and blah blah blah. at 35 they did an mri and found a tumor in her spine. now if they'd done that they would have found it five years earler but the organization was encouraging people not to use. so how are we going to make our judgment about whether we've got quality of care if the major factor is going to be money? i mean, what's built into this to actually look at the quality of care? >> so i think at the heart of the question the most important thing above all else is making sure patients get high quality care and we do believe that if patients are getting high quality care that's going to lead to better cost control because if someone gets the right surgery they won't need to
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have a second surgery. like wise, if somebody as the quality -- is defined as making sure the care is coordinated so if somebody needs to have a follow-up visit or has a prescription or something that -- with an instruction that they understand what that is, it's explained to them and that the system works and supports them. so our job here is to enforce that, number one. number two, i think our job isn't to define quality here ourselves as much as it is to take the best standards of care that the specialists and the physicians around the country have defined as quality and make sure we keep up with that and that we keep those measures as the things that physicians decide as a group that they should be measured on and those are the things -- and third as i said earlier that things differ at the practice level and we believe the practices by and large are the people that know best for what's right with their
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patients and the dialogue between the patient and iffy sigs so nothing we are doing should be seen to be interfering with that in any way and in fact we ought to be reinforcing those things and i think macra gives us the opportunity to say if you're delivering a better quality care outcome for your patient out out to be rewarded for that. >> you're suggesting the whole question of evidence-based medicine. that is if -- i mean, i've been to the doctor recently and they send out from the university of washington a sheet that des "did you have good care? was he polite? was he nicely dressed, blah blah blah." at the bottom "were you satisfied with your care?" for some people if they don't get a prescription or an x-ray or a blood test or something they haven't had -- the doctor hasn't done anything so how do you measure, then, the patient who says well i wasn't satisfied because i went away and i
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still -- my sinuses are a mess and he didn't give me antibiotics. how do you deal with that issue in the quality of care? >> i think one of the nice things is -- i'll give you an example. i was sitting down with physicians from a -- that are practicing medicine in rural arkansas, i referred to them recently. they are in one of these models, medical home model where they have a per member per month payment in order to coordinate the care and they have hired care coordinators and what they told me was, the physician i was talking to told me he said now i can get paid to practice medicine the way i'm supposed to practice medicine instead of practicing medicine the right way and getting paid on something completely different. so i think the more we evolve our health care system to a way that reinforce what is physicians know are the right things to do in delivering quality care to patients the better off we're going to be as
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opposed to a system where if you don't make a cut in someone's skin or give them a prescription or something that they leave the office with, that's not success. >> i have a medical home at the university of washington, thank you. >> thank you, dr. mcdermott, that was good. we agree on something. thank you so much. i have 12 different questions i could ask you on 12 different topics and my mom has one she shared with me last night but it doesn't have to do with macra and i would like to remind members to keep the topic to this important law we passed. with that, mr. johnson is recognized for five minutes. >> thank you, mr. chairman. mr. slavitt, welcome. you've said cms is working to regain the hearts and minds of physicians through implementation of macra and
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that's great because many physicians have struggled to stay afloat and while there are a lot of good things in the proposed rule i have one issue i'd like to raise with you. i'm concerned by the estimates in table 64 where cms projects the greatest negative impact on payments to practice with nine or fewer doctors and the least harm to large systems with 100 or more docs. if cms is trying to win back the hearts and minds of physicians, this proposal falls short since it will continue to push physicians out of their solo or small practices. the you tell me specifically what cms is doing to ensure solo practitioners and small groups can succeed under the mips and participate in alternative payment models by 2019?
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>> thank you, congressman johnson, for the question and i actually welcome the opportunity to address this table and for anyone who hasn't seen the table, the table is designed to estimate what the impact of these regulations could be on practices of various size. and the first thing i want to make very clear is that the is question of making sure that small groups and solo practitioners can be successful is of utmost importance and i would indicate despite what that table shows, our data shows that physicians who are in small and solo practices can do just as well and actually do do just as well as physicians that are in practices that are larger than that. now, the reason the table looks the way it does is for one simple and important reason, it counts for the fact that in 2014
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when the table the data uses, most physicians in small and solo practices did not report on their quality and this is important for a couple reasons. first of all i should say in 2015 and subsequent years the reporting went soup at best this table would be very, very conservative and, of course, as i explained to chairman tiberi, reporting will get easier going forward. but it does point to a couple things i think we'd be wise to pay attention to, one, making sure it's as easy as possible for physicians to report one of the reasons why we don't have the hearts and minds of physicians is there's too much paperwork in health care. >> i would agree. >> they need to practice medicine not do paperwork. so there has been a tremendous amount of effort so far and this is just a proposal so this next period of time for comments are a time when we were hoping people can give us even further ideas and further ways that we
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can reduce the administrative reporting burden but to be very clear, there's absolutely every opportunity and an equal opportunity for small and solo practices to be successful. >> well, thank you. maybe we better indoctrinate the nurses, too. don't they do most of it? i thank you, mr. chairman, i yield back my time. >> thank you, mr. johnson. >> thank you, mr. chairman, thank you, mr. slavitt for your testimony here today. i think congress in passing macra gave you a huge undertaking and with a 900 page rule i think it's obvious we need to keep the lines of communication open and your outreach will continue as it has been not justify sigss but patient feedback as well. i know many members have been pushing hard to get a more integrated coordinated health care delivery system. i come from a region in wisconsin that established
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models of care and has been pushing in this direction for quite some time. ultimately alternative payment methods so we get quality, value-vased outcome based reimbursement so that's the directive macra gave you. but a lot of my providers were early stage first generation aco models. my question is what more can be done in order to provide an onramp to those early stage acos? are they going to have to leapfrog and go on to jen gen 2n 3, gen 4? >> you're raising an important question which is where physicians have an opportunity -- as we mention, all physicians inner program will have the opportunity to get rewarded for quality care but where physicians have an opportunity to and have had the opportunity to the last several years to join with other physicians in these more coordinated care models, the
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medical home would be one example we think those are a good idea if they're right for iffy sigs. if the physicians think they make sense for their parents mack a gives them an opportunity to earn 5% additional bonus on top of what they may be earning in these advance models. so what's the requirement to get access to that bonus and the legislation puts forward a number of requirements and it's that there has to be a higher degree of shared accountability from the physician and that shared accountability is shared accountability from the oust come to the patient and a minimal sharing of the cost with the medicare program itself. so in other words in order to qualify for this 5% bonus i
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think the words in the legislation are there has to be a -- more than a nominal risk so our job in putting this regulation together is the definition of what is nominal risk, we've tried to do that in as consistent and simple a way as possible but it's one of the areas where we're inviting feedback. all of our models, whatever model we're in will have to qualify based upon that definition and so even if afy sigts is in a model that doesn't qualify because there's not a risk, there's still great opportunities and opportunities for them to grow into other models. >> finally, you know, the great cost driver in our society, it's true at the federal level with our budget for families and businesses is rising health care cost so with the direction this rule is taking, can we sit here with reasonable confidence that this may lead to cost savings is
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but without jeopardizing the outcome or quality of care that our patients are receiving or will this turn into a lake woe begone situation where everyone is qualifying for bonus payments and there's no cost savings at the end of the day? >> well, i think we all are striving for a higher quality health care system, we want our money spent more wisely and we don't want to do in the a way that people feel like they're skimping on care, we have 10,000 new seniors everyday in america and our jobs are to figure out how to take care of them better for less money and that means taking care of them in lower cost settings, more comfortable settings like their homes rather than institutions like hospitals so they're vital to this program, within the regulation the pool palaces out and so we are going to have to allocate money and have upward and downward adjustments as part of this program in order to be able
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too meet the sustainability test you talked about. that's nothing new. there are upward and downward adjustment ins programs today. what is new is this will be a simpler more a simpler, more aligned program that's easier to measure and take tack of. >> great, thank you. thank you, mr. chairman. >> mr. roskam is recognized for five minutes. >> thank you. i have an observation, a point and a nudge. my observation is this. there's a level of anxiety out there in our public life today because people look at congress and they say nothing's happen g happening. and yet, here we've got this issue where both sides of the aisle, the white house, everybody came together, arrested a complicated issue to the ground, came up with a solution, and it doesn't involve snarling at one another on television. it doesn't involve hi besh lee and so forth, but there was a very serious effort, and we're on the verge of i think some good things.
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so, just a little shout out, and that is three cheers for something getting done. and i think there's an encouraging element to that. my point is that debate matters. i would argue that one of the reasons that we were able to have that discussion when speaker boehner and leader pelosi were able to come together, and the two of them really drove the discussion, it was because it had been well wrestled through in the united states over the past several years that we needed to do something on medicare. and both sides have different views of the world and so forth, but there was, you know, it had become normalized in that sense that these things had to change. so debate does matter, and i think we are better off if our debate doesn't involve snarling at one another, and it's two various points, but debate matters because debate is a prelude to action. margaret thatcher said first you win the debate, then you win the vote. okay, now here's the nudge. and this is the nudge for you, mr. slavitt. one of the things that i think
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you and i have talked about offline and you've alluded to some of this too a minute ago, there is this tension that's out there, and there's a tension that manifests -- and let me just tell you a quick story. so, i served in the state legislature and we had some education testing issues that came before us. you know how this works. there's always a new test, there's always a new standard. so i called a friend of mine who's an old friend from high school who is a high school administrator. and i said, give me the straight scoop on these tests. and he said, peter, look, will you just pick a test and stick with it and not change it every four years? and he goes, we're happy to be accountable, but stick with a test, stick with a program. and that deeply resonated with me. so, the tension is that i think health care providers want a standard. they want something that's
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predictable. but now also, the tension is they don't want something that's declarative and dispositive and can never be revisited, because that's big and that's overwhelming and that's what sgr had -- that's what we had to do for, you know, the doc fix for all those years. that was declarative. it was an overcharacterization, and it failed. and the proof that it failed was you had to kick -- we all had to kick the can down the road. so my nudge is this. as you are going through and you're figuring this out -- and i really appreciate the disposition and the attitude and the open rule time that you have now and the comments that you're taking in -- if you could really be mindful of those smaller practices that mr. johnson mentioned, the point that mr. mcdermott made, and that is, how is it that a physician that is maybe, you know, stewarding antibiotics correctly or not giving in to patient pressure for a prescription, how is that
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physician protected? and also, i hadn't thought about it until mr. kind mentioned it, and that is, are the bonus payments, so to speak, are they simply a new floor? and does the average become the expectation? so, all of those -- you know, i'm here and i think that the chairman has set the great tone here, and that is to try for us to listen and to learn. but as you're navigating through those natural tensions of having something that can be predictable but also maintaining that level of flexibility where it can be revisited and changed i think is the best of both worlds. with that, you don't need to respond. i'll yield back. thank you. >> if you'd like to respond, you may. it's up to you. >> well, we had these conversations, including a little bit yesterday. i think this idea of making sure that people don't feel like the game is changing on them midcourse is critical. so there's enough in this
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legislation that allows us to tell folks going in, hey, here's how it works in advance. i think there's nothing more frustrating than being told after you took the test how it's being graded. and then i think you make an important point as well, which is how do you trade off making sure you're predictable with staying current with the state of the art and the state of medicine and what physicians are saying they want. and i think we have a process for that. we take comment on that process. we think it's an effective process. but it's also important that physicians have the flexibility to navigate the process, particularly at different times in their practice. >> thank you. mr. thompson is recognized for five minutes. >> thank you, mr. chairman, for having the hearing today. thank you, sir, for being here. i'm sorry, i had to step out, so i hope i'm not going to be repetitive here. but we're all very, very
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interested, i think you can tell by the tone of all the questions, that this law works. we have a very vested interest in that, not only as the committee of jurisdiction but also these are the people, providers and patients that we represent at home, and we want to make sure that it works. and so, to that end, i'd like to hear what the administration's doing to help providers get ready ahead of the 2017 start date and what would you recommend providers be doing to get ready? and is there anything that we, as members of congress, should be doing to help facilitate this transiti transition? >> yeah. thank you. so, i guess maybe i will start to direct that question as if -- what i would say to a physician who is wondering what does this all mean. and it's a conversation that i get to have frequently because i've been having a lot of conversations with physicians.
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and i think there are probably five things i would say that i would keep in mind as a physician or from, i think, our perspective. number one and most importantly, keep focusing on your patients and on patient care. don't worry about the score-keeping. it will be our job to put this forward in a way where it becomes easier, and indeed, it will be easier and more streamlined than the processes people have to go through today. so that's the good news and that's the first thing. the second thing is that we have to continue to talk to people and educate people is there opportunity, as the chairman's question implied earlier -- is it because physicians will have the opportunity to decide which measures and which ways of measuring quality they want to be measured on, that at some point they'll be able to think about what those things are and be able to put those into motion, and that's really one of the important early things. i think if there are
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opportunities to participate in these more advanced models, these care coordination models like medical homes, they should obviously consider those because there are some extra rewards for that. but it won't be until the spring of 2018 that physicians would first need to report on macra. and so, it's important that they not get too concerned about that. and then the final thing i'd say, and i think we're trying to encourage for everybody is to provide us feedback. during this comment period, we really want physicians to be able to review this. we're setting up a number of sessions. i talked to 3,000 physicians yesterday on a call. we do twice-a-week webinars, to get your questions answered and then give us feedback on how you think this is going to affect your practice. >> and as far as us being able to do anything to help facilitate the transition, any comments for the committee? >> i think the more listening
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sessions and open forums that there can be with physicians and giving physicians an opportunity not just to hear what's in the rule but to tell us how it's going to impact them. i spoke with one of the members of the subcommittee who asked me to participate in one of those sessions with people in his district. i think we have a lot of the staff at cms that are available to do phone calls and other things to reach out directly. so let us know what you're hearing from your constituents and our job is to be responsive. >> and so, in my particular case, would you rather do a phone call into the napa valley or would you rather come out and do an in-person? i yield back. [ laughter ] >> maybe a future subcommittee hearing. dr. price, recognized for five minutes. >> thank you, mr. chairman, and thank you, mr. slavitt, for joining us today. i think as has been said, i think we're moving in a better
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direction, but we still have a long way to go. and if we're going to make it so that physicians can once again be able to care for patients without an inordinate amount of influence or burden from outside, we've got to continue to work through this, and i appreciate your willingness to do so. i've got a couple specific areas, and then i want to tick through. one is you've got -- moving from meaningful use to aci, or whatever we're going to call it, we've got a 365-day rule. in the past it's always been a 90-day rule, which means that practices have to demonstrate that they comply for a 90-day continuous period within a 365-day period. it only makes sense. nobody is perfect every day. and if they're going to get dinged because they're not able to comply one day or two days or three days, then we've simply got to move to a 90-day, and i hope that you're able to work in that direction. >> so, it's one of the key areas we're inviting comment right now during the comment period. >> good. so, i invite comment as well
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from folks from whom i have heard. >> okay. >> on the alternative payment models, you've got a lot of folks out there, a lot of docs, guys and gals who have already modified what they're doing. the bundled payments, the bbci programs, the future cjr program. and yet, it appears that those programs that cms has pushed on docs and encouraged docs, incentivized docs to do don't even qualify for apms. that doesn't make any sense at all. so i hope you're looking at just grandfathering those or moving them in or allowing them to qualify as apms. >> so, congressman, one of the things that i think we have to do now that the law is being implemented is to go back and look at all of our models and see where we can make changes to them so that the participants in them can qualify. and i know that dr. conway is very much directing the team to look for ways to do that where possible. that has to meet -- there are
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certain requirements that have to be met. an example would be what percentage of the patients i'm seeing are part of this bundled payment. and so, because that's in the statute in the law, we have to look at how we can modify with these programs or work with you on what our flexibility is to be able to -- >> i agree. if you expand the ability for them to use their entire practice instead of just medicare, that oftentimes gets them to that point. >> right. >> so i would urge you to look at that. >> okay. >> docs are really frustrated for things which they are held accountable which they have no control over. one is on the meaningful use aci issue, this data-blocking that's occurring by the vendors. docs don't have any control over what the vendors do at all. so how we can have a system that actually punishes docs or potentially punishes docs because of something somebody else does that they don't have any control over, again, that doesn't make any sense at all, and they're pulling their hair out trying to comply with this. so if you can look at that, that would be appreciated as well. >> will do.
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>> i want to touch on the nominal risk that you talked about. >> okay. >> the nominal risk, as i understand it, is 4% -- minimum of 4% of total spending to be qualified under an apm? >> that's correct. >> and as you know, the physicians control, i don't know, pick your number, 14%, 15%, 16% of total spending. so, 4% of total spending is really 25%, 30% hit for the docs. so how can we have a system that punishes the people that are -- where the rubber hits the road, trying to care for these patients, and again for which they have little control over? shouldn't that be 4% of the physician total reimbursement? >> so, one of the areas where we're looking for feedback in the comment period is both what is nominal risk, quantitatively. we chose a number that was consistent across the mips program, but that's just in the proposal, so -- >> doesn't that presume that the
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physician controls every dollar of spending? >> and that's the second area that we seek feedback, which is under what universe total cost of care, which of course, the benefit of a total cost of care is a primary care physician has the opportunity to get rewarded for being able to keep their patient out of the hospital when they don't belong there and so forth. of course, as you point out, the challenge with that as well -- so, it is an area where we're looking for feedback and very much -- >> a lot of those things are out of their control. >> sure. >> we'd like to believe that they control them, but in an ideal world, that might be nice, but a lot of those things are out of their control. i have a few seconds left and i want to point out the table you identified, table 64, which by your own data stipulates that solo practitioners are going to -- 87% of solo practitioners are going to see a negative adjustment. this is your own data. granted, it's two years old, but it's going to be two-year-old data that's going to reward them in '19 based on what happens in '17, so i urge you to relook at how you're adjusting that and in
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realtime providing an update. >> right. and we'll look at the final rule and having the most updated and accurate information in that table. again, while that table would not be good news if it were reality, i don't believe it is reality. however, i will say that the silver lining is i think drawing attention to the impact of this regulation on small and solo practices is a good thing. and so, i think it's where we need to have dialogue. and so, despite the fact that i don't think that table represents the reality, i do think that the reality of how difficult it is to practice medicine in a small or solo practice is very real. so we're looking for ways to make sure we make it better. >> great. thank you very much. thank you, mr. chairman. >> thank you. i think you might be sensing a theme up here. mr. blumenauer, you're recognized for five minutes. >> thank you, mr. chairman. i appreciate the opportunity to have the conversation today. mr. administrator, i appreciate the approach that you folks have taken to help us turn the corner.
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i personally have found the the charade we went through for some 17 years embarrassing, dancing away from an event we know nobody had any expectation should happen. we're dealing with a budget fiction. i think the agreement that was struck is reasonable. there is still much value to be squeezed out of the system, but i appreciate the fact and some of the references from my friend, dr. price. we've got people who are in the middle of practice patterns, limitations on data, and just a whole host of other changes taking place. and i appreciate the commitment to do so in a thoughtful and deliberate fashion. you have also heard another theme emerge that people are keenly interested in making sure that we make this transition to rewarding value over volume and that we've had problems in the
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past with some things theoretically. i mean, i have strongly supported medicare advantage. but at the same time, the parts of the affordable care act to try to coax more value out of it, because theoretically, it should enable us to deliver care more efficiently. >> more efficient. >> and we continue to have a pretty significant premium. the compromise that was struck and one that i thought was healthy was to provide bonuses based on performance and try and deal with some of the areas where there is some decidedly -- i don't know if one wants to call them outliers, but there's some real performance problems, being overcompensated, coming from one of those regions that we like to think that if everybody practiced medicine like they do in my congressional district, we wouldn't have the funding problems that we have.
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i'm looking at charts like this that kind of display how it's supposed to work over time. i wonder if you can just give us a sense of where you think the pinch points are, where will be some of the things that we need to be prepared to be able to work with you, if there's further adjustments legislatively, if there are things that we need to do a better job of just being able to understand ourselves, to explain to our community at home. where are the pinch points that you think we need to zero in on? >> thank you, congressman blumenauer. i think i point to a couple of areas that i think are really critical focus areas for us. one is the education and communication process, particularly with smaller practices and individuals, solo physicians. it's vital that we hear their feedback and understand what the
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impact of the decisions that we're making here today will be on their practices several years from now. so that education process i think means a couple of things. one is that we talk in plain english instead of acronyms, which we are quite guilty of here, i know, but we're trying very hard to do a better job at that. we've created simple fact sheets and training sessions and powerpoints and as many options as possible to do that. and to the extent that you can help us do that and tell us what you're hearing, that's going to be critical. the second thing that i think we will need to continue to hear from you all on, and i think the conversation with congressman price is apropos to this, is where there are places where you think there should be flexibility and how we should be exercising flexibility, whether it's with smaller practices or whether it's in how we define
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the models that are the qualifier for the 5% bonus. in all of those areas, your feedback on our interpretations are critical because we really do want to get to the best answer. and i will tell you that we don't have a monopoly on that. we want to do that through the dialogue and the debate that congressman roskam referred to. and we also are going to have to make this an ongoing commitment, because we'll have to look at this program at the end of its first year and understand what worked well and what didn't and what could work better, and we can't be afraid to call out the things that didn't work as well and sit down together and try to figure out how to make those things better, whether it's with technical improvements or whether it's simply in how we're implementing things. >> mr. chairman, i do appreciate the opportunity to get into something which i hope we're able to periodically update, review. i appreciate part of this is process and part of it is
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performance and being able to strike that balance in a way that's protective of the people who depend on the service but also for the taxpayer i think is going to be a challenge for our friends at cms and for the committee. and i hope we can continue sort of zeroing in in that fashion. thank you. >> thank you. well said. mr. smith of nebraska's recognized for five minutes. >> thank you, mr. chairman. thank you, administrator slavitt, for being here today. i represent a very rural district, in some parts more rural than others, in fact. 75 counties touching 6 states. obviously, we're very spread out. number one agriculture district in the nation. very productive. of the nearly 60 hospitals in my district, about 54 are designated as critical access. and that might be a single designation, but that's about 54 different types of expertise and providers, and i'm actually inspired by the work that they do serving communities from
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smaller than 1,000 up to about 12,000-plus. nonetheless, they've got a very large task, and i guess so do you. can you discuss the feedback you received from rural providers in response to the initial rfi and how you address that in producing the rule, and then what rural providers and critical access hospitals can expect from this rule? >> yeah. thank you, congressman. in your district, and i think throughout the country, we face the challenge of not having enough physicians in many cases, enough specialties, and there are many districts around the country where there are only one or two providers in certain specialties. so we cannot allow the sideshow that goes along with the practice of medicine to make the practice of medicine less fulfilling and less rewarding.
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so as it relates to the small physician practices, the medical home models that many of them are participating in, we've had really terrific feedback from. and i think what i hear from small physicians is give us the opportunity, find ways for us to have the opportunity to participate. and some of these same opportunities and models that people do in urban settings, and make them work for us. so, can you make changes to them that can work for us? so, that's i think one of the things. and then on critical access hospitals, obviously for us, so many of our medicare beneficiaries get taken care of and get treated and rely on those critical access hospitals. and the economics of health care in rural america is different than it is in other places, and that is both a short-term issue that we have regulations, as you know, to set up to deal with, but it's also a longer-term question around how those
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hospitals are structured, what they provide and how we support them in the appropriate way. >> okay. in your response to the chairman, you had mentioned a reporting exemption for small providers. at the same time, i've heard questions from those who fall below the reporting threshold who would like to be able to report data. will they have that opportunity? >> it's interesting you say that. i had that feedback last night in talking to a speciality society who said we want our speciality to be more engaged in the practice of medicine with seniors. and so, even our physicians who are only seeing small amounts, we want to do that. so, i will tell you, i have heard feedback in both directions, and i think our job will be over the comment period to take all of that in and figure out how to do the best job accommodating the most types of practice as possible. >> well, i appreciate that. i know that the providers that i talk to are constantly not just saying what the problem is, but
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provider solutions and innovations, and i would hope that we can empower providers to care for their patients without the government getting in the way or messing things up. thank you, mr. chairman. i yield back. >> thank you. the former mayor of paterson, new jersey, is recognized, mr. pascrell, for five minutes. >> thank you very much, mr. chairman. administrator slavitt, under your leadership, cms has stressed the importance of better data to improve quality, to improve outcomes, and has made great strides in making that data available. macra included a provision that allows innovators to use qe data to help us make smarter decisions.
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do you agree that the medical devices used in care -- and i'll focus in on that -- particularly for the most common medicare procedure, joint replacements, play a role in health care quality and outcomes? medicare has no information on the medical devices implanted in medicare beneficiaries. i think we should let that settle in for a few seconds. extremely problematic, i think, from an oversight perspective, and most importantly, from a safety perspective. you and i have had discussions. there is a history here that we need to address. so, shouldn't this information be made available?
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administrator. >> thank you, congressman. so, the question you raise is really one of should there be -- and how should we capture a device identifier in a unique way on every device. and i think that's a goal that we share, it's a goal that the fda shares, and it's critical for postmarket surveillance to be able to understand the safety of how these devices work. so, there are several, i think, critical things that we can do and are doing and are trying to do to make this possible. so, despite our enthusiasm for this, and this is an issue that's long preceded me. as you know, it's been an issue for quite some time. there are a number of parties who have a say in the matter of how this happens. i think as a first step, we're moving forward with the incorporation of a unique device
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identifier into electronic health records. i think this is a strong step, particularly considering the dramatic growth in electronic health records. but i know that there are also -- there is also an interest that on claim forms that there is a way for providers to provide care to indicate the device identifier on the claim form. we think that also has merit, particularly from a research perspective. i think there are a couple of issues to making that a reality. one is the committee that essentially designs the claim form, which is made up of a wide group of participants and hospitals and physician groups. second is making sure that if we at cms are given the charge to do this that we can fund it and have the funds to do it operationally. and then the third, there will be an education and training process, because the history is
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that physicians don't automatically put the information they need to down on a form unless it's critical to them getting paid. so i think we need to work through all of these issues with you. we've pledged to do this with your office and we're working closely with the fda to find the best path forward. >> i think you've used the best word, critical. but if we don't do it this time, then we've got to wait another 15 years before we change those forms. and our seniors will not be well served. this is important. i've been frustrated with cms's resistance to what i believe is a very important priority, particularly of safety, including the unique device identifiers on health insurance claims. in order for udi to be added to the claims form as part of the next update, it would go into
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effect i think in 2021. that's the soonest. we need to act now. and i think -- i can't stress enough, mr. chairman, we're talking about the safety of the people who use these devices. and we all want to be on the same page. this is i think a good time for us to address this issue. number of cases, a number of stories about not only seniors, by the way, but we're talking about seniors here because we're talking about medicare, that have had the problems. and we need to address that in order to improve safety. i mean, everybody on this committee talks about it, and i believe them in their hearts. here's a chance for us to do something about it. but i want to thank you, mr. slavitt. you've done a great job. thank you for putting up with us, but we're not going away. thank you. >> thank you, congressman. >> thank you, mr. pascrell.
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ms. jenkins, you're recognized for five minutes. >> thank you, chairman. thank you, mr. administrator, for joining us today. medicare obviously plays an important role for many kansasans. it's the larger payer for medical services, an american life-saving benefit for many people. last year, over 485,000 kansans had health coverage through medicare. we were pleased macra passed last year in a bipartisan m manner. with the passage of macra, we repealed sgr and put in place what hopefully will be a better reimbursement system for physicians. mr. slavitt, the relationship between a physician and a beneficiary cannot be underscored in importance. and i believe this is especially true when talking about seniors. with the moves that macra makes towards higher-value care centered on the quality of care administered by clinicians, it's ever important to ensure that we encourage greater and greater communication around
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decision-making between the doctors and their patients. so, as macra's implementation continues over the next several years, do you see room to begin including patient activation measures, placing greater responsibility on this relationship with the hopeful result of shared responsibility over health care maintenance, and thus furthering the quality of care? >> yes. thank you, congresswoman, for that. i think that's a really important question, and i think there is an opportunity over the next several years to begin to incorporate those engagement measures in. there are a few things that are in the current proposal that i would point to that takes steps in that direction. one is there is a practice improvement focus opportunity on the creation of a joint care plan between a patient and a physician. secondly, in the advancing care information area, there are opportunities that focus on
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measures around how patients and physicians are communicating using technology and making sure that information's being made available to patients electronically and through other means. but i think this is a, as you point out, a ripe opportunity and a brand-new area of focus for more patient engagement. we have been meeting with a number of patient groups as we've been putting this work together, and that's an important area of feedback for us. >> all right. thank you, mr. chairman. i yield back. >> thank you. mr. davis is recognized for five minutes. >> thank you very much, mr. chairman. let me welcome you, mr. slavitt. i know that you spent considerable growing up time in effigyston, illinois, which isn't very far from my district. and i also know that your mother lives in my district. and i'm pleased to tell you that i have not had any real
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complaints from her. and so, that makes me feel good. >> that makes one of us. >> but let me compliment you on your work. madison is a very complex environment, and there's tremendous complexity. and i also want to thank your staff. i have 24 hospitals in my district, four large medical schools, a number of research institutions, and a very activated citizenry. so we get lots of inquiries, lots of calls for assistance, a lot of calls for clarification. and so, we spend considerable time not pestering, but certainly inquiring of your staff. and i want to thank them for the
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kinds of sensitivities they have displayed. i also have a very activated medical community, physicians associations and organizations. and just last week i had a meeting with the chicago medical society. but i've heard concerns that under the proposed rule that we're talking about, only a limited number of physicians will meet the alternative payment model or apm criteria to earn the payment bonus. by your own estimation, you have indicated that there may be only 30,000 to 90,000 physicians who meet these terms, which is a tiny fraction of the total medicare-eligible doctors in the country. and i'm certain that we'll hear some more from these physician
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groups. they'd like to know what could make it -- how likely is it that anything will make it easier for there to be more pathways to qualify for the apm bonus payments? and how can cms improve the opportunities for physicians to meet the advanced apm criteria and achieve the incentive to drive medicare that congress intended? and would you consider additional pathways that qualify as advanced apms to provide assistance for physicians who wish to enter the current model? >> thank you, congressman. and my mother made me promise to tell you that she was a teacher at howe and working with the
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principal who she knows knows you well. she wanted to make sure i said this publicly, so i've delivered that for my mother. >> thank you. >> and your question is an important question because it speaks to -- physicians, all physicians who participate in the medicare program are going to have a significant opportunity to get rewarded and get paid for providing quality medicine, which is exactly what we hear from physicians that they want. some physicians will have the opportunity to go further. and i think the law allows those physicians to get a 5% bonus if they participate in these advanced payment models. so, our goal is not just to make the core program good, but to create as many opportunities for physicians as possible to move into these programs. and we can do that a number of ways. one of the important ways to do
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that is to simply create more models and more opportunities. we also have to make it easy for people to move back and forth if they choose to between programs. and i think that's one of the things that we're striving to achieve. and then as we talked about earlier with dr. price, how do we -- we also have to look at are there ways we can take existing models and make them compliant with this new law? so, we are going to work on all three of those avenues, because it is a goal that for any physician that wants to move to one of these advanced care -- you know, advanced apm or care coordination models, that they have the opportunity to do so. >> thank you very much. thank you, mr. chairman. and i yield back. >> former mayor marchant of texas is recognized for five minutes. >> thank you, mr. chairman. mr. slavitt, does the cms have the resources to approve and implement the new alternative
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payment model proposals in a timely manner? >> thank you. so, i believe the question is can we implement new models in a timely manner. and one of the things that we have to do, and the answer is yes, we do. we need to, in concert with the committee that was set up by congress, the ptac, we need to receive proposals from physicians, because physicians can generate their own proposals for models and quality, and then work with them to as rapidly as possible test them and put them into action. it's one of the things that we have had the opportunity -- and we are eager to get going with this committee to get as many models in as possible so that we can get more and more models approved. and i had a chance to speak with that committee and speak in front of that committee to try
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to encourage more model development. >> there is a deadline period, so you're confident that you can get all that done by the deadline? >> well, this, fortunately, this is something that will be ongoing. so you know, as soon as we get models in, we can get them tested. but this committee i believe will be standing for a number of years. i'm not sure if we know the exact number of years, but it will be ongoing because physicians will be able to continue to develop new models. >> so the transition in governments that's coming up won't have any effect on this process? >> no. the committee -- the staff at cms will work with the new secretary, whoever that is, and continue moving that forward very much with that, and i think there is, as i've heard today and i think as we continue to hear, there is a strong bipartisan commitment and a strong commitment to this program and moving this forward, so i don't see any concerns at this point.
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>> and just some input. in my district, i hear from two different groups, and this is concerning the new program where you basically are, let's say a knee replacement or a hip replacement, you're basically going to fund a lump sum for that. i'm hearing from seniors who think that the doctors and hospitals are going to cut corners so that they'll make the most amount of profit and just hurry them through the system. and then i'm hearing from the doctors in the hospitals who are afraid that they don't -- they're not going to get enough money to take the kind of care of their patients that they need to take care of. so i guess you've created a pretty -- these two tensions that are working out there. could you just make a comment about that?
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>> sure. i think what you're referring to is a new type of payment approach, new for medicare, but it's been ongoing in health care for a long time. it's called bundled payment. >> yep. >> and really, the idea behind a bundled payment is so that people -- everyone who's involved in patient care, whether it's before they would have a surgery, the surgeon, the anesthesiologist, but also the people that take care of the patient afterwards have an alignment to get on the same page to provide a high-quality outcome and to do it as a team. and so, it's relatively new to medicare. we've had good experience, good feedback so far. but as with anything new, we continue to look for feedback, for data, for experiences, and in particular, if there are beneficiaries in your district or hospitals or physicians in your district that have experience with the program, we would love to get them from you or your staff. >> well, the group that i hear
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from the most is the in-home health care people who feel like they're kind of at the tail end of the process and that they may be the ones -- they feel like they're the most cost-effective of all, yet they feel like at the end of that process there may be some short-changing going on. >> thank you. >> okay. thank you. >> thank you. mr. lewis is recognized for five minutes. >> thank you very much, mr. chairman, for holding this hearing today. mr. administrator, thank you for being with us. thank you for all of your great and good work. can you talk more about what people on medicare might experience as a result of this change in payment policy, how the smaller provider groups will be impacted and the doctors who
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need help can get up to speed? >> thank you. so, i think the most important thing that we have an opportunity to focus on here is patient care and improving patient care. and i think the ways to do this are several fold. first is this new legislation allows us to pay physicians more for providing higher quality care. and the objective is to do this in a way which allows the physician to define what they believe to be the highest quality care from a menu of options and reward them for achieving those benchmarks. and i think physicians have been asking for that in one form or another for quite some time. secondly, though it's important to do that in a way that frees up physicians to actually practice medicine instead of just keeping score. too many programs result in a lot of paperwork and a lot of score-keeping, a lot of report
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'and we need to minimize that by simplifying wherever possible. the role of small physician practices, which you also mentioned, is critical here, and as we mentioned earlier, we believe that small, solo and solo practitioners have every opportunity to be just as successful as larger size practices, and our data suggests that that indeed happens so long as the smaller practices report. so that means we need to minimize paperwork. we've also put in place some accommodations for smaller practices, including some technical assistance, some additional models, and ways that they can get excluded from reporting if their volumes are too low. >> thank you. mr. administrator, this is a very large revelation, over 900 pages. that's pretty big.
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it's a lot to digest, a lot to understand. if you have to tell your doctor the highlights of these changes, what will you tell her? what would your doctor need to know to maximize benefits and avoid payment cuts? >> great. that's a great question, and it may be one of the most important things that i can communicate today. first of all, to keep focusing on patient care. there is nothing in here that should distract anybody from patient care. and in fact, it will make it easier by streamlining a patchwork of programs that are already out there today into something simpler. so, that's first. second is they'll have the opportunity to select goals that they believe are right for their practice, right for their patient population, and at some point in time, they'll have the opportunity to do that. third i think would be that over time there will be opportunities for them to participate in more
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advanced models, like the kinds you asked me about earlier. fourth is they don't need to really worry about reporting anything until spring of 2018, and we will make it clear what needs to be done well before then. and then finally, the last thing, and this is more of my ask of them, is to provide feedback, whether it's to this rule, whether it's through the medical society they belong to, the state medical society, directly to us. we really need line physicians who are practicing medicine every day to give us their feedback on what works about this rule and what might be the unintended consequences. >> thank you very much. and again, i appreciate your effort, your good work, and thank you for being willing to serve. >> thank you. >> mr. chairman, i yield back. >> thank you, mr. lewis. mr. paulsen is recognized for five minutes. >> thank you, mr. chairman. mr. slavitt, great to see you here.
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welcome. rather than on a airplane, going back and forth to minnesota. as has already been said, last year both sides took very historic action to move forward, finally get rid of the flawed medicare payment formula based on the sgr, and then wonder if we're going to fix it every six months or every year. and like any law, passage is just the first step, right? it's the implementation that has to be carried out and followed through. and so, and making sure it's done correctly and so that we're achieving the intended results. i want to thank you at the outset for working with patients, working with physicians, having that connecting dialogue with all of the appropriate stakeholders, including members of the committee, to making sure we're implementing in the correct fashion. i want to continue on the common theme and just mention at the outset that it is important to know that i continue to hear from folks back in minnesota as well that aren't in large, integrated practices, solo practices, small group practices, et cetera, that do have that concern. and as you mentioned, you want to make sure that they have every opportunity to participate. i think they want that reassurance. and we just kind of need to keep
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monitoring that going forward, and i thank you for that. let me ask you this question. i've also heard from a lot of physicians and doctors in minnesota about the meaningful use program for electronic health records and how it doesn't do a very good job of taking into account the way physicians treat patients and use their electronic health care records. this rule the same old same old, or do you make real changes in how you are going to be encouraging doctors now to actually use their electronic health care records? >> thank you, congressman. and i would agree that our district practices some of the best medicine. the meaningful use program is something that we took an extremely hard look at. we took a step back. because the meaningful use program actually is responsible for helping to make technology pervasive in medicine. and that's a very good thing. we look back five or six years ago, most physician offices, most hospitals didn't have
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adequate information technology. today, by and large, 97% of hospitals, 70% of physician practices have technology. but as we look at how to go forward, we spend a lot of time talking to physicians and hearing exactly what you said, congressman, which is that the meaningful use program was focusing on making sure that we're using their computers and not focusing on taking care of patients. we also heard that physicians want their technology to be more connected. they want to be able to get information back and forth from other physicians when they refer patients or from hospitals. and they're also frustrated that there isn't enough connectivity and the data doesn't flow as easily as it should. and so, we've been asked to focus on it, and i believe have focused on in this rule changing the program so it becomes much more flexible, moves the focus to the patient, away from the use of the technology, focuses on interaction and communication and allowing the free flow of
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data to move back and forth. and those are the areas that we emphasized. we look forward to comments during the comment period about whether or not we've done that well. >> does it seem like the proposed rule, you know, replacing meaningful use with this new category, advancing care information. we have all these different acronyms. but accounting for 25% of a physician's performance score in the first year, is that going to essentially be interoperability now for electronic health care information for vendors, hospitals, all of the actors, players, physicians and other providers? is that that intent that that information will be that widely shared that readily available, not just on the computer, but actually using the information? >> right, that is the intent. i'll tell you, everybody has a job to do in that regard. if any of us here could wave our magic wand and make the health care system more interoperable, i think we'd do it, but this really requires vendors to share data, to publish who what they call open apis, to not practice
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data-blocking, which the congress has expressly asked that vendors not do. and physicians to a large extent are really a victim of what the technology allows. they all want to share data. i have not met a physician who when they refer a patient doesn't want to know what happened to that patient and get that back electronically. but it's the technology that really needs to do that job we think in the ehr certification that just came out and in a number of the other activities we think vendors are going to move in that direction. they need to move in that direction. >> good. thank you, mr. chairman. appreciate it. i yield back. >> thank you, mr. paulsen. thank you, mr. slavitt. one comment related to that is, we can discuss this morning. as you develop a final rule and the performance period begins on january of 2017, vendors are going to have a limited time to
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reconcile with this new rule. then physicians are going to have to digest the new rule. so i hope that, again, particularly for the small group, rural markets, i hope that you'll work with us to make sure that that implementation is done smoothly. and related to that, i don't know if you think you have some authority in this area. so, the gap of time between performance period and then the payment year for physicians is two years. yet, the clinician reporting period is a shorter period of time. do you think cms has the ability through rulemaking, the authority to change that a little bit? >> yep. so, one of the things we do see comment on are the proposed measurement periods and naming
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periods. what i will say is a couple things. one is we have two feedback periods built in so that -- one in the middle of 2017 and one in the middle of 2018, to provide information back to physicians. so there is a more current feedback loop. second thing i'd say is because we have focused so much on reducing burden and reducing the number of measures and so forth, we have had some feedback that people want to make sure that that starts as early as possible. we've had other feedback, of course, which tells us make sure we have enough time, make sure we have enough time to do the things we need to do, make sure we don't get penalized unnecessarily because we didn't have enough time. and to your earlier question, mr. chairman, if people will begin on the older technology and move to the newer technology, they will not get penalized for that. so, we are making those accommodations. but of course, the purpose of the comment period is for people to tell us, what are the things we missed, what are the things
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that could have an impact on someone's practice or on their patients that we didn't think of. and that's one of the reasons why if there's an important message today to get out, it's to please engage in the rule and give us the feedback that we need to hear. >> well, i can't thank you enough for coming today. as you can tell, in a bipartisan way members have a lot of interest in this, and not just the subcommittee level but the committee as a whole as well as the congress. and we really appreciate you taking the time and look forward to working with you and your team as you continue to develop this, and ultimately, put it into process the way that we all intended it to be. >> right. >> and appreciate the fact that you were so kind yesterday as well. look forward to working with you. hopefully, we've treated you nice enough that you'll come back as we have this bipartisan concern about the way this unfolds. so, as a reminder, any member
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wishing to commit a question for the record will have 14 days to do so. if any members submit questions after the hearing, i ask that the witnesses respond in writing in a timely manner. with that, again, thank you, again, and this committee is adjourned. >> thank you.
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this weekend, road to the
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white house coverage of the libertarian convention in orlando, florida. on saturday, we'll have a debate with the presidential candidates live at 8:00 p.m. eastern. and on sunday, beginning at 9:45 a.m. eastern, live coverage of the nomination process, delegate votes for the candidates and victory speeches. that's all this weekend on c-span. in addition to the graduating classes all over this god's planet. i wish you be graduating into a world of peace, light and love, but that's not the case. we don't live in a fairy tale, but i guess the 1% does. >> this memorial day, watch commencement speeches in their entirety, offering advice and encouragement to the graduating class of 2016 from business leaders like ncta president michael powell at pepperdine university, founder of oracle, larry ellison, at the university
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of southern california, and maria contreras-sweet, administrator of the small business administration at whittier college. >> you can count on yourself. what makes you special? what distinguishes you from others? in business, we call it your unique value proposition. figuring out yours is key. >> politicians. senator jeff sessions at the university of alabama in huntsville. senator barbara boxer at the university of california berkeley. and governor mike pence at indiana wesleyan university. >> to be strong and to be courageous and to learn to stand for who you are and what you believe is a way that you've changed here and will carry into the balance of your life. >> and white house officials. vice president joe biden at the university of notre dame, attorney general loretta lynch at spelman college, and president barack obama at rutgers university. >> is it any wonder that i am
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optimistic? throughout our history, a new generation of americans has reached up and bent the arc of history in the direction of more freedom and more opportunity and more justice. and class of 2016 it is your turn now to shape our nation's destiny as well as your own so get to work. commencement speeches this memorial day at 12:00 eastern. it's just over an hour. as one of only two research institute in the nation dedicated to the exploration of
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anti-semitism. the institute has made the institute made invaluable contributions to the community by bringing leading scholars and activists to campus from all parts of the globe to share their experiences, expertise and perspectives. this week's conference alone has brought some 70 scholars from 16 different countries to our campus. and this is the third such international conference sponsored by the institute in the past five years. in short, the efforts of the professor and all those who work with the institute have established bloomington as a worldwide hub for the study of anti-semitism and equally as important a hub for a global community of individuals dedicated to the enduring power
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of diversity and inclusion. this evening i'm delighted to continue this tradition by welcoming back to our campus ir u win cotler to deliver our address. he has served various roles in the canadian government, including a as member of parliament, minister of justice and attorney general. his career has been defined by a commitment to human rights and equality in all its fompls. in commitment has been evident in everything from his efforts to make the canadian supreme court the most gender representative in the world to his leadership of the canadian delegation to the stockholm
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conference on the prevention and combatting of genocide. further more professor cotler distinguished himself as an international human rights lawyer serving as council of prisoners of conscience who include notable figurings as nelson mandela, and andre, a former lecturer of the former soviet union. he testified as an expert witness on human rights and government assemblies around the world including the united states, russia, sweden and israel. his advocacy for human rights reminds us of the powerful words
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of dr. martin luther king. in justice anywhere is a threat to justice everywhere. most recently his lifelong commitment to human rights led to the creation of the wallen berg center for human rights named after the swedish diplomat who saved thousands of jews from the nazis during world war ii. only to tragically disappear after being captured by soviet forces in 1945. as you might expect from his leadership, the center has a distinctly international scope. focusing on issues of pressing contemporary importance such as human rights in iran. his work brought him to the summit for human rights and democracy. we're so pleased that his work brings him back to university bloomington. join me in welcoming professor irwin cotler.
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[ applause ] >> thank you for that warm and heartwarming introduction. when i come to indiana amongst such a community of scholars, i feel very much at home. i have to say that i'm particularly moved to participate in the visiting scholars program because as i mentioned to both of them, just before coming in here, they have been heroes of my wife. my wife was a parliamentary secretary, but very close to the former prime minister.
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so for me this is an unexpected connection, but a very, very welcome one on a personal as well as a scholarly basis. i want to as well join in the tribute to professor alvin he is a model of moral and intellectual leadership. he is made of this conference, this gathering of international scholars. the preeminent gathering of its kind internationally. he made it the institute of the contemporary study of anti-semitism, a preeminent institute in that regard. also his work reminds me of something. if you'd pardon me, that is the
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debt that i owe to my parents of the blessed memory. and the reason for that who taught me when i was a young boy before i understood the profundity of his remarks when he would say to me repeatedly to all the other commandments combined. this as he put it you must teach on to your children. but it was my mother who when she would hear my father saying this would say to me that if you want to pursue justice, you have to understand, you have to feel the injustice about you. you have to go in and about your community and beyond and feel the injustice and combat the injustice.
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the great human rights of the second half of the 20th century. the struggle for human rights and during the former soviet union and apartheid who became the face and identity and vision of those struggles. and nelson mandela in south africa. but the reason i'm mentioning this and connecting it to alvin is because his work with respect to the scholarly inquiry and the moral intellectual leadership that he's providing is really not just the struggle against anti-semitism, but in the larger sense of the word, the struggle
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against injustice. that is what brings us together. that is what my mother would have liked to have seen us do as part of my father's call to justice but my mother's warning by combatting injustice. and that is what we are doing in convening as we are today. so i'm pleased to share u with you this evening some thoughts, some concerns, some reflections, and, yes, even some hope. someone said am i going to be adding to that bruting presence that we have been hearing about the shadows of anti-semitism, the dangers, the threats, the terror and the like. but i want to say that i'm also hoping to end on a hopeful ending. and i'm encouraged by the fact that we do have these gatherings of scholars coming together. so our struggle then is not
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anned a miezed struggle, but we come together in common cause here and beyond. so invest that context that i want to share these remarks with you this evening about the jewish condition and the human condition. about assault on jews and assaults on human rights. about the state of jews in the world today and the state of the world inhabited by jews. about anti-semitism not only being the oldest and most enduring of hatreds. i would say the paradigm of radical hatred is the paradigm of radical evil. but the most toxic, the most lee thal as our colleague put it.


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