Public Safety Officer Family Health Benefits Act

H.R.3962, Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 H.R.3590, Patient Protection and Affordable Care Act H.R.3162, Public Safety Officer Family Health Benefits Act H.R.5902, Direct Care Workforce Empowerment Act S.J.Res.39, A joint resolution providing for congressional disapproval under chapter 8 of title 5, United States Code, of the rule relating to status as a grandfathered health plan under the Patient Protection and Affordable Care Act Issues related to health care reform and quality measurement Prescription Drug User Fee Act renewal, provisions related to direct consumer advertising and consumer protections Issues related to FDA reform and drug importation FDA user fee budget proposal, issues related to user fees for reinspections

Client expense: $40,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Centers For Disease Control & Prevention (CDC), Consumer Product Safety Commission (CPSC), Energy, Dept of, Environmental Protection Agency (EPA), Federal Communications Commission (FCC), Federal Deposit Insurance Corporation (FDIC), Federal Trade Commission (FTC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Natl Highway Traffic Safety Administration (NHTSA), Office of Science & Technology Policy (OSTP), SENATE, Transportation, Dept of (DOT), Treasury, Dept of, White House Office

Insurance Market Reform: Healthy Choice Act; MLR; Guaranteed Issue; HSAs / Dependent Health Insurance Coverage Comparative Effectiveness Research HR. 3162 - Federal Regulatory functions - Anti-Trust and McCarran-Ferguson State Oversight of Premiums S. 3078 HR. 4757 HR 4700/ Transparency PL-111-148 Implementation "good faith compliance standards"

Client expense: $50,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Financial Sevices Legislation and tax legislation. H.R. 3162-To establish the Consumer financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring American Financial Stability Act of 2010. Tax Simplification. Return Free-Filing. Refund Anticipation Loans (RALs). Legislation concerning access to the Federal Debt Indicator. Policies related to the unbanked.

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Sevices Legislation and tax legislation. H.R. 3162-To establish the Consumer financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring American Financial Stability Act of 2010. Tax Simplification. Return Free-Filing. Refund Anticipation Loans (RALs). Access to the Debt Indicator.

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Sevices Legislation and tax legislation. H.R. 3162-To establish the Consumer financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring American Financial Stability Act of 2010. Anticipation Loans (RALs). Access to the Debt Indicator.

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Insurance Market Reform: Healthy Choice Act; MLR; Guaranteed Issue; HSAs / Dependent Health Insurance Coverage Comparative Effectiveness Research HR. 3162 - Federal Regulatory functions - Anti-Trust and McCarran-Ferguson State Oversight of Premiums S.3078 HR. 4757 HR 4700/Transparency PL-111-148 Implementation "good faith compliance standards"

Client expense: $40,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Financial Services legislation and tax legislation. H.R. 3162- To establish the Consumer Financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring America Financial Stability Act of 2010. Tax Simplification. Return Free-Filing. Refund Anticipation Loans (RAL).

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Services legislation and tax legislation. H.R. 3162- To establish the Consumer Financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring America Financial Stability Act of 2010. Tax Simplification. Return Free-Filing. Refund Anticipation Loans (RAL). Consumer Protection Legislation.

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Services legislation and tax legislation. H.R. 3162- To establish the Consumer Financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring America Financial Stability Act of 2010. Tax Simplification. Return Free-Filing. Refund Anticipation Loans (RAL).

Client expense: $500,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Services legislation and tax legislation. H.R 3162- To establish the Consumer Financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring American Financial Stability Act of 2010. Tax simplification.

Client expense: $400,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Financial Services legislation and tax legislation. H.R 3162- To establish the Consumer Financial Protection Agency. S. 414- To establish the Consumer Credit Protection Act. Tax Preparer Regulation legislation. H.R. 4173- Wall Street Reform and Consumer Protection Act of 2009; Restoring American Financial Stability Act of 2010. Tax simplification.

Client expense: $400,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, Internal Revenue Service (IRS), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the PGP demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. These provisions were included in Subtitle D of the House Bill, HR 3962, the Affordable Health Care for America Act, and in 6002 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. These provisions were included in Section 1123 of the House Bill, HR 3962, the Affordable Health Care for America Act. Medicare Payment Improvement Act of 2009, HR 2844. To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as "fee-for-service," and incentivizes the number of services performed. The Braley bill shifts this to "value-based care," and incentivizes high quality care and low costs. This proposal will transition our current "quantity-based system" to a "quality-based system." Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader 'Quality Coalition,' who have been pushing for a 'value index' in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- "Instruct IOM to study how to implement a 'value index' in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. "After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote "high-value care," defined as the "efficient delivery of high quality, evidence-based, patient-centered care." "The Secretary will then submit a 'plan of implementation' to the Congress, to implement the recommendations of the IOM. "Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity- "In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. "Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. "A "Medicare Improvement Fund" is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. "In 2012 and 2013, a 'Hold Harmless' will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The 'Hold Harmless' expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration. The Reconciliation Act of 2010, HR 4872, introduced by Rep. John Spratt included Section 1108 amending Section 3102 of the Patient Protection and Affordable Care Act, which increase the practice expense component of Medicare physician payment in localities that are below the mean of costs nationwide, effective January 1, 2010.

Insurance Market Reform: Healthy Choice Act; MLR; Guaranteed Issue;HSAs Comparative Effectiveness Research HR. 3162 - Federal Regulatory functions - Anti-Trust and McCarran-Ferguson TAA HR. 3801 and S. 1848 / Genetic Non Discrimination HR. 493 and S. 358 Patient Protection and Affordability Act HR. 3590 - HealthCare & Education Affordibility Reconcilliation Act 0f 2010

Client expense: $40,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Medicare Patient Access to Physical Therapists Act [H.R.1552/S.932]; Children's Health and Medicare Protection Act [H.R.3162]; Medicare Access to Rehabilitation Services Act [S.450/H.R.748]; Medicare Access to Physical Medicine and Rehabilitation Services Improvement Act [H.R.1846]; Long-term Care Quality and Modernization Act [H.R.4082]

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Labor, Dept of (DOL), SENATE

Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; bonus payments for efficient providers; bonus payments for primary care providers; establishment and funding of comparative effectiveness research; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the PGP demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; and opposition to the establishment of a public option in Health Insurance Exchanges if it were to reimburse providers at Medicare rates. Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. These provisions were included in Sections 1159 and 1160 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3007 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. These provisions were included in Sections 1161 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3201 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the it HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. These provisions were included in Sections 1157 and 1158 and 1194 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. These provisions were included in Sections 1157 and 1158 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 3102 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. These provisions were included in Sections 1401 of the House Bill, HR 3962, the Affordable Health Care for America Act, and in section 6301 and 6302 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. These provisions were included in Subtitle D of the House Bill, HR 3962, the Affordable Health Care for America Act, and in 6002 of the Senate Bill HR 3590, the Patient Protection and Affordable Care Act. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and as a candidate for appointment to the Medicaid and CHIP Payment and Access Commission (MACPAC) in 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. These provisions were included in Section 1123 of the House Bill, HR 3962, the Affordable Health Care for America Act. Medicare Payment Improvement Act of 2009, HR 2844. To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as fee-for-service, and incentivizes the number of services performed. The Braley bill shifts this to value-based care, and incentivizes high quality care and low costs. This proposal will transition our current quantity-based system to a quality-based system. Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader Quality Coalition, who have been pushing for a value index in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- Instruct IOM to study how to implement a value index in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote high-value care, defined as the efficient delivery of high quality, evidence-based, patient-centered care. The Secretary will then submit a plan of implementation to the Congress, to implement the recommendations of the IOM. Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. A Medicare Improvement Fund is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. In 2012 and 2013, a Hold Harmless will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The Hold Harmless expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. CMS Physician Group Practice Demonstration Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

Insurance Market Reform and Healthy Choice Act Comparative Effectiveness Research HR. 3162 TAA HR. 3801 and S. 1848 / Genetic Non Discrimination HR. 493 and S. 358 Patient Protection and Affordability Act HR. 3592

Client expense: $50,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Insurance Market Reform and Healthy Choice Act Mental Health Parity Comparative Effectiveness Research HR. 3162 TAA HR. 3801 and S. 1848 Genetic Non Discrimination HR. 493 and S. 358

Client expense: $50,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Program Marshfield Clinic has concerns about payment projections and policy changes outlined by the Centers for Medicare and Medicaid Services in its Advance Notice of Methodological Changes for Calendar Year 2010 for Medicare Advantage Capitation Rate and Part C and Part D Payment Policies, dated February 20, 2009. Our first concern is that the national per capita growth rate projected in CMSs Advance Notice deviates significantly from the growth rate health plans are experiencing. CMSs projection is based in large part on an unrealistic assumption that Medicare fee-for-service payments for physician services will be cut by 21% this year. However, since 2003, previously scheduled fee reductions have been overridden by Congress. Secondly, an across-the-board 3.74% reduction for risk score coding patterns for all health plans appears quite large. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. Medicare Payment Improvement Act of 2009 H.R.2844 : To amend title XVIII of the Social Security Act to create a value indexing mechanism for the physician work component of the Medicare physician fee schedule. Introduced by Rep. Ron Kind and Bruce Braley. Goal: To increase quality of health care in America and decrease cost. The Medicare Payment Improvement Act will fundamentally restructure the Medicare payment system by finally providing an incentive for physicians to provide high quality care. The bill eliminates a geographic adjuster (Work Geographic Practice Cost Index) from Medicare, and replaces it with a figure that measures Value. The value figure measures both quality of care and cost of care. Regions that provide high quality care at low cost will see their Medicare reimbursements increase. Regions that provide low quality care at high cost will see their reimbursements decrease. The current structure of Medicare is known as fee-for-service, and incentivizes the number of services performed. The Braley bill shifts this to value-based care, and incentivizes high quality care and low costs. This proposal will transition our current quantity-based system to a quality-based system. Rep. Braley introduced HR 2201, the Medicare Equity & Accessibility Act. This bill would increase Medicare Part B reimbursement rates in Iowa, by placing a floor on the geographic adjuster (GPCI) that is part of the Part B formula. The bill would have the effect of increasing Part B reimbursements in Iowa and other rural states every time a health care provider sees a patient under Part B. Rep. Braley and others supporting the Medicare Payment Improvement Act including Reps. Kind, Inslee, and McCollum, who were representing a much broader Quality Coalition, who have been pushing for a value index in the Medicare Part B reimbursement equation to measure quality and efficiency of care. This provision includes the following: Quality-Based Care-- Instruct IOM to study how to implement a value index in the Medicare payment system. They will consider geographic differences, access to care, measures of quality, and the role of incentives to impact quality and efficient outcomes of care. After a set two-year timeframe, IOM will make recommendations to the Secretary of HHS on how to specifically change the Medicare payment system to promote high-value care, defined as the efficient delivery of high quality, evidence-based, patient-centered care. The Secretary will then submit a plan of implementation to the Congress, to implement the recommendations of the IOM. Congress will have a finite amount of time to pass a joint resolution of disapproval. If Congress fails to act, or if the recommendations are not expressly disapproved by both Chambers, then the recommendations of the IOM will be implemented, thereby reforming the Medicare payment system to incentivize high-value care. Addressing Geographic Disparity In addition, the deal resulted in substantive action to address geographic disparity in Medicare payments. IOM will do another study, completed within a year after enactment, to determine whether the data and assumptions used to determine the geographic adjusters (Geographic Practice Cost Indexes and Wage Index) are accurate, or based on flawed data. Many believe the factors that determine these indexes are based on flawed data. Upon completion of the study (within one year), the Secretary will take immediate action to adjust the GPCIs and Wage Index to ensure they are based on accurate data. A Medicare Improvement Fund is established, which will consist of $8 billion. From this fund, payments will immediately be made in 2012 and 2013, to ensure the money is there for regions who see an increase in their reimbursement due to the adjusted GPCIs and Wage Index. In 2012 and 2013, a Hold Harmless will exist to ensure that payments do not decrease in any region as a result of these more accurate measurements. The Hold Harmless expires after 2013, to allow budget neutrality for all appropriate shifts that must be made due to correcting the data in the long-term. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments.

Children's Health and Medicare Protection Act (H.R.3162) Medicare Improvements for Patients and Providers Act (H.R.6331)

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE

Children's Health and Medicare Protection Act (H.R.3162) Medicare Improvements for Patients and Providers Act (H.R.6331)

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE

Medicare Patient Access to Physical Therapists Act [H.R.1552/S.932]; Children's Health and Medicare Protection Act [H.R.3162]; Medicare Access to Rehabilitation Services Act [S.450/H.R.748]; Medicare Access to Physical Medicine and Rehabilitation Services Improvement Act [H.R.1846]; Long-term Care Quality and Modernization Act [H.R.4082]

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Labor, Dept of (DOL), SENATE

Medicare Patient Access to Physical Therapists Act [H.R.1552/S.932]; Children's Health and Medicare Protection Act [H.R.3162]; Medicare Access to Rehabilitation Services Act [S.450/H.R.748]; Medicare Access to Physical Medicine and Rehabilitation Services Improvement Act [H.R.1846]; Long-term Care Quality and Modernization Act [H.R.4082]

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Labor, Dept of (DOL), SENATE

Health Care Reform (No Bill Numbers) Health Equity and Accountability Act H.R. 3090 S.RES.148, Expressing the sense of the Senate that there is a critical need to increase research, awareness, and education about cerebral cavernous malformations Policy option to address infant mortality in Senate HCR bill (No Bill Numbers) Oral health services are an integral part of health reform (No Bill Numbers) The elimination of racial and ethnic health disparities is a core component of the health reform measure that is signed into law Tri-Caucus letter to Pelosi, Reid, Obama (No Bill Numbers) E.O. 13166 & other language access issues (HHS) Revamp the Office of Civil Rights (HHS) Address Section 440 of PRWORA (HHS) Regulations on Mandatory HPV Vaccination (HHS) Implementation of the following laws through agency review: Community Health Workers Act (S. 586, H.R. 1968) Legal Immigrant Childrens Health Improvement Act (S. 764, H.R. 1308) Childrens Health and Medicare Protection Act (H.R. 3162) Children's Health Insurance Program Reauthorization Act of 2007 (S. 1893, H.R. 976) Health Equity and Accountability Act of 2007 (H.R. 3014) Minority Health Improvement and Health Disparity Elimination Act (S.1576, H.R. 3333)

Client expense: $120,000 · Firm income: Not reported

Insurance Market Reform and Healthy Choice Act Mental Health Parity HIT: Standards, ICD-10 Implementation HR. 1368 Wired for Health Care Act S. 1783 and S. 1693 Comparative Effectiveness Research HR. 3162 TAA HR. 3801 and S. 1848 Genetic Non Discrimination HR. 493 and S. 358

Client expense: $50,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). Value Index Rewarding Value in the Reimbursement System Congress must introduce a value index into Medicare Parts A and B, to reward physicians and hospitals who provide safe, high quality care with excellent service to Medicare patients at a reasonable cost. The value index can be constructed for many types of payment models, including hospital DRG payments, physician fees, payment updates, and other payment formulas. We recommend that the geographic adjustment of physician work should be eliminated as recommended in legislation introduced by Senator Feingold (S 712) and Senator Grassley (S 318), and replaced with a quality/efficiency based coefficient for physician work as soon as possible. Legislation that we strongly support and would accomplish this objective, has been introduced by Iowa Rep. Bruce Braley and Wisconsin Rep. Ron Kind in the House and by Minnesota Senator Amy Klobuchar and Wisconsin Senators Feingold and Kohl in the Senate. The Medicare Payment Improvement Act (HR 2844, S 1249) seeks to reform the Medicare system to one that rewards the value of care over quantity of procedures, improving quality and lowering the total cost of care over time. The bills outcome-based approach creates the incentive for physicians and hospitals to work together to improve quality and use resources efficiently. Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Program Marshfield Clinic has concerns about payment projections and policy changes outlined by the Centers for Medicare and Medicaid Services in its Advance Notice of Methodological Changes for Calendar Year 2010 for Medicare Advantage Capitation Rate and Part C and Part D Payment Policies, dated February 20, 2009. Our first concern is that the national per capita growth rate projected in CMSs Advance Notice deviates significantly from the growth rate health plans are experiencing. CMSs projection is based in large part on an unrealistic assumption that Medicare fee-for-service payments for physician services will be cut by 21% this year. However, since 2003, previously scheduled fee reductions have been overridden by Congress. Secondly, an across-the-board 3.74% reduction for risk score coding patterns for all health plans appears quite large. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense. Practice Expense Payment Floor Congress must require the Centers for Medicare & Medicaid Services (CMS) to administratively revise its measurement of the cost of practice to assure the validity and fairness of payment. However, in the interim, a payment floor must be established for practice expense to stem the inequities of the current methodology as proposed by Reps. Braley and Kind in HR 2201, the Medicare Equity and Accessibility Act of 2009. Extreme variation induced by errors in the payment methodology may also be reduced without compromising the relativity of payment by establishing a geographic practice expense index that limits to the difference between relative wages and rents between fee schedule areas and the national average as proposed by Senator Grassley in S 318. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments.

Reimbursement Issues Medicare/Medicaid Issues - H.R. 3162: Children's Health and Medicare Protection Act H.R. 6331: Medicare Improvement for Patients and Providers Act of 2008

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Children's Health and Medicare Protection Act (H.R.3162) Medicare Improvements for Patients and Providers Act (H.R.6331)

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE

Medicare Patient Access to Physical Therapists Act [H.R.1552/S.932]; Children's Health and Medicare Protection Act [H.R.3162]; Medicare Access to Rehabilitation Services Act [S.450/H.R.748]; Medicare Access to Physical Medicine and Rehabilitation Services Improvement Act [H.R.1846]; Long-term Care Quality and Modernization Act [H.R.4082]

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Labor, Dept of (DOL), SENATE

S1893 - State Children's Health Insurance Program HR976/HR3963 - State Children's Health Insurance Program HR3162 - State Children's Health Insurance Program

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Reimbursement Issues Medicare/Medicaid Issues - H.R. 3162: Children's Health and Medicare Protection Act H.R. 6331: Medicare Improvement for Patients and Providers Act of 2008

Client expense: Not reported · Firm income: $20,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Insurance Market Reform and Healthy Choice Act Mental Health Parity HIT: Standards, ICD-10 Implementation HR.1368 Wired for Health Care Act S.1783 and S.1693 Comparative Effectiveness Research HR.3162 TAA HR.3801 and S.1848 Genetic Non Discrimination HR.493 and S.358 Michelle Law HR.2851 and S.400 SCHIP HR.976 and HR.3963 "Extension Bill" HR.6357 Pro (Tech) Act of 2008

Client expense: $40,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

HR 976, S 1893, HR 3162, S 2499, SCHIP Reauthorization, Support passage of an expansion to include oral health benefits for children Monitor health care reform proposals

Client expense: Not reported · Firm income: $60,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). General Issue Area Code MMM (Medicare and Medicaid) Provisions of the FY 2010 Budget and Budget Resolution (S Con Res 13 and H C Res 85) regarding health care reform, funding for the Centers for Medicare and Medicaid Services (CMS) for implementation of the Medicare program and Medicare Advantage Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, value based purchasing and geographic fairness in Medicare reimbursement, a freeze in Medicare reimbursement updates for physician services, and comparative effectiveness research at the Agency for Health Research and Quality (AHRQ). Value Based Purchasing In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. According to a recent report by the Congressional Budget Office spending in high-spending regions could be reduced without producing worse outcomes, on average, or reductions in the quality of care. (CBO February 2008) Alternatives: Medicare must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Improve access to care in rural areas. The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Program Marshfield Clinic has concerns about payment projections and policy changes outlined by the Centers for Medicare and Medicaid Services in its Advance Notice of Methodological Changes for Calendar Year 2010 for Medicare Advantage Capitation Rate and Part C and Part D Payment Policies, dated February 20, 2009. Our first concern is that the national per capita growth rate projected in CMSs Advance Notice deviates significantly from the growth rate health plans are experiencing. CMSs projection is based in large part on an unrealistic assumption that Medicare fee-for-service payments for physician services will be cut by 21% this year. However, since 2003, previously scheduled fee reductions have been overridden by Congress. Secondly, an across-the-board 3.74% reduction for risk score coding patterns for all health plans appears quite large. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulas to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulas measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. Information Technology Under current law the capital and operating expenses of installing and maintaining electronic medical records (EMRs) are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS now obsolete measurement of physician practice expenses reflect minimal average expense associated with IT. Alternatives: Congress should provide incentives for EMR adoption, and/or utilization, and Establish standards to facilitate the sharing and exchange of data. CMS must update its mechanism for evaluating the cost of medical practice. Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Alternatives: The payment floor should be extended indefinitely; Geographic adjustment of work should be eliminated entirely; and replaced with a coefficient of quality and efficiency. Support Senator Feingolds bill, the Rural Medicare Equity Act, S 712. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments; A payment floor could be established for practice expense; or Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley in the 110th Congress to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley 110th Congress to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments.