Patient Centered Healthcare Savings Act of 2011

The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; establishment and funding of comparative effectiveness research; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; 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 CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations: Medicare and other payors 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. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. 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. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage 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. Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. 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 formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae 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. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2023, would be converted to a defined contribution program which has been described as a premium support program.

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

Government targets: Centers For Disease Control & Prevention (CDC), Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), SENATE, White House Office

H.R. 2, Repealing the Job-Killing Health Care Law Act H.R. 4, Small Business Paperwork Mandate Elimination Act of 2011 H.R. 5, Protecting Access to Healthcare Act H.R. 436, Health Care Cost Reduction Act of 2012 H.R. 450, Restoring Assistance for Families and Seniors Health Expenses Act of 2011 H.R. 452, Medicare Decisions Accountability Act of 2011 H.R. 605 / S. 312, Patients Freedom to Choose Act H.R. 1051, Medicare Beneficiary Freedom to Choose Act of 2011 H.R. 1173, Fiscal Responsibility and Retirement Security Act of 2011 H.R. 1370, To repeal the annual fee on health insurance providers enacted by the Patient Protection and Affordable Care Act H.R. 1744 / S. 20, American Job Protection Act H.R. 2010, Family and Retirement Health Investment Act of 2011 H.R. 2077, MLR Repeal Act of 2011 H.R. 2112, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, Vitter Amendment (#769 - prescription drug reimportation) H.R. 2529, Restoring Access to Medication Act H.R. 2590, Seniors Protection Act of 2011 H.R. 2676, Small Business Health Relief Act of 2011 H.R. 3487, Job Creation Act of 2011 H.R. 3682, Patient Centered Healthcare Savings Act of 2011 H.R. 4095 / S. 2002, Online Pharmacy Safety Act H.R. 4626, Health Insurance Fair Competition Act H.R. 5141/S. 3578, Small Business Paperwork Mandate Elimination Act H.R. 5651, Food and Drug Administration Reform Act of 2012 H.R. 5842, Restoring Access to Medication Act of 2012 H.R. 5853, Fiscal Responsibility and Retirement Security Act H.R. 6048, Healthcare Tax Relief and Mandate Repeal Act H.R. 6079, Repeal of Obamacare Act S. 17, Medical Device Access and Innovation Protection Act S. 20, American Job Protection Act S. 223, FAA Air Transportation Modernization and Safety Improvement Act, including the Amendment offered by Senator McConnell to repeal P.L. 111-148, the Patient Protection and Affordable Care Act and an Amendment offered by Senator Stabenow which would repeal Section 9006 of the Patient Protection and Affordable Care Act S. 493, SBIR/STTR Reauthorization Act of 2011, including an Amendment offered by Senator Johanns which would fully repeal Section 9006 of the Patient Protection and Affordable Care Act and Amendment Number 197 offered by Senator Hutchison S. 510, FDA Food Safety Modernization Act, issues related to 1099 reporting amendments S. 668, Health Care Bureaucrats Elimination Act S. 720, Repeal the CLASS Entitlement Act S. 848, Consumer Information Enhancement Act of 2011 S. 1049, Small Business Health Relief Act of 2011 S. 1098, Family and Retirement Health Investment Act of 2011 S. 1368, Restoring Access to Medication Act S. 1880, Jobs and Premium Protection Act S. 2068, Access to Independent Health Insurance Advisors Act of 2012 S. 3187, Food and Drug Administration Safety and Innovation Act S. 3501, American Job Protection Act S. 3673, Patients Freedom Choice Act Filed comments and met with relevant agencies on regulations implementing health care reform (P.L. 111-148 and P.L. 111-152) Notice of Proposed Rulemaking and Notice of Public Hearing Regarding Fees on Health Insurance Policies and Self-Insured Plans for the Patient-Centered Outcomes Research Trust Fund (77 Fed. Reg. 22691-22706, Apr. 17, 2012) Notice and Request for Comments on Minimum Value of an Employer-Sponsored Plan (Notice 2012-31, Apr. 26, 2012) Request for Information Regarding Stop Loss Coverage (77 Fed. Reg. 25788-25790, May 1, 2012) Notice and Request for Comments on Reporting of Health Insurance Coverage (Notice 2012-32, May 14, 2012) Notice and Request for Comments on Reporting by Applicable Large Employers on Health Insurance Coverage Under Employer-Sponsored Plans (Notice 2012-33, May 14, 2012) Final Regulations on Health Insurance Premium Tax Credit (77 Fed. Reg. 30377-30400, May 23, 2012 (to be codified at 26 C.F.R. pts 1 and 602)) Notice and Request for Comments on Health Flexible Spending Arrangements (Notice 2012-40, May 30, 2012) Notice and Request for Comments on the Guidance on 90-Day Waiting Period Limitation (DOL Technical Release 2012-02, Aug. 31, 2012) Notice and Request for Comments on Determining Full-Time Employees For Purposes of Shared Responsibility for Employers Regarding Health Coverage (Notice 2012-58, Aug. 31, 2012) Various issues relating to the implementation of the Patient Protection and Affordable Care Act (P.L. 111-148), including implementation of regulatory process, legislative corrections, coverage, financing, delivery reform, 1099 reporting, grandfathering, CMS claims database, IPAB, CLASS program, employer mandate, medical loss ratio, mandated insurance requirements, medical malpractice reform, exchanges, Medicare reform, regulatory reform, essential health benefits package, health insurance tax, medical device tax, flexible spending accounts and health savings accounts, cost impact analyses, lack of quantified benefit analysis, and the need for empirical data sources on which to base cost and benefits; regulatory process and legislative corrections to Health Care and Education Affordability Reconciliation Act of 2010 (P.L. 111-152), including ERISA preemption and the impact on small business

H.R. 1996/S. 1061, the Government Litigation Savings Act, including provisions relating to the Equal Access to Justice Act H.R. 3682, the Sunshine for Regulatory Decrees and Settlement Act, including provisions relating to regulatory reform

Client expense: $223,091 · Firm income: Not reported

Government targets: Army, Dept of (Other), Defense, Dept of (DOD), Energy, Dept of, HOUSE OF REPRESENTATIVES, Natl Aeronautics & Space Administration (NASA), Office of Management & Budget (OMB), SENATE, U.S. Information Agency (USIA), White House Office

The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; establishment and funding of comparative effectiveness research; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; 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 CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations: Medicare and other payors 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. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. 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. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage 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. Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. 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 formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae 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. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2023, would be converted to a defined contribution program which has been described as a premium support program. 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 Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

Monitoring and lobbied issues related to medical malpractice reform; entire bills of the following: H.R.816, the Provider Shield Act of 2011 H.R.5 (H.RES.591, H.RES.596, H.R.3682, H.R.5652, S.12, S.218, S.1099), Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Monitoring and lobbied issues related to healthcare; entire bills of the following: H.R.816, the Provider Shield Act of 2011 H.R.5 (H.RES.591, H.RES.596, H.R.3682, H.R.5652, S.12, S.218, S.1099), Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 2, Repealing the Job-Killing Health Care Law Act H.R. 4, Small Business Paperwork Mandate Elimination Act of 2011 H.R. 5, Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011 H.R. 436, Protect Medical Innovation Act of 2011 H.R. 450, Restoring Assistance for Families and Seniors Health Expenses Act of 2011 H.R. 452, Medicare Decisions Accountability Act H.R. 605 / S. 312, Patients Freedom Choose Act H.R. 1051, Medicare Beneficiary Freedom to Choose Act of 2011 H.R. 1173 / S. 720, Fiscal Responsibility and Retirement Security Act of 2011 H.R. 1370 / S.1880, To repeal the annual fee on health insurance providers enacted by the Patient H.R. 1744 / S. 20, American Job Protection Act Protection and Affordable Care Act H.R. 2010, Family and Retirement Health Investment Act of 2011 H.R. 2077, MLR Repeal Act H.R. 2112, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, Vitter Amendment (#769 - prescription drug reimportation) H.R. 2529 / S. 1368, Restoring Access to Medication Act H.R. 2590, Seniors Protection Act of 2011 H.R. 2676, Small Business Health Relief Act of 2011H.R. 4095 / S. 2002, The Online Pharmacy Safety Act H.R. 3682, Patient Centered Healthcare Savings Act of 2011 H.R. 4095 / S. 2002, Online Pharmacy Safety Act H.R. 4626, Health Insurance Fair Competition Act H.R. 5141/S. 3578, Small Business Paperwork Mandate Elimination Act H.R. 5842 / S.1368, Restoring Access to Medication Act H.R. 5858, Health Savings Accounts Improvements Act of 2012 H.R. 5651, Food and Drug Administration Reform Act of 2012 H.R. 5853, Fiscal Responsibility and Retirement Security Act S. 1049, Small Business Health Relief Act S. 17, Medical Device Access and Innovation Protection Act S. 223, FAA Air Transportation Modernization and Safety Improvement Act, including the Amendment offered by Senator McConnell to repeal P.L. 111-148, the Patient Protection and Affordable Care Act and an Amendment offered by Senator Stabenow which would repeal Section 9006 of the Patient Protection and Affordable Care Act S. 312, Patients Freedom to Choose Act S. 493, SBIR/STTR Reauthorization Act of 2011, including an Amendment offered by Senator Johanns which would fully repeal Section 9006 of the Patient Protection and Affordable Care Act and Amendment Number 197 offered by Senator Hutchison S. 510, FDA Food Safety Modernization Act, issues related to 1099 reporting amendments S. 668, Health Care Bureaucrats Elimination Act S. 720, Repeal the CLASS Entitlement Act S. 848, Consumer Information Enhancement Act of 2011 S. 1049, Small Business Health Relief Act S. 1098, Family and Retirement Health Investment Act of 2011 S. 1880, Jobs and Premium Protection Act S. 2068, Access to Independent Health Insurance Advisors Act of 2012 S. 2516, Food and Drug Administration Safety and Innovation Act including amendments related to company market exclusivity S. 3187, Food and Drug Administration Safety and Innovation Act including amendments related to company market exclusivity S. 3501, American Job Protection Act S. 3673, Patients Freedom Choice Act Filed comments and met with relevant agencies on regulations implementing health care reform (P.L. 111-148 and P.L. 111-152) Regulations commented on include: Medical Loss Ratio (MLR) Request for Information; Adult Child Coverage (Age 26) Interim Final Rule; Grandfathered Plan Status Interim Final Rule; Preexisting Condition Exclusion; Lifetime & Annual Limits; Rescissions; Patient Protections Interim Final Rule; Preventive Services Coverage Interim Final Rule; Internal Claims & Appeals and External Review Processes Interim Final Rule; Preexisting Condition Insurance Plan (PCIP) Interim Final Rule; 1099 Reporting Requirements Request for Comments; Planning and Establishment of State-level Exchanges Request for Comments; Non-Discrimination in Favor of Highly Compensated Individuals Request for Comments; Essential Health Benefits (IOM Study); Amended Interim Final Rule for Grandfathered Plan Status; Guidance on OTC Medicine & Definition of Medical Expenses; Development of Health Risk Assessment; Medical Loss Ratio; Nondiscrimination in favor of Highly Compensated Individuals - second notice re: timing; DOL: Retrospective Review Under E.O. 13563; Treasury: Retrospective Review Under E.O. 13563; State Innovation Waivers; ACOs & Medicare Shared Savings Program; Shared Responsibility for Employers Regarding Health Coverage (Section 4980H); Amendment to the Interim Final Rule on Internal Claims and Appeals and External Review Processes; HIPAA Privacy Rule Accounting of Disclosures; Medical Data Sharing. Summary of benefits and Coverage and the Uniform Glossary; Exchange Functions in the Individual market; Health Insurance Premium Tax Credit; Establishment of Exchanges and Qualified Health Plans; Health Coverage Affordability Safe Harbor for Employers; Medical Loss Ratio (MLR) Requirements Final Rule; Medical Loss Ratio (MLR) Notice of Rebate Forms; Essential Health Benefits Bulletin - Response to Request for Comments; Establishment of Exchanges and Qualified Health Plans / Exchange Standards for Employers Final Rule and Interim Final Rule; FAQs from Employers Regarding Automatic Enrollment, Employer Shared Responsibility, and Waiting Periods Request for Comments; Notice 2012-31 Minimum Value of an Employer-Sponsored Plan Request for Comments; Notice 2012-32 Reporting of Health Insurance Coverage Request for Comments; Notice 2012-33 Reporting by Applicable Large Employers on Health Insurance Coverage Under Employer-Sponsored Plans Request for Comments. Comprehensive health reform (bills in the Senate and House) including all aspects relating to coverage, financing, and delivery reform, including: 1099 reporting, Grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS Act, employer mandate, medical loss ratio, mandated insurance requirements, Exchanges, Medicare reform, regulatory reform, Essential Health Benefits Package, Health Insurance Tax, and the Medical Device Tax Various issues relating to the Patient Protection and Affordable Care Act (P.L. 111-148), including implementation of regulatory process, legislative corrections, coverage, financing, delivery reform, 1099 reporting, grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS program, employer mandate, medical loss ratio, medical malpractice reform, exchanges, and flexible spending accounts and health savings accounts; regulatory process and legislative corrections to Health Care and Education Affordability Reconciliation Act of 2010 (P.L. 111-152) including ERISA preemption and the impact on small business; importation of foreign pharmaceuticals into the United States

The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; establishment and funding of comparative effectiveness research; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; 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 CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration into an accountable care organization program; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations: Medicare and other payors 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. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. 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. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage 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. Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. 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 formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae 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. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2023, would be converted to a defined contribution program which has been described as a premium support program. 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 Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013.

Monitoring and lobbied issues related to medical malpractice reform; entire bills of the following: H.R.816, the Provider Shield Act of 2011 H.R.5 (H.RES.591, H.RES.596, H.R.3682, H.R.5652, S.12, S.218, S.1099), Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Monitoring and lobbied issues related to healthcare; entire bills of the following: H.R.816, the Provider Shield Act of 2011 H.R.5 (H.RES.591, H.RES.596, H.R.3682, H.R.5652, S.12, S.218, S.1099), Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 2, Repealing the Job-Killing Health Care Law Act H.R. 4, Small Business Paperwork Mandate Elimination Act of 2011 H.R. 5, Protecting Access to Healthcare Act, including issues related to Med Malpractice and IPAB Reform H.R. 436, Protect Medical Innovation Act of 2011 H.R. 450, Restoring Assistance for Families' and Seniors' Health Expenses Act of 2011 H.R. 452, Medicare Decisions Accountability Act of 2011 H.R. 605 / S. 312, Patients Freedom Choose Act H.R. 1051, Medicare Beneficiary Freedom to Choose Act of 2011 H.R. 1173 / S. 720, Fiscal Responsibility and Retirement Security Act of 2011 H.R. 1370, To repeal the annual fee on health insurance providers enacted by the Patient Protection and Affordable Care Act H.R. 1744 / S. 20, American Job Protection Act H.R. 2010, Family and Retirement Health Investment Act of 2011 H.R. 2077, MLR Repeal Act of 2011 H.R. 2112, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, Vitter Amendment (#769 - prescription drug reimportation) H.R. 2529 / S. 1368, Restoring Access to Medication Act H.R. 2590, Seniors Protection Act of 2011 H.R. 2676, Small Business Health Relief Act of 2011 H.R. 3682, Patient Centered Healthcare Savings Act of 2011 H.R. 4095 / S. 2002, Online Pharmacy Safety Act H.R. 4626, Health Insurance Fair Competition Act H.R. 4853, Middle Class Tax Act of 2010 H.R. 5141/S. 3578, Small Business Paperwork Mandate Elimination Act H.R. 5853, Fiscal Responsibility and Retirement Security Act S. 17, Medical Device Access and Innovation Protection Act S. 223, FAA Air Transportation Modernization and Safety Improvement Act, including the Amendment offered by Senator McConnell to repeal P.L. 111-148, the Patient Protection and Affordable Care Act and an Amendment offered by Senator Stabenow which would repeal Section 9006 of the Patient Protection and Affordable Care Act S. 312, Patients Freedom to Choose Act S. 493, SBIR/STTR Reauthorization Act of 2011, including an Amendment offered by Senator Johanns which would fully repeal Section 9006 of the Patient Protection and Affordable Care Act and Amendment Number 197 offered by Senator Hutchison S. 510, FDA Food Safety Modernization Act, issues related to 1099 reporting amendments S. 668, Health Care Bureaucrats Elimination Act S. 720, Repeal the CLASS Entitlement Act S. 848, Consumer Information Enhancement Act of 2011 S. 1049, Small Business Health Relief Act S. 1098, Family and Retirement Health Investment Act of 2011 S. 1880, Jobs and Premium Protection Act S. 2068, Access to Independent Health Insurance Advisors Act of 2012 S. 3501, American Job Protection Act S. 3673, Patients Freedom Choice Act Filed comments and met with relevant agencies on regulations implementing health care reform (P.L. 111-148 and P.L. 111-152) Regulations commented on include: Medical Loss Ratio (MLR) Request for Information; Adult Child Coverage (Age 26) Interim Final Rule; Grandfathered Plan Status Interim Final Rule; Preexisting Condition Exclusion; Lifetime & Annual Limits; Rescissions; Patient Protections Interim Final Rule; Preventive Services Coverage Interim Final Rule; Internal Claims & Appeals and External Review Processes Interim Final Rule; Preexisting Condition Insurance Plan (PCIP) Interim Final Rule; 1099 Reporting Requirements Request for Comments; Planning and Establishment of State-level Exchanges Request for Comments; Non-Discrimination in Favor of Highly Compensated Individuals Request for Comments; Essential Health Benefits (IOM Study); Amended Interim Final Rule for Grandfathered Plan Status; Guidance on OTC Medicine & Definition of Medical Expenses; Development of Health Risk Assessment; Medical Loss Ratio; Nondiscrimination in favor of Highly Compensated Individuals - second notice re: timing; DOL: Retrospective Review Under E.O. 13563; Treasury: Retrospective Review Under E.O. 13563; State Innovation Waivers; ACOs & Medicare Shared Savings Program; Shared Responsibility for Employers Regarding Health Coverage (Section 4980H); Amendment to the Interim Final Rule on Internal Claims and Appeals and External Review Processes; HIPAA Privacy Rule Accounting of Disclosures; Medical Data Sharing. Summary of benefits and Coverage and the Uniform Glossary; Exchange Functions in the Individual market; Health Insurance Premium Tax Credit; Establishment of Exchanges and Qualified Health Plans; Health Coverage Affordability Safe Harbor for Employers; Medical Loss Ratio (MLR) Requirements Final Rule; Medical Loss Ratio (MLR) Notice of Rebate Forms Comprehensive health reform (bills in the Senate and House) - all aspects relating to coverage, financing, and delivery reform, including: 1099 reporting, Grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS Act, employer mandate, medical loss ratio, mandated insurance requirements, Exchanges, Medicare reform, regulatory reform, Essential Health Benefits Package, Health Insurance Tax; Medical Device Tax Various issues relating to the Patient Protection and Affordable Care Act (P.L. 111-148), including: implementation of, regulatory process, legislative corrections, coverage, financing, delivery reform, 1099 reporting, Grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS program, employer mandate, medical loss ratio, medical malpractice reform, exchanges, and flexible spending accounts and health savings accounts. Various issues relating to the regulatory process and legislative corrections to Health Care and Education Affordability Reconciliation Act of 2010 (P.L. 111-152); ERISA preemption; impact on small business

H.R. 2, Repealing the Job-Killing Health Care Law Act H.R. 4, Small Business Paperwork Mandate Elimination Act of 2011 H.R. 5, Protecting Access to Healthcare Act, including issues related to Med Malpractice and IPAB Reform H.R. 436, Protect Medical Innovation Act of 2011 H.R. 450, Restoring Assistance for Families' and Seniors' Health Expenses Act of 2011 H.R. 452, Medicare Decisions Accountability Act of 2011 H.R. 605 / S. 312, Patients Freedom Choose Act H.R. 1051, Medicare Beneficiary Freedom to Choose Act of 2011 H.R. 1173 / S. 720, Fiscal Responsibility and Retirement Security Act of 2011 H.R. 1370, To repeal the annual fee on health insurance providers enacted by the Patient Protection and Affordable Care Act H.R. 1744 / S. 20, American Job Protection Act H.R. 2010, Family and Retirement Health Investment Act of 2011 H.R. 2077, MLR Repeal Act of 2011 H.R. 2112, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, Vitter Amendment (#769 - prescription drug reimportation) H.R. 2529 / S. 1368, Restoring Access to Medication Act H.R. 2590, Seniors Protection Act of 2011 H.R. 2676, Small Business Health Relief Act of 2011 H.R. 3682, Patient Centered Healthcare Savings Act of 2011 H.R. 4095 / S. 2002, Online Pharmacy Safety Act H.R. 4626, Health Insurance Fair Competition Act H.R. 4853, Middle Class Tax Act of 2010 H.R. 5141/S. 3578, Small Business Paperwork Mandate Elimination Act H.R. 5853, Fiscal Responsibility and Retirement Security Act S. 17, Medical Device Access and Innovation Protection Act S. 223, FAA Air Transportation Modernization and Safety Improvement Act, including the Amendment offered by Senator McConnell to repeal P.L. 111-148, the Patient Protection and Affordable Care Act and an Amendment offered by Senator Stabenow which would repeal Section 9006 of the Patient Protection and Affordable Care Act S. 312, Patients Freedom to Choose Act S. 493, SBIR/STTR Reauthorization Act of 2011, including an Amendment offered by Senator Johanns which would fully repeal Section 9006 of the Patient Protection and Affordable Care Act and Amendment Number 197 offered by Senator Hutchison S. 510, FDA Food Safety Modernization Act, issues related to 1099 reporting amendments S. 668, Health Care Bureaucrats Elimination Act S. 720, Repeal the CLASS Entitlement Act S. 848, Consumer Information Enhancement Act of 2011 S. 1049, Small Business Health Relief Act S. 1098, Family and Retirement Health Investment Act of 2011 S. 1880, Jobs and Premium Protection Act S. 2068, Access to Independent Health Insurance Advisors Act of 2012 S. 3501, American Job Protection Act S. 3673, Patients Freedom Choice Act Filed comments and met with relevant agencies on regulations implementing health care reform (P.L. 111-148 and P.L. 111-152) Regulations commented on include: Medical Loss Ratio (MLR) Request for Information; Adult Child Coverage (Age 26) Interim Final Rule; Grandfathered Plan Status Interim Final Rule; Preexisting Condition Exclusion; Lifetime & Annual Limits; Rescissions; Patient Protections Interim Final Rule; Preventive Services Coverage Interim Final Rule; Internal Claims & Appeals and External Review Processes Interim Final Rule; Preexisting Condition Insurance Plan (PCIP) Interim Final Rule; 1099 Reporting Requirements Request for Comments; Planning and Establishment of State-level Exchanges Request for Comments; Non-Discrimination in Favor of Highly Compensated Individuals Request for Comments; Essential Health Benefits (IOM Study); Amended Interim Final Rule for Grandfathered Plan Status; Guidance on OTC Medicine & Definition of Medical Expenses; Development of Health Risk Assessment; Medical Loss Ratio; Nondiscrimination in favor of Highly Compensated Individuals - second notice re: timing; DOL: Retrospective Review Under E.O. 13563; Treasury: Retrospective Review Under E.O. 13563; State Innovation Waivers; ACOs & Medicare Shared Savings Program; Shared Responsibility for Employers Regarding Health Coverage (Section 4980H); Amendment to the Interim Final Rule on Internal Claims and Appeals and External Review Processes; HIPAA Privacy Rule Accounting of Disclosures; Medical Data Sharing. Summary of benefits and Coverage and the Uniform Glossary; Exchange Functions in the Individual market; Health Insurance Premium Tax Credit; Establishment of Exchanges and Qualified Health Plans; Health Coverage Affordability Safe Harbor for Employers; Medical Loss Ratio (MLR) Requirements Final Rule; Medical Loss Ratio (MLR) Notice of Rebate Forms Comprehensive health reform (bills in the Senate and House) - all aspects relating to coverage, financing, and delivery reform, including: 1099 reporting, Grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS Act, employer mandate, medical loss ratio, mandated insurance requirements, Exchanges, Medicare reform, regulatory reform, Essential Health Benefits Package, Health Insurance Tax; Medical Device Tax Various issues relating to the Patient Protection and Affordable Care Act (P.L. 111-148), including: implementation of, regulatory process, legislative corrections, coverage, financing, delivery reform, 1099 reporting, Grandfathering, HSA and FSA changes, CMS claims database, IPAB, CLASS program, employer mandate, medical loss ratio, medical malpractice reform, exchanges, and flexible spending accounts and health savings accounts. Various issues relating to the regulatory process and legislative corrections to Health Care and Education Affordability Reconciliation Act of 2010 (P.L. 111-152); ERISA preemption; impact on small business

The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda: value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; establishment and funding of comparative effectiveness research; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; 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 CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations: Medicare and other payors 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. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. 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. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage 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. Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. 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 formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae 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. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care." The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to "Provide residents with access to training using simulation". The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2023, would be converted to a defined contribution program which has been described as a premium support program. 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 Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

H.R. 1063 - The Strengthening Medicare and Repaying Taxpayers Act, related to enforcement of Medicare Secondary Payer Act requirements; H.R. 3682 - Patient Centered Healthcare Savings Act, Section 705, related to timely enforcement of Medicare Secondary Payer Act requirements in liability cases.

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

Government targets: HOUSE OF REPRESENTATIVES

H.R. 1063 - The Strengthening Medicare and Repaying Taxpayers Act, related to enforcement of Medicare Secondary Payer Act requirements; H.R. 3682 - Patient Centered Healthcare Savings Act, Section 705, related to timely enforcement of Medicare Secondary Payer Act requirements in liability cases.

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

Government targets: HOUSE OF REPRESENTATIVES

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; 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 CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities 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. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. 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. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage 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. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. 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.