Rural Hospital Access Act of 2012

Implementation of P.L. 111-148, Patient Protection and Affordable Care Act and P.L. 111-152, Health Care and Education Reconciliation Act; CMS/HHS on Medicare and Medicaid reimbursement; P.L. 112-96, Middle Class Tax Relief and Job Creation Act of 2012; CMS Innovation Center Grants; Rural Hospital Access Act of 2012 (S. 2620 / H.R. 5943) regarding extension of the Medicare-dependent hospital (MDH) program; Long-Term Care Hospital issues; Sequestration Transparency Act of 2012 (P.L. 112-155); American Taxpayer Relief Act.

Client expense: Not reported · Firm income: $100,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Advocated against FY 13 Presidents budget proposal and proposed House Budget reconiliation to eliminate the Medicaid Provider Fee that provides federal matching funds for Medicaid programs and advocated to keep provider fee in light of the deficit negotiations. Advocated for payroll fix legislation extending SGR payments but not at the cost of hospitals Advocated to extend outpatient hold-harmless provision for rural and sole community hospitals Advocated for Rural Hospital Access Act (S2620 and HR 5943) Requested support from House and Senate to have FCC release bridge funding on Rural Health Care Pilot Project Advocated against proposed across-the-board cuts under sequestration Requested support for FCC Rural Health Program on TeleHealth services Advocated for support of reimbursement of low volume medicare dependent hospitals

Client expense: Not reported · Firm income: $15,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 5652, Sequester Replacement Reconciliation Act (Medicaid provider taxes) Medicare physician fee schedule fix Medicare hospital wage index H.R. 3519, To exempt the Medicaqre program from fallback sequestration under the Budget Control Act of 2011 Medicaid provider taxes Medicare and Medicaid Payment reductions, including Graduate Medical Education, bad debt payments, post-acute care payments, CAH payments, IPPS coding offset, rural hospital payments, section 508 wage index reclassification, Medicare Dependent Hospital authorization, inpatient coding offset, small rural clinical hold harmless, Sole Community Hospital (SCH) outpatient department hold harmless, outpatient therapy cap moratorium, and hospital outpatient department (HOPD) evaluation and management (E/M) service. H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011 S. 2620/H.R. 5943, Rural Hospital Access Act (MDH/LV Adjustment 1-year extension) S. 1680/H.R. 3859, Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act H.R. 2224, Improving Physician Access to Teaching Hospitals Act (Medicare residency slots) S.1627/H.R. 6562, Resident Physician Shortage Reduction Act (Medicare residency slots) H.R. 452, Medicare Decisions Accountability Act of 2011 (IPAB repeal) Medicare and Medicaid Programs; Electronic Health Record Incentive ProgramStage 2; Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology; Final Rules (CMS and ONC Medicare and Medicaid EHR Meaningful Use Incentive Program Stage 2 final rules) New York State 1115 Medicaid Waiver Application to CMS Medicare and Medicaid Recovery Audit Contractor (RAC) Programs

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Participated in a conference call with Majority staff of the Health subcommittee of the House Energy and Commerce Committee regarding congressional efforts to restrict states use of provider taxes to fund their Medicaid programs Urged the Missouri congressional delegation to: 1) consider hospitals need for stability and predictability in making their spending and policy decisions; 2) support expected legislative efforts to repeal or revamp section 3141 of the Patient Protection and Affordable Care Act of 2010; 3) support expected legislative efforts to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; 4) reauthorize the Medicare Dependent Hospital Payment program for one year effective October 1, 2012, through H.R. 5943 or S. 2620; 5) oppose congressional proposals to curtail states capacity to use provider taxes to generate federal matching funds for their Medicaid programs; 6) repeal or revise the Medicare sustainable growth rate formula used to determine Medicare physician payments and do so without reducing payments to non-physician providers to offset the cost of doing so; 7) reject future congressional proposals to terminate the designation of critical access hospitals which qualify for separate payment and regulatory standards Provided background information and data on the Medicare Dependent Hospital program to support H.R. 5943 Responded to congressional staff queries about the Medicare Payment Advisory Commissions report regarding the delivery and financing of hospitals and other health care services in rural regions Promoted congressional awareness of and support for the Center for Medicare & Medicaid Services promulgation of regulations to clarify the authority of certified registered nurse anesthetists to be paid to provide pain management services to Medicare enrollees Provided background information to congressional staff to respond to a query regarding regulatory standards governing the use of tasers and weapons by hospital security staff Consulted with congressional staff regarding the wording and content of draft legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives Conducted and conveyed the results of research needed to respond to a query regarding the number of Missouri hospitals receiving payments under the Medicare Low-Volume Hospital program, in response to H.R. 5943 or S. 2620 Coordinated arrangements for a briefing of congressional staff of Missouri legislators regarding expected legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives Participated in conference calls with staff of the CMS regional office in Kansas City to discuss arrangements for a potential 2013 trip by CMS officials to tour rural hospitals in Missouri

Client expense: $70,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Medicaid Funding in the Federal Budget, Medicare Funding in the Federal Budget, H.R. 1656 & S. 1900 Urban Medicare Dependent Hospital Act, Sustainable Growth Rate Formula - Permanent Medicare Doctor Payment Fix, H.R. 1543 & S.818 Improving Access to Medicare Coverage Act, MedPac Recommendations on Area Wage Index Adjustments, Demonstration Projects, H.R. 5943 Rural Hospital Access Act, H.R. 6532 Resident Physician Shortage Reduction and Graduate Medical Education

Client expense: $100,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 3. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 4. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the state of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 5. The Rural Hospital Access Act of 2012 (H.R. 5943/S. 2620), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 6. The Patient Protection and Affordable Care Act (Pub. L. No. 111-148), provisions relating to payment cuts by hospitals and the Medicaid expansion by states. 7. The Preventive Health Savings Act of 2012 (H.R. 6482), request to co-sponsor bill that allows CBO to score legislation outside the ten-year window. 8. The American Taxpayer Relief Act of 2012 (Pub. L. No. 112-240), provisions related to hospital payments, the sustainable growth rate and sequestration.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 3. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 4. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the state of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 5. The Rural Hospital Access Act of 2012 (H.R. 5943/S. 2620), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 6. The Patient Protection and Affordable Care Act (Pub. L. No. 111-148), provisions relating to payment cuts by hospitals and the Medicaid expansion by states. 7. Lobby against the use of cuts for evaluation and management services in the hospital outpatient department as an offset in future legislation. 8. The American Taxpayer Relief Act of 2012 (Pub. L. No. 112-240), provisions related to hospital payments, the sustainable growth rate and sequestration.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S.3187 - Food and Drug Administration and Safety and Innovation Act and Related Conference Report PL 112-144 (drug shortage provisions). S.296/H.R.2245 - Preserving Access to Life-Saving Medications Act (drug shortage provisions). S.319 - Pharmaceutical Market Access and Drug Safety Act (drug shortages provisions). H.R.5651 - Food and Drug Administration Reform Act (drug shortage provisions). H.R.3839 - Drug Shortage Prevention Act (drug shortage provisions). Medicare physician fee schedule fix (issue only). Medicare hospital wage index (issue only). Inpatient Prospective Payment system final proposed regulation (coding offset). H.R.3519 - To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011, (entire bill). S.2620/H.R.5943 - Rural Hospital Access Act, (entire bill). H.R.2224 - Improving Physician Access to Teaching Hospitals Act, (entire bill). S.1627/H.R.6562 - Resident Physician Shortage Reduction Act (entire bill). H.R.452 - Medicare Decisions Accountability Act (IPAB repeal). S.668 - Health Care Bureaucrats Elimination Act. Resident Physician Shortage Reduction and Graduate Medical Education Accountability Act, H.R.6352 (entire bill).

Client expense: $209,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), SENATE

H.R.5 - Health Act. H.R.5994 - The Choice in Healthcare Act. H.R.5651 - Food and Drug Administration Reform Act of 2012. H.R.436 - Health Care Cost Reduction Act of 2012. H.R.5652 - Sequester Replacement Reconciliation Act of 2012. S.3187 - Food and Drug Administration Safety and Innovation Act. H.R.5943/S.2620 - The Rural Hospital Access Act of 2012. CMS-1588-P - Medicare Program; Proposed changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Proposed Rule. CMS-0040-P - Administrative Simplification Act: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the Natioanl Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets; Proposed Rule.

Client expense: $228,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE

Promoted HSHS innovation aimed at quality and efficiency in the delivery of care. Pressed lawmakers to avoid blunt cuts in upcoming budget negotiations, extend certain rural payment provisions, and avoid policy changes that would hurt ability of Critical Access Hospitals to serve their communities. Asked lawmakers to co-sponsor S.2620/H.R.5943, the Rural Hospital Access Act of 2012. Supported introduction of H.R.6352, the Resident Shortage Reduction and Graduate Medical Education Accountability Act.

Client expense: $195,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

HR 452 Medicare Decisions Accountability Act of 2011, to repeal the provisions of the Patient Protection and Affordable Care Act providing for the Independent Payment Advisory Board; HR 541 Pay for all your Undocumented Procedures (PAY UP!) Act of 2011, amends the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to make permanent the program of federal reimbursement of emergency health services furnished to undocumented aliens. Requires a re-allotment of unspent program funds in a fiscal year among eligible providers in full expenditure states according to a specified ratio. Requires addition of such funds to the aggregate amount available for allotment for the succeeding fiscal year in the event there is no full expenditure state; HR 876 and S 58 The Registered Nurse Safe Staffing Act of 2011, to amend title XVIII of the Social Security Act to provide for patient protection by establishing safe nurse staffing levels at certain Medicare providers; HR 1159, to repeal certain provisions of the Patient Protection and Affordable Care Act relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests; HR 1186, a bill to repeal changes made by health care reform laws to the Medicare exception to the prohibition on certain physician referrals for hospitals; S 374 and HR 2783 Medicare Mental Health Inpatient Equity Act, a bill to amend title XVIII of the Social Security Act to eliminate the 190-day lifetime limit on inpatient psychiatric hospital services under the Medicare program; HR 1398 Rural Hospital Protection Act, legislation which would amend the Social Security Act to ensure that the full cost of certain provider taxes are considered allowable costs for purposes of Medicare reimbursements to CAHs; S 1486 Long-Term Care Hospital Improvement Act of 201, a bill to amend title XVIII of the Social Security Act to clarify and expand on criteria applicable to patient admission to and care furnished in long-term care hospitals participating in the Medicare program; Raising concerns about CMS flawed methodology that overstates the effect of the documentation and coding changes to PPS payments, ensuring that CMS does not go beyond its charge of ensuring budget-neutral implementation of MS-DRGs; Working with CMS to clarify requirements and ensure that the systems to register for the meaningful use incentives and attest to meeting the requirements are useable, including ensuring that hospitals can, with permission, help their physicians sign up for the program and attest to meeting the requirements; Worked with ONC to modify the certification requirements for EHRs to allow the flexibility promised in the rules for meaningful use; Worked to get legislative fix introduced for ACA provision related to readmission policy to eliminate a computation error and ensure that unrelated and planned readmissions are excluded from the policy; Worked to improve the regulation to implement ACOs; Urging CMS to update, streamline, and modernize the Medicare conditions of participation; HR 1852/ S 950 Children's Hospital GME Support Reauthorization Act of 2011, the current CHGME authorization expired in September 2011, and the bills would reauthorize the CHGME program for an additional five years, through fiscal year (FY) 2016, at the current authorization level of up to $330 million a year; HR 1683/ S 868 Medicaid MOE, strikes provisions of ACA related to maintaining Medicaid eligibility levels; HR 1543 Improving Access to Medicare Coverage Act of 2011, to amend title XVIII of the Social Security Act to count a period of receipt of outpatient observation services in a hospital toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare; S 1251Medicare and Medicaid FAST Act, a bill to amend titles XVIII and XIX of the Social Security Act to curb waste, fraud, and abuse in the Medicare and Medicaid programs; HR 2500 Equal Access and Parity for Multi-Campus Hospitals Act, a bill to amend titles XVIII and XIX of the Social Security Act to clarify the application of EHR payment incentives in cases of multi-campus hospitals; HR 2674 340B Program Improvement Act, a bill to amend section 340B of the Public Health Service Act to improve the provision of discounts on drug purchases for certain safety net providers; HR 3630 Temporary Payroll Tax Cut Continuation Act of 2011 or Middle Class Tax Relief and Job Creation Act of 2011, a bill that cuts hospitals to pay for the doc fix, it contains the Social Security payroll tax cut and the Unemployment Insurance extension; HR 3519 a bill to amend and exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011; S. 1680 Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act of 2011, a bill to amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program; Letter to Rehberg and DeLauro in support of the CHGME program that was circulated by Reps. Capps and Bilbray; Wyden/Crapo letter to CMS to actively oppose a Senate Dear Colleague letter to CMS in support of updating Medicare payments to ambulatory surgery centers (ASCs). The letter did not request a payment update for ASCs. Rather, the letter advocated against the Medicare payment rate for services provided in hospital outpatient department settings; HR 2954 and S 2474 Health Equity and Accountability Act of 2011, Comprehensive bill focused on eliminating racial and ethnic disparities in health care through improved data collection and reporting, culturally and linguistically-appropriate health care, workforce diversity, health information technology, and other actions; Discussions with the Administration (CMS) on applying the therapy cap to hospital outpatient departments; Worked to change CMS definition of allowed EHR costs for CAH Meaningful Use incentive payments to include capital lease purchases of EHRs; HR 3859 Rural Hospital and Provider Equity (R-HOPE) Act of 2012, to amend title XVIII of the SSA to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program; HR 4245 Veterans Co-Pay Fairness Act, to amend title 38, United States Code, to require the Secretary of Veterans Affairs to reimburse eligible veterans who are entitled to Medicare benefits for Medicare deductibles and other expenses that are owed by the veterans for emergency medical treatment provided in non-Department of Veterans affairs facilities; S 2620 and HR 5943 Rural Hospital Access Act of 2012, a bill to amend title XVIII of the Social Security Act to provide for an extension of the Medicare-dependent hospital (MDH) program and the increased payments under the Medicare low-volume hospital program; S 3187 and HR 5651Prescription Drug User Fee Amendments of 2012, a bill to amend the Federal Food, Drug, and Cosmetic Act to revise and extend the user-fee programs for prescription drugs and medical devices, to establish user-fee programs for generic drugs and biosimilars.

Client expense: $3,550,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Equal Employment Opportunity Commission (EEOC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Housing & Urban Development, Dept of (HUD), Internal Revenue Service (IRS), Office of Management & Budget (OMB), SENATE, White House Office

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 3. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 4. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the state of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 5. The Rural Hospital Access Act of 2012 (H.R. 5943/S. 2620), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 6. The Patient Protection and Affordable Care Act (Pub. L. No. 111-148), provisions relating to payment cuts by hospitals and the Medicaid expansion by states. 7. The Preventive Health Savings Act of 2012 (H.R. 6482), request to co-sponsor bill that allows CBO to score legislation outside the ten-year window.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 3. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 4. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the state of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 5. The Rural Hospital Access Act of 2012 (H.R. 5943/S. 2620), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 6. The Patient Protection and Affordable Care Act (Pub. L. No. 111-148), provisions relating to payment cuts by hospitals and the Medicaid expansion by states. 7. Lobby against the use of cuts for evaluation and management services in the hospital outpatient department as an offset in future legislation.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Advocated against FY 13 Presidents budget proposal and proposed House Budget reconiliation to eliminate the Medicaid Provider Fee that provides federal matching funds for Medicaid programs and advocated to keep provider fee in light of the deficit negotiations. advocated for payroll fix legislation extending SGR payments but not at the cost of hospitals advocated to extend outpatient hold-harmless provision for rural and sole community hospitals advocated for Rural Hospital Access Act (S2620 and HR 5943) requested support from House and Senate to have FCC release bridge funding on Rural Health Care Pilot Project

Client expense: Not reported · Firm income: $15,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

"S. 3187, Food and Drug Administration Safety and Innovation Act (drug shortages in hospitals) and Related Conference Report PL 112-144 "S. 296/H.R. 2245, Preserving Access to Life-Saving Medications Act (drug shortages in hospitals) "S. 319, Pharmaceutical Market Access and Drug Safety Act (drug shortages in hospitals) H.R. 5651, Food and Drug Administration Reform Act (drug shortages in hospitals) H.R. 3839, Drug Shortage Prevention Act (drug shortages in hospitals) Medicaid provider taxes Medicare and Medicaid Payment reductions, including Graduate Medical Education, bad debt payments, post-acute care payments, CAH payments, IPPS coding offset, rural hospital payments, section 508 wage index reclassification, Medicare Dependent Hospital authorization, inpatient coding offset, small rural clinical hold harmless, Sole Community Hospital (SCH) outpatient department hold harmless, outpatient therapy cap moratorium, and hospital outpatient department (HOPD) evaluation and management (E/M) service. Medicare physician fee schedule fix Medicare hospital wage index H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011 S. 2620/H.R. 5943, Rural Hospital Access Act (MDH/LV Adjustment 1-year extension) S. 1680/H.R. 3859, Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act H.R. 2224, Improving Physician Access to Teaching Hospitals Act (Medicare residency slots) S.1627/H.R. 6562, Resident Physician Shortage Reduction Act (Medicare residency slots) H.R. 452, Medicare Decisions Accountability Act of 2011 (IPAB repeal) Medicare and Medicaid Programs; Electronic Health Record Incentive ProgramStage 2; Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology; Final Rules (CMS and ONC Medicare and Medicaid EHR Meaningful Use Incentive Program Stage 2 final rules) New York State 1115 Medicaid Waiver Application to CMS Medicare and Medicaid Recovery Audit Contractor (RAC) Programs

Client expense: Not reported · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES

- S.3187, Food and Drug Administraton Safety and Innovation Act (drug shortages in hospitals) and Related Conference Report P.L.112-144. - S.296/H.R.2245, Preserving Access to Life-Saving Medications Act (drug shortages in hospitals). - H.R.3839, Drug Shortage Prevention Act (drug shortages in hospitals) - S.319, Pharmaceutical Market Access and Drug Safety Act (drug shortages in hospitals). - H.R.5651, Food and Drug Administration Reform Act (drug shortages in hospitals). - Medicaid provider taxes. - Medicare and Medicaid Payment reductions, including Graduate Medical Education, bad debt payments, post-acute care payments, CAH payments, IPPS coding offset, rural hospital payments, section 508 wage index reclassification, Medicare Dependent Hospital authorization, inpatient coding offset, small rural clinical hold harmless, Sole Community Hospital (SCH) outpatient department hold harmless, outpatient therapy cap moratorium, and hospital outpatient department (HOPD) evaluation and management (E/M) service. - Medicare physician fee schedule fix. - Medicare hospital wage index. - H.R.3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011. - S.2620/H.R.5943, Rural Hospital Access Act (MDH/LV Adjustment 1-year extension). - S.1680/H.R.3859, Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act. - H.R.2500, The Equal Access and Parity for Multi-Campus Hospitals Act (Electronic Health Record multi-campus incentive bill). - H.R.2224, Improving Physician Access to Teaching Hospitals Act (Medicare residency slots). - S.1627/H.R.6562, Resident Physician Shortage Reduction Act (Medicare residency slots). - H.R.452, Medicare Decisions Accountability Act of 2011 (IPAB repeal). - S.668, Health Care Bureaucrats Elimination Act (IPAB repeal). - Medicare and Medicaid Programs; Electronic Health Record Incentive ProgramStage 2; Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology; Final Rules (CMS and ONC Medicare and Medicaid EHR Meaningful Use Incentive Program Stage 2 final rules). - New York State 1115 Medicaid Waiver Application to CMS. - H.R.6118, Taking Essential Steps for Testing (TEST) Act (unintentional proficiency testing laboratory referrals). - Medicare and Medicaid Recovery Audit Contractor (RAC) Programs.

Client expense: $190,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE

See attached sheet Iroquois Healthcare Alliance Extension of key Medicare provisions No additional funding cuts to Medicaid Also, we have been publicly supportive of NYS 1115 Medicaid Waiver proposal H.R.6446 /S .3473 Sequestration Prevention Act of 2012 creates incentive for innovative diagnostics by improving the process for determining Medicare payment rates for new tests. S.2620/H.R. 5943 Rural Hospital Access Act provides an extension of the enhanced low-volume Medicare adjustment for PPS hospitals through Sept 30, 2013

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 98, Illegal Immigration Enforcement and Social Security Protection Act of 2011 H.R. 280, Secure the Capitol Act H.R. 282, To require Federal contractors to participate in the E-Verify Program for employment eligibility verification H.R. 399, STAPLE Act H.R. 483, Electronic Employment Eligibility Verification and Illegal Immigration Control Act H.R. 693, E-Verify Modernization Act of 2011 H.R. 695, Legal Eligibility for Granting a Loan Act of 2011 H.R. 800, Jobs Recovery by Ensuring a Legal American Workforce Act of 2011 H.R. 959, Secure Travel and Counterterrorism Partnership Program Act of 2011 H.R. 1091, Unlawful Border Entry Prevention Act of 2011 H.R. 1114, StartUP Visa Act of 2011 H.R. 1120, International Travelers Bill of Rights Act of 2011 H.R. 1134, Enforce the Law for Sanctuary Cities Act H.R. 1156, Accountability in Immigrant Repatriation Act of 2011 H.R. 1164, National Language Act of 2011 H.R. 1196, LEAVE Act H.R. 2055, FY 2012 Consolidated Appropriations Act H.R. 2161, IDEA Act H.R. 2164, Legal Workforce Act H.R. 2847, American Specialty Agriculture Act H.R. 2885, Legal Workforce Act H.R. 2895, To amend the Immigration and Nationality Act to provide for a temporary agricultural worker program, and for other purposes H.R. 2972, Creating American Jobs Through Foreign Capital Investment Act H.R. 3012, Fairness for High-Skilled Immigrants Act of 2011 H.R. 3039, Welcoming Business Travelers and Tourists to America Act of 2011 H.R. 3116, Department of Homeland Security Authorization Act for Fiscal Year 2012 H.R. 3119, Protecting American Families and Businesses Act of 2011 H.R. 3146, American Innovation and Education Act of 2011 H.R. 3162, To prohibit the Secretary of Labor from implementing certain rules relating to employment of aliens described in section 101(a)(15)(H)(ii)(b) of the Immigration and Nationality Act, and for other purposes H.R. 3341, VISIT USA Act H.R. 3686, Save Our Small and Seasonal Businesses Act of 2011 H.R. 3692, Immigration and Naturalization Investment Ventures for Engineering, Science, and Technology (INVEST) in America Act of 2011 H.R. 3718, Save Our Small and Seasonal Businesses Act of 2011 H.R. 3720, New Illegal Deduction Elimination Act H.R. 3855 / S. 2046, Visa Waiver Program Enhanced Security and Reform Act H.R. 3875, Outsourcing Accountability Act of 2012 H.R. 3983, Strengthening Americas Public Schools Through Promoting Foreign Investment Act H.R. 3992, E-2 nonimmigrant visas for Israeli nationals H.R. 4159 / S. 2167, American Jobs in American Forests Act of 2012 H.R. 5741, Jobs Originated through Launching Travel Act of 2012 (JOLT Act of 2012) H.R. 5855 / S. 3216, Department of Homeland Security Appropriations Act, 2013, including provisions related to the Visa Waiver Program and Customs and Border Protection staffing at U.S. ports of entry H.R. 5869, Studying Towards Adjusted Residency Status (STARS) Act H.R. 5874, American Entrepreneurship and Investment Act of 2012 H.R. 5893 / S. 3217, Startup Act 2.0 H.R. 5943, Prohibiting Back-door Amnesty Act H.R. 5957, To prohibit the Secretary of DHS from granting deferred action H.R. 5964 / S. 3279, Cross-Border Trade Enhancement Act of 2012 H.R. 5968, Services to Allow New Destinations for Tourism Act H.R. 6001, Equal Protection for American Workers Act H.R. 6055, Facilitating Access of Services and Trade (FAST) Act of 2012 H.R. 6069, Protecting Department of Homeland Security Personnel Act H.R. 6070, To require the Comptroller General to conduct a study on the impact of prosecutorial discretion H.R. 6210, American Investment and Job Creation Act of 2012 H.R. 6412, Attracting the Best and Brightest Act of 2012 H.R. 6429, STEM Jobs Act of 2012 S. 497, Secure Travel and Counterterrorism Partnership Program Act of 2011 S. 565, StartUP Visa Act of 2011 S. 638, SCAAP Reimbursement Protection Act of 2011 S. 639, SCAAP Reauthorization Act S. 642, To permanently reauthorize the EB-5 Regional Center Program S. 952, DREAM Act of 2011 S. 1196, Achieving Accountability Through Electronic Verification Act S. 1258, Comprehensive Immigration Reform Act of 2011 S. 1601, Department of State, Foreign Operations, and Related Programs Appropriations Act, 2012 S. 1653, International Tourism Facilitation Act S. 1746, VISIT USA Act S. 1857, Fairness for High-Skilled Immigrants Act S. 1866, AGREE Act S. 1965, Startup Act of 2011 S. 1986, IDEA Act S. 1983, Fairness for High-Skilled Immigrants Act of 2011 (Schumer version) S. 2005, E-3 Irish Nationals S. 2046, Visa Waiver Program Enhanced Security and Reform Act S. 2233, Jobs Originated Through Launching Travel Act (JOLT Act) S. 3185, Securing the Talent America Requires for the 21st Century (STAR) Act of 2012 S. 3192, Sustaining our Most Advanced Researchers and Technology (SMART) Jobs Act of 2012 S. 3199, Jobs Originated Through Launching Travel Act of 2012 (JOLT Act of 2012) S. 3216, Department of Homeland Security Appropriations Act, 2013 S. 3217, Startup Act 2.0 S. 3222, Federal Entrepreneur-in-Residence Act of 2012 S. 3245, A bill to extend by 3 years the authorization of the EB-5 Regional Center Program, the E-Verify Program, the Special Immigrant Nonminister Religious Worker Program, and the Conrad State 30 J-1 Visa Waiver Program S. 3279, Cross-Border Trade Enhancement Act H.J. RES. 104, Disapproving a rule submitted by the Department of Labor relating to Temporary Non-agricultural Employment of H-2B Aliens in the United States Various issues relating to the H1-B Visa Program; the H2-B Visa Program; the E-Verify Program; private-public partnerships with the Department of Homeland Security at land border ports of entry; STEM visa reform; need for data to inform employment based immigration decisions

Client expense: $31,650,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Commerce, Dept of (DOC), Commodity Futures Trading Commission (CFTC), Defense, Dept of (DOD), Education, Dept of, Energy, Dept of, Equal Employment Opportunity Commission (EEOC), Executive Office of the President (EOP), Federal Highway Administration (FHA), Federal Reserve System, Federal Trade Commission (FTC), Federal Transit Administration (FTA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Interior, Dept of (DOI), Internal Revenue Service (IRS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Maritime Administration (MARAD), Natl Economic Council (NEC), Natl Institute of Standards & Technology (NIST), Natl Labor Relations Board (NLRB), Natl Security Council (NSC), Office of Management & Budget (OMB), Office of the Vice President of the United States, Patent & Trademark Office (PTO), Pension Benefit Guaranty Corporation (PBGC), SENATE, Securities & Exchange Commission (SEC), Small Business Administration (SBA), State, Dept of (DOS), Transportation Security Administration (TSA), Transportation, Dept of (DOT), Treasury, Dept of, U.S. Copyright Office, U.S. Customs & Border Protection, U.S. Trade Representative (USTR), White House Office

S. 3187, Food and Drug Administration and Safety and Innovation Act and Related Conference Report PL 112-144 (drug shortage provisions) S. 296/H.R. 2245, Preserving Access to Life-Saving Medications Act (drug shortage provisions) S. 319, Pharmaceutical Market Access and Drug Safety Act (drug shortages provisions) H.R. 5651, Food and Drug Administration Reform Act (drug shortage provisions) H.R. 3839, Drug Shortage Prevention Act (drug shortage provisions) Medicare physician fee schedule fix (issue only) Medicare hospital wage index (issue only) Inpatient Prospective Payment system final proposed regulation (coding offset) H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011, (entire bill) S. 2620/H.R. 5943, Rural Hospital Access Act, (entire bill) H.R. 2224, Improving Physician Access to Teaching Hospitals Act, (entire bill) S.1627/H.R. 6562, Resident Physician Shortage Reduction Act (entire bill) H.R. 452, Medicare Decisions Accountability Act (IPAB repeal) S. 668, Health Care Bureaucrats Elimination Act Resident Physician Shortage Reduction and Graduate Medical Education Accountability Act, H.R. 6352 (entire bill)

Client expense: $628,940 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), SENATE

Implementation of P.L. 111-148 Patient Protection and Affordable Care Act and P.L. 111-152 Health Care and Education Reconciliation Act; CMS/HHS on Medicare and Medicaid reimbursement; P.L. 112-96 Middle Class Tax Relief and Job Creation Act of 2012; CMS Innovation Center Grants; Rural Hospital Access Act of 2012 (S. 2620 / H.R. 5943) regarding extension of the Medicare-dependent hospital(MDH)program; Long-Term Care Hospital issues; The Sequestration Transparency Act of 2012 (P.L. 112-155).

Client expense: Not reported · Firm income: $100,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 1543 and S. 818, Improving Access to Medicare Coverage Act of 2011, entire bill. H.R. 6365, the National Security and Job Protection Act of 2011, entire bill. H.R. 4872, the Health Care & Education Affordability Reconciliation Act of 2010: provisions relating to hospitals and physicians, including: Section 1106: physician-owned hospitals and self-referral; Section 2302: 340B program; Section 1104 and Section 1203: Medicare and Medicaid DSH Payments; Sections 1108 and 1109 involving geographic disparities in Medicare payment; Section 1105: Market basket updates; Section 1201: Federal funding for States; Section 1202: Payments to primary care physicians. H.R. 3590, the Patient Protection and Affordable Care Act, provisions relating to hospitals, hospice and physicians including: Section 3001: hospital value-based purchasing; Section 3125: low-volume hospital payment; Section 3401: productivity adjustments; Section 6001: physician-owned hospital and self-referral; Section 3121: outpatient hold harmless for hospitals; Sections 7101-7103: 340B Program; Section 3401: Independent Payment Advisory Board; Section 3015: hospital readmissions program; Section 3124: Extension of Medicare Dependent Hospital program; Section 3137: Section 508 Reclassification; Section 9007: non-profit hospital provision; Section 3105: ambulance services; Section 3008 and Section 2702: payment adjustment for hospital acquired conditions; Section 3133: Medicare DSH; Section 2551: Disproportionate Share Hospitals; Section 5501: Primary Care Provisions; Section 5503: Graduate Medical Education; Sections 2001-2081: Expansion of Medicaid, CHIP; Sections 1311-1343: CO-OPs and Exchanges; Section 3022: Accountable Care Organizations; Section 3023: Hospital Bundling Provision; Section 6401-6402: Program Integrity Provisions; Section 6501-6503, 6505, 6508: Medicaid Program Integrity Provisions. H.R. 2674, 340B Program Improvement Act, entire bill. S. 722 and H.R. 3506, Hospice Evaluation and Legitimate Payment Act, entire bills. S. 778, Protecting Access to Rural Therapy Services (PARTS) Act, entire bill. H.R. 3285, Medicare Equity Extension Act, entire bill. H.R. 3630, Middle Class Tax Relief and Job Creation Act of 2011, Title II, Subtitle C--Medicare Extensions; Other Health Provisions, Part 1--Medicare extensions, Section 2201, Physician payment update. Section 2202: Ambulance Add-ons; Section 2203: Medicare payment for outpatient therapy services; Section 2204: Work geographic Adjustment; Part 3--Offsets, Section 2223: Parity in Medicare payments for hospital outpatient department evaluation and management office visit services; Section 2224, Reduction of bad debt treated as an allowable cost; Section 2225, Rebasing of State DSH allotments for FY 2021. Part 2 of Subtitle C--Other Health Provisions, Section 2213: Modification to requirements for qualifying for exception to Medicare prohibition on certain physician referrals for hospitals. H.R. 3859 and S. 1680, The Rural Hospital and Provider Equity (R-HOPE) Act of 2012, entire bills. H.R. 3630, The Middle Class Tax Relief and Job Creation Act of 2012, entire bill. H.R. 5943 and S. 2620, the Rural Hospital Access Act of 2012, entire bills. H.R. 2461, Physician Pathology Services Continuity Act of 2011, entire bill. H.R. 2104, Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and Radiation Therapy Act of 2011, entire bill. 2013 Outpatient Prospective Payment System proposed rule, entire rule. 2013 Inpatient Prospective Payment System final rule, entire rule. 2013 Physician Fee Schedule proposed rule, entire rule. Other issues: Proposals surrounding the Sustainable Growth Rate (SGR) and deficit/debt reduction as related to hospitals and physicians. Accountable Care Organizations and the Innovation Center's demonstration programs. Medicare and Medicaid Recovery Audit Contractor programs. Geographic Variation in Medicare spending, IOM studies on high value and Medicare geographic adjusters. Medical Liability Reform. Medicare and Medicaid Electronic Health Record Payment Incentive Programs. Hospital wage index reform, including Section 3137(b) of the Affordable Care Act. Implementation of the state health insurance exchanges. 2013 Inpatient Rehab rule, entire rule. 2013 LTCH rule, entire rule Hospice Quality Reporting Program. 2013 Home Health rule, entire rule. Dual Eligible Demonstration Programs.

Client expense: $50,463 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Federal Communications Commission (FCC), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), SENATE

H.R.5943/S.2620 Rural Hospital Access Act -- rural health care

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

Government targets: Agriculture, Dept of (USDA), Environmental Protection Agency (EPA), HOUSE OF REPRESENTATIVES, Labor, Dept of (DOL), SENATE

Medicaid Funding in the Federal Budget, Medicare Funding in the Federal Budget, H.R. 1656 & S.1900 Urban Medicare Dependent Hospital Act, Sustainable Growth Rate Formula - Permanent Medicare Doctor Payment Fix , H.R.1543 & S.818 Improving Access to Medicare Coverage Act, MedPac Recommendations on Area Wage Index Adjustments, Demonstration Projects, H.R.5943 Rural Hospital Access Act, H.R.6532 Resident Physician Shortage Reduction and Graduate Medical Education

Client expense: $80,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

See Next Page for Narrative. Congressional efforts to restrict states use of provider taxes to fund their Medicaid programs; Advocated the consideration for hospitals need for stability and predictability in making their spending and policy decisions; 2) support expected legislative efforts to repeal or revamp section 3141 of the Patient Protection and Affordable Care Act of 2010; 3) support expected legislative efforts to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; 4) reauthorize the Medicare Dependent Hospital Payment program for one year effective October 1, 2012, through H.R. 5943 or S. 2620; 5) oppose congressional proposals to curtail states capacity to use provider taxes to generate federal matching funds for their Medicaid programs; 6) repeal or revise the Medicare sustainable growth rate formula used to determine Medicare physician payments and do so without reducing payments to non-physician providers to offset the cost of doing so; 7) reject future congressional proposals to terminate the designation of critical access hospitals that qualify for separate payment and regulatory standards; Additional support for H.R. 5943, provisions relateed to Medicare Dependent Hospital programs; Medicare Payment Advisory Commissions report regarding the delivery and financing of hospitals and other health care services in rural regions; Promoted awareness of and support for the Center for Medicare and Medicaid Services promulgation of regulations to clarify the authority of certified registered nurse anesthetists to be paid to provide pain management services to Medicare enrollees; Regulatory standards governing the use of tasers and weapons by hospital security staff; Worked on the wording and content of draft legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; H.R. 5943 or S. 2620, with respect to payments received by Missouri hospitals under the Medicare Low-Volume Hospital program; Expected legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; Discussed the effect the RAC program is having on Missouri hospitals.

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Medicare physician fee schedule fix (issue only) Medicare hospital wage index (issue only) Inpatient Prospective Payment system final proposed regulation (coding offset) H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011, (entire bill) S. 2620/H.R. 5943, Rural Hospital Access Act, (entire bill) H.R. 2224, Improving Physician Access to Teaching Hospitals Act, (entire bill) S. 1627/H.R. 6562, Resident Physician Shortage Reduction Act, (entire bill) Resident Physician Shortage Reduction and Graduate Medical Education Accountability Act, H.R. 6352, (entire bill)

Client expense: $90,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 1370 - To repeal the annual fee on health insurance providers enacted by the Patient Protection and Affordable Care Act H.R. 5943 - Rural Hospital Access Act of 2012 H.R. 6079 - Repeal of Obamacare Act S. 1880 - Jobs and Premium Protection Act S. 2620 Rural Hospital Access Act of 2012 PPACA Safe Harbor Provision PPACA Mandates PPACA Repeal Vote Health Savings Accounts Flexible Spending Accounts Rural Hospital Access Medicare-Dependent Hospitals Low-Volume Hospitals Medical Device Tax Health Insurance Tax Guidance on 90-Day Waiting Period Limitation under Public Health Service Act Definition of Seasonal Worker

Client expense: $600,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Army, Dept of (Corps of Engineers), Bureau of Land Management (BLM), Commerce, Dept of (DOC), Commodity Futures Trading Commission (CFTC), Environmental Protection Agency (EPA), Executive Office of the President (EOP), Federal Communications Commission (FCC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Homeland Security, Dept of (DHS), Interior, Dept of (DOI), Labor, Dept of (DOL), SENATE, State, Dept of (DOS), Transportation, Dept of (DOT), U.S. Trade Representative (USTR)

H.R. 5943, S 2620. Support Medicare Dependent Hospital and Low Volume Hospital provision within the Rural Hospital Act of 2012

Client expense: $114,551 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

- Participated in a conference call with Majority staff of the Health subcommittee of the House Energy and Commerce Committee regarding congressional efforts to restrict states use of provider taxes to fund their Medicaid programs - Urged the Missouri congressional delegation to: 1) consider hospitals need for stability and predictability in making their spending and policy decisions; 2) support expected legislative efforts to repeal or revamp section 3141 of the Patient Protection and Affordable Care Act of 2010; 3) support expected legislative efforts to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; 4) reauthorize the Medicare Dependent Hospital Payment program for one year effective October 1, 2012, through H.R. 5943 or S. 2620; 5) oppose congressional proposals to curtail states capacity to use provider taxes to generate federal matching funds for their Medicaid programs; 6) repeal or revise the Medicare sustainable growth rate formula used to determine Medicare physician payments and do so without reducing payments to non-physician providers to offset the cost of doing so; 7) reject future congressional proposals to terminate the designation of critical access hospitals that qualify for separate payment and regulatory standards - Provided background information and data on the Medicare Dependent Hospital program to support H.R. 5943 - Responded to congressional staff queries about the Medicare Payment Advisory Commissions report regarding the delivery and financing of hospitals and other health care services in rural regions - Promoted congressional awareness of and support for the Center for Medicare and Medicaid Services promulgation of regulations to clarify the authority of certified registered nurse anesthetists to be paid to provide pain management services to Medicare enrollees - Provided background information to congressional staff to respond to a query regarding regulatory standards governing the use of tasers and weapons by hospital security staff - Consulted with congressional staff regarding the wording and content of draft legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives - Conducted and conveyed the results of research needed to respond to a query regarding the number of Missouri hospitals receiving payments under the Medicare Low-Volume Hospital program, in response to H.R. 5943 or S. 2620 - Coordinated arrangements for a briefing of congressional staff of Missouri legislators regarding expected legislation to assess and limit the administrative burdens imposed by demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives - Participated in conference calls with staff of the CMS regional office in Kansas City to discuss arrangements for a potential 2013 trip by CMS officials to tour rural hospitals in Missouri - Participated in meeting with staff of the CMS regional Kansas City office and the WPS office to discuss the effect the RAC program is having on Missouri hospitals

Client expense: $110,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

S. 3187, Food and Drug Administration Safety and Innovation Act (drug shortages in hospitals) and Related Conference Report PL 112-144 S. 296/H.R. 2245, Preserving Access to Life-Saving Medications Act (drug shortages in hospitals) S. 319, Pharmaceutical Market Access and Drug Safety Act (drug shortages in hospitals) H.R. 5651, Food and Drug Administration Reform Act (drug shortages in hospitals) H.R. 3839, Drug Shortage Prevention Act (drug shortages in hospitals) H.R. 5652, Sequester Replacement Reconciliation Act (Medicaid provider taxes) Medicare physician fee schedule fix Medicare hospital wage index H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011 S. 2620/H.R. 5943, Rural Hospital Access Act (MDH/LV Adjustment 1-year extension) S. 1680/H.R. 3859, Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act H.R. 2500, The Equal Access and Parity for Multi-Campus Hospitals Act (Electronic Health Record multi-campus incentive bill) H.R. 2224, Improving Physician Access to Teaching Hospitals Act (Medicare residency slots) S.1627, Resident Physician Shortage Reduction Act (Medicare residency slots) H.R. 452, Medicare Decisions Accountability Act of 2011 (IPAB repeal) S. 668, Health Care Bureaucrats Elimination Act (IPAB repeal) S.218/H.R. 5, Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011 (Medical liability reform)

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. H.R. 1852/S. 958, funding for the children's hospital graduate medical education program. 3. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 4. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 5. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the State of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 6. The Equal Access and Parity for Multi-Campus Hospitals Act (H.R. 2500), incentive payments to hospitals for the implementations of electronic health records and achieving meaningful use. 7. The Rural Hospital Access Act of 2012 (H.R. 5943), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 8. Requested members sign a letter to Secretary Kathleen Sebelius that expressed concern regarding the recently proposed FY2013 Medicare update rule for long-term care hospitals. 9. The Preserving Access to Life Saving Medications Act (H.R. 2245/S. 296) and the Drug Shortage Prevention Act (H.R. 3839), legislation that addresses prescription drug shortages and processes at the Food & Drug Administration. 10. The Patient Protection and Affordable Care Act, provisions related to the expansion of health insurance coverage and $155 billion in cuts to hospital payments.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

1. The Budget Control Act of 2011 (Pub. L. No. 112-25, S. 365), provisions relating to the use of sequestration and payment cuts to hospitals. 2. The Temporary Payroll Tax Cut Continuation Act of 2011 (H.R. 3630), provisions related to Medicare physician payments, cuts to hospital reimbursement, and the elimination of rural hospital payment programs. 3. The Long-Term Care Hospital Improvement Act of 2011 (S. 1486), relating to the creation of patient criteria and elimination of the 25 percent rule. 4. Provided education to Members of Congress and their staff about the submission of a Medicare 1115 Waiver by the state of Texas to modify payments made under the Upper Payment Limit (UPL) Program. 5. The Equal Access and Parity for Multi-Campus Hospitals Act (H.R. 2500), incentive payments to hospitals for the implementations of electronic health records and achieving meaningful use. 6. The Rural Hospital Access Act of 2012 (H.R. 5943), legislation would reauthorize the Medicare-Dependent Hospital Program and extend the enhanced low-volume Medicare adjustment for prospective payment system hospitals for one year through September 2013. 7. Requested members sign a letter to Secretary Kathleen Sebelius that expressed concern regarding the recently proposed FY2013 Medicare update rule for long-term care hospitals.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

HR 452 Medicare Decisions Accountability Act of 2011, to repeal the provisions of the Patient Protection and Affordable Care Act providing for the Independent Payment Advisory Board; HR 541 Pay for all your Undocumented Procedures (PAY UP!) Act of 2011, amends the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to make permanent the program of federal reimbursement of emergency health services furnished to undocumented aliens. Requires a re-allotment of unspent program funds in a fiscal year among eligible providers in full expenditure states according to a specified ratio. Requires addition of such funds to the aggregate amount available for allotment for the succeeding fiscal year in the event there is no full expenditure state; HR 876 and S 58 The Registered Nurse Safe Staffing Act of 2011, to amend title XVIII of the Social Security Act to provide for patient protection by establishing safe nurse staffing levels at certain Medicare providers; HR 1159, to repeal certain provisions of the Patient Protection and Affordable Care Act relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests; HR 1186, a bill to repeal changes made by health care reform laws to the Medicare exception to the prohibition on certain physician referrals for hospitals; S 374 and HR 2783 Medicare Mental Health Inpatient Equity Act, a bill to amend title XVIII of the Social Security Act to eliminate the 190-day lifetime limit on inpatient psychiatric hospital services under the Medicare program; HR 1398 Rural Hospital Protection Act, legislation which would amend the Social Security Act to ensure that the full cost of certain provider taxes are considered allowable costs for purposes of Medicare reimbursements to CAHs; S 1486 Long-Term Care Hospital Improvement Act of 201, a bill to amend title XVIII of the Social Security Act to clarify and expand on criteria applicable to patient admission to and care furnished in long-term care hospitals participating in the Medicare program; Raising concerns about CMS flawed methodology that overstates the effect of the documentation and coding changes to PPS payments, ensuring that CMS does not go beyond its charge of ensuring budget-neutral implementation of MS-DRGs; Working with CMS to clarify requirements and ensure that the systems to register for the meaningful use incentives and attest to meeting the requirements are useable, including ensuring that hospitals can, with permission, help their physicians sign up for the program and attest to meeting the requirements; Worked with ONC to modify the certification requirements for EHRs to allow the flexibility promised in the rules for meaningful use; Worked to get legislative fix introduced for ACA provision related to readmission policy to eliminate a computation error and ensure that unrelated and planned readmissions are excluded from the policy; Worked to improve the regulation to implement ACOs; Urging CMS to update, streamline, and modernize the Medicare conditions of participation; HR 1852/ S 950 Children's Hospital GME Support Reauthorization Act of 2011, the current CHGME authorization expired in September 2011, and the bills would reauthorize the CHGME program for an additional five years, through fiscal year (FY) 2016, at the current authorization level of up to $330 million a year; HR 1683/ S 868 Medicaid MOE, strikes provisions of ACA related to maintaining Medicaid eligibility levels; HR 1543 Improving Access to Medicare Coverage Act of 2011, to amend title XVIII of the Social Security Act to count a period of receipt of outpatient observation services in a hospital toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare; S 1251Medicare and Medicaid FAST Act, a bill to amend titles XVIII and XIX of the Social Security Act to curb waste, fraud, and abuse in the Medicare and Medicaid programs; HR 2500 Equal Access and Parity for Multi-Campus Hospitals Act, a bill to amend titles XVIII and XIX of the Social Security Act to clarify the application of EHR payment incentives in cases of multi-campus hospitals; HR 2674 340B Program Improvement Act, a bill to amend section 340B of the Public Health Service Act to improve the provision of discounts on drug purchases for certain safety net providers; HR 3630 Temporary Payroll Tax Cut Continuation Act of 2011 or Middle Class Tax Relief and Job Creation Act of 2011, a bill that cuts hospitals to pay for the doc fix, it contains the Social Security payroll tax cut and the Unemployment Insurance extension; HR 3519 a bill to amend and exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011; S. 1680 Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act of 2011, a bill to amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program; Letter to Rehberg and DeLauro in support of the CHGME program that was circulated by Reps. Capps and Bilbray; Wyden/Crapo letter to CMS to actively oppose a Senate Dear Colleague letter to CMS in support of updating Medicare payments to ambulatory surgery centers (ASCs). The letter did not request a payment update for ASCs. Rather, the letter advocated against the Medicare payment rate for services provided in hospital outpatient department settings; HR 2954 Health Equity and Accountability Act of 2011, Comprehensive bill focused on eliminating racial and ethnic disparities in health care through improved data collection and reporting, culturally and linguistically-appropriate health care, workforce diversity, health information technology, and other actions; Discussions with the Administration (CMS) on applying the therapy cap to hospital outpatient departments; Worked to change CMS definition of allowed EHR costs for CAH Meaningful Use incentive payments to include capital lease purchases of EHRs; HR 3859 Rural Hospital and Provider Equity (R-HOPE) Act of 2012, to amend title XVIII of the SSA to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program. HR 4245 Veterans Co-Pay Fairness Act, to amend title 38, United States Code, to require the Secretary of Veterans Affairs to reimburse eligible veterans who are entitled to Medicare benefits for Medicare deductibles and other expenses that are owed by the veterans for emergency medical treatment provided in non-Department of Veterans Affairs facilities; S 2620 and HR 5943 Rural Hospital Access Act of 2012, a bill to amend title XVIII of the Social Security Act to provide for an extension of the Medicare-dependent hospital (MDH) program and the increased payments under the Medicare low-volume hospital program; S 3187 and HR 5651Prescription Drug User Fee Amendments of 2012, a bill to amend the Federal Food, Drug, and Cosmetic Act to revise and extend the user-fee programs for prescription drugs and medical devices, to establish user-fee programs for generic drugs and biosimilars.

Client expense: $4,150,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Equal Employment Opportunity Commission (EEOC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Housing & Urban Development, Dept of (HUD), Internal Revenue Service (IRS), Office of Management & Budget (OMB), SENATE, White House Office

H.R. 436 - Health Care Cost Reduction Act of 2012 H.R. 1744 - American Job Protection Act H.R. 5842 - Restoring Access to Medication Act of 2012 H.R. 5943 - Rural Hospital Access Act of 2012 S. 2620 Rural Hospital Access Act of 2012 Health Insurance Exchanges Safe Harbor Provision PPACA Mandates PPACA Supreme Court Ruling PPACA Repeal Vote Health Savings Accounts Flexible Spending Accounts Rural Hospital Access Medicare-Dependent Hospitals Low-Volume Hospitals Medical Device Tax Health Insurance Tax

Client expense: $627,183 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Army, Dept of (Corps of Engineers), Commodity Futures Trading Commission (CFTC), Council on Environmental Quality (CEQ), Environmental Protection Agency (EPA), Executive Office of the President (EOP), Federal Communications Commission (FCC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Homeland Security, Dept of (DHS), Labor, Dept of (DOL), Legal Services Corporation, SENATE, U.S. Trade Representative (USTR)

S.3187, Food and Drug Administration Safety and Innovation Act (drug shortages in hospitals) and Related Conference Report PL 112-144; S.296/H.R.2245, Preserving Access to Life-Saving Medications Act (drug shortages in hospitals); S.319, Pharmaceutical Market Access and Drug Safety Act (drug shortages in hospitals); H.R. 5651, Food and Drug Administration Reform Act (drug shortages in hospitals); H.R. 3839, Drug Shortage Prevention Act (drug shortages in hospitals); H.R. 5652, Sequester Replacement Reconciliation Act (Medicaid provider taxes); H.R. 3560, Middle Class Tax Relief and Job Creation Act and Related Conference Committee Report PL 112-399: Medicare and Medicaid Payment reductions, including Graduate Medical Education, bad debt payments, post-acute care payments, CAH payments, IPPS coding offset, rural hospital payments, section 508 wage index reclassification, Medicare Dependent Hospital authorization, inpatient coding offset, small rural clinical hold harmless, Sole Community Hospital (SCH) outpatient department hold harmless, outpatient therapy cap moratorium, and hospital outpatient department (HOPD) evaluation and management (E/M) service; Medicare physician fee schedule fix; Medicare hospital wage index; H.R. 3519, To exempt the Medicare program from fallback sequestration under the Budget Control Act of 2011; S. 2620/H.R. 5943, Rural Hospital Access Act (MDH/LV Adjustment 1-year extension); H.R. 6064 Temporary Surface Transportation Act and Related Conference Report PL 112-140 (Pension provisions); S. 1680/H.R. 3859, Craig Thomas Rural Hospital and Provider Equity (R-HoPE) Act; H.R. 2500, The Equal Access and Parity for Multi-Campus Hospitals Act (Electronic Health Record multi-campus incentive bill); H.R. 2224, Improving Physician Access to Teaching Hospitals Act (Medicare residency slots); S.1627, Resident Physician Shortage Reduction Act (Medicare residency slots); H.R. 452, Medicare Decisions Accountability Act of 2011 (IPAB repeal); S. 668, Health Care Bureaucrats Elimination Act (IPAB repeal); S.218/H.R. 5, Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act of 2011 (Medical liability reform). Recovery Auditor Contractor program modifications

Client expense: $210,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE

Improving Access to Medicare Coverage Act of 2011, HR1543 and S818, supported. Rural Hospital Access Act of 2012, HR5943 and S2620, supported. Advocated for appropriate wage indexing and low-volume adjustment factors. Proposed Rulemaking on Preventive Services, CMS-9968-ANPRM, supported the repeal of the contraceptive mandateor to modify the definition of religious employer to include religious sponsored hospitals. Supported measures to ensure appropriate reimbursement for hospital and other health care services.

Client expense: $58,003 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, SENATE

Implementation of P.L. 111-148 Patient Protection and Affordable Care Act and P.L. 111-152 Health Care and Education Reconciliation Act; CMS/HHS on Medicare and Medicaid reimbursement; P.L. 112-96 Middle Class Tax Relief and Job Creation Act of 2012; CMS Innovation Center Grants; Rural Hospital Access Act of 2012 (S. 2620 / H.R. 5943) regarding extension of the Medicare-dependent hospital(MDH)program.

Client expense: Not reported · Firm income: $100,000

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

H.R. 5652, Sequester Replacement Reconciliation Act of 2012 H.R. 5943/S. 2620, The Rural Hospital Access Act of 2012 CMS- 1588-P, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Proposed Rule CMS-0040-P, Administrative Simplification: Adoption of a Standard for Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets; Proposed Rule H.R. 436, Health Care Cost Reduction Act of 2012

Client expense: $100,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

See Next Page for Narrative. Medicare payments to certified registered nurse anesthetists for pain management services and Support for Associations related letter; Opposing budget reconciliation proposals that would reduce states capacity to use provider taxes to fund their Medicaid programs; Proposals to restrict states use of provider taxes to fund their Medicaid programs in budget reconciliation legislation pending in the House Energy and Commerce Committee; Support for H.R. 5651 based on its provisions to reduce the incidence and severity of shortages of drugs and other pharmaceuticals; The revision in a final rule of 42 C.F.R. 482.12 to require selected hospitals, including governmental hospitals, to have a physician as a member of the hospital governing board; Missouri Hospitals and their placement in congressional districts redrawn in the redistricting process. Oppose restrictions on states use of provider taxes to fund their Medicaid programs as a funding mechanism for extending subsidized interest rates on federal Stafford student loans; Development and sponsorship of legislation that would set new standards governing the ability of Medicare program integrity contractors to require health care providers to submit medical records and supporting documentation for review; H.R. 5707 (Physician Payment Innovation Act of 2012); Medicare Payment Advisory Commissions report regarding the delivery and financing of hospitals and other health care services in rural regions; S. 2620/H.R. 5943, to reauthorize the Medicare Dependent Hospital program. Regulatory and payment topics, generally; Support to: 1) consider hospitals need for stability and predictability in making their spending and policy decisions; 2) support provisions of H.R. 2245/S. 296/H.R. 3839 to respond to concerns about shortages of drugs and other pharmaceutical products; 3) reauthorize the Medicare Dependent Hospital program before it lapses on October 1, 2012; 4) repeal section 3141 of the Patient Protection and Affordable Care Act of 2010; 5) examine the administrative burdens associated with the demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; and 6) consider the Missouri Hospital Associations written observations regarding the budget proposal adopted by the U.S. House of Representatives regarding health care financing.

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

H.R. 4872, the Health Care & Education Affordability Reconciliation Act of 2010: provisions relating to hospitals and physicians, including: Section 1106: physician-owned hospitals and self-referral; Section 2302: 340B program; Section 1104 and Section 1203: Medicare and Medicaid DSH Payments; Sections 1108 and 1109 involving geographic disparities in Medicare payment; Section 1105: Market basket updates; Section 1201: Federal funding for States; Section 1202: Payments to primary care physicians. H.R. 3590, Patient Protection and Affordable Care Act, provisions relating to hospitals, hospice, and physicians including: Section 3001: hospital value-based purchasing; Section 3125: low-volume hospital payment; Section 3401: productivity adjustments; Section 6001: physician-owned hospital and self-referral; Section 3121: outpatient hold harmless for hospitals; Sections 7101-7103: 340B Program; Section 3403: Independent Payment Advisory Board; Section 3025: hospital readmissions provision; Section 3124: extension of Medicare Dependent Hospital program; Section 3137: Section 508 reclassification; Section 9007: non profit hospital provision; Section 3105: ambulance services; Section 3008 and Section 2702: payment adjustment for hospital acquired conditions; Section 3133: Medicare DSH; Section 2551: Disproportionate Share Hospitals; Section 5501: primary care provisions; Section 5503: Graduate Medical Education; Sections 2001-2081: expansion of Medicaid, CHIP; Sections 1311-1343: CO-OPs and Exchanges; Section 3022: accountable care organizations; Section 3023: hospital bundling provision; Section 6401-6402, Program Integrity Provisions; Section 6501-6503, 6505, 6508, Medicaid Program Integrity Provisions. H.R. 2674, 340B Program Improvement Act, entire bill. S. 722 and H.R. 3506, Hospice Evaluation and Legitimate Payment Act, entire bills. S. 778, Protecting Access to Rural Therapy Services (PARTS) Act, entire bill. H.R. 3285, Medicare Equity Extension Act, entire bill. H.R. 3630, Middle Class Tax Relief and Job Creation Act of 2011, Title II, Subtitle C--Medicare Extensions; Other Health Provisions, Part 1--Medicare extensions, Section 2201. Physician payment update; Section 2202. Ambulance add-ons; Section 2203. Medicare payment for outpatient therapy services; Section 2204. Work geographic adjustment. Part 3--Offsets, Section 2223, Parity in Medicare payments for hospital outpatient department evaluation and management office visit services; Section 2224, Reduction of bad debt treated as an allowable cost; Section 2225, Rebasing of State DSH allotments for FY 2021. Part 2 of Subtitle C--Other Health Provisions, Sec. 2213. Modification to requirements for qualifying for exception to Medicare prohibition on certain physician referrals for hospitals. H.R. 3859 and S.1680, The Rural Hospital and Provider Equity (R-HOPE) Act of 2012, entire bills. H.R. 3630, The Middle Class Tax Relief and Job Creation Act of 2012, entire bill. H.R. 2461, Physician Pathology Services Continuity Act of 2011, entire bill. S. 3187, the FDA Safety and Innovation Act, entire bill. H.R. 5651, FDA Reform Act, entire bill. S. 2516, Food and Drug Administration Safety and Innovation Act, entire bill. H.R. 5943 and S. 2620, the Rural Hospital Access Act of 2012, entire bills. H.R. 876, Registered Nurse Safe Staffing Act of 2011, entire bill. H.R. 4966, Sequester Replacement Act of 2012, entire bill. H.R. 3839, the Drug Shortage Prevention Act, entire bill. H.R. 2245, the Preserving Access to Lifesaving Medications Act, entire bill. S. 1734, Generating Antibiotic Incentives Now Act of 2011, entire bill. 2012 Outpatient Prospective Payment System rule, focusing on provisions affecting physicians and hospitals including: policies related to the physician supervision of outpatient therapeutic services and hospital value-based purchasing program. 2012, 2013 Inpatient prospective payment system rules: entire rules. 2012 Hospice wage index proposed rule, entire rule. Changes to Hospital CoPs, entire rule. Reporting and Returning Medicare Overpayments, entire rule. Other issues: "Super Committee" deliberations related to S. 365, Budget Control Act of 2012. Proposals involving the Sustainable Growth Rate (SGR) formula. The Deficit Commission Report and President's 2013 budget proposal, including proposals that involve Medicare and Medicaid payments to hospitals. 2011 March CBO proposal to eliminate the CAH, SCH, MDH programs. Accountable Care Organizations regulations and the Innovation Center's demonstration programs. Medicare and Medicaid Recovery Audit Contractor programs. Geographic Variation in Medicare spending, IOM studies on high value and Medicare geographic adjusters. Medical Liability Reform. Medicare and Medicaid Electronic Health Record Payment Incentive Programs (Meaningful Use), including the release of the Stage 2 Meaningful Use regulation. Hospital wage index reform, including Section 3137(b) of the Affordable Care Act. Implementation of state health insurance exchanges.

Client expense: $62,554 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

H.R. 5: Health Act H.R. 5994: The Choice in Healthcare Act H.R. 5651: Food and Drug Administration Reform Act of 2012 H.R. 436: Health Care Cost Reduction Act of 2012 H.R. 5652: Sequester Replacement Reconciliation Act of 2012 S. 3187: Food and Drug Administration Safety and Innovation Act H.R.5943/S. 2620: The Rural Hospital Access Act of 2012 CMS-1588-P: Medicare Program; Proposed changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Proposed Rule CMS-0040-P: Administrative Simplification Act: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the Natioanl Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets; Proposed Rule

Client expense: $442,530 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), SENATE

Budget Sequestration, Medicare cuts, S.2620, HR 5943, Rural Hospital Access Act, sunscreen ingredient retinol palmitate, debt ceiling

Client expense: $10,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

-Developed and endorsed a joint letter from four state hospital associations to Secretary Sebelius regarding Medicare payments to certified registered nurse anesthetists for pain management services. Distributed a copy of the letter to the Missouri congressional delegation and requested that the legislators support the associations stance outlined in the letter. -Contacted the Republican members of the U.S. House of Representatives representing Missouri to express appreciation for their endorsement of a letter to the House Energy and Commerce Committee opposing budget reconciliation proposals that would reduce states capacity to use provider taxes to fund their Medicaid programs. -Communicated with Missouri congressional health staff regarding proposals to restrict states use of provider taxes to fund their Medicaid programs in budget reconciliation legislation pending in the House Energy and Commerce Committee. -Contacted the Missouri members of the U.S. House of Representatives to promote enactment of H.R. 5651 based on its provisions to reduce the incidence and severity of shortages of drugs and other pharmaceuticals. -Sent a letter to the CMS acting administrator regarding the revision in a final rule of 42 C.F.R. 482.12 to require selected hospitals, including governmental hospitals, to have a physician as a member of the hospital governing board. -Contacted offices of the Missouri members of the U.S. House of Representatives regarding hospitals and their placement in congressional districts redrawn in the redistricting process. -Contacted the Missouri congressional delegation to express opposition to restrictions on states use of provider taxes to fund their Medicaid programs as a funding mechanism for extending subsidized interest rates on federal Stafford student loans. -Discussed the development and sponsorship of legislation by a Missouri legislator that would set new standards governing the ability of Medicare program integrity contractors to require health care providers to submit medical records and supporting documentation for review. -Reviewed and commented on the provisions of H.R. 5707 (Physician Payment Innovation Act of 2012) at the request of a Missouri federal legislator. -Responded to congressional staff queries about the Medicare Payment Advisory Commissions report regarding the delivery and financing of hospitals and other health care services in rural regions. -Discussed with selected congressional health staff legislation (S. 2620, H.R. 5943) to reauthorize the Medicare Dependent Hospital program. -Participated in a meeting of state hospital associations convened by the CMS regional office as a forum to present and discuss selected regulatory and payment topics. -Urged the Missouri congressional delegation to: 1) consider hospitals need for stability and predictability in making their spending and policy decisions; 2) support provisions of H.R. 2245/S. 296/H.R. 3839 to respond to concerns about shortages of drugs and other pharmaceutical products; 3) reauthorize the Medicare Dependent Hospital program before it lapses on October 1, 2012; 4) repeal section 3141 of the Patient Protection and Affordable Care Act of 2010; 5) examine the administrative burdens associated with the demands for records by Medicare Recovery Audit Contractors and other program integrity initiatives; and 6) consider the Missouri Hospital Associations written observations regarding the budget proposal adopted by the U.S. House of Representatives regarding health care financing.

Client expense: $90,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE