Making Public Lands Public Access Act

H.R.39, Multinational Species Conservation Funds Reauthorization Act of 2013; H.R.47, Farmland Preservation and Land Conservation Act of 2013; H.R.250, To amend the Antiquities Act of 1906 to place additional requirements on the establishment of national monuments under that Act, and for other purposes; H.R.262/S.231, Multinational Species Conservation Funds Semipostal Stamp Reauthorization Act; H.R.542, To limit restrictions on deer hunting within the Kisatchie National Forest;H.R.576, Save Endangered Species Act of 2013; H.R.432, To prohibit the further extension or establishment of national monuments in Nevada except by express authorization of Congress; H.R.596/S.279, Public Lands Renewable Energy Development Act of 2013; H.R.686, Protect our Prairies Act; H.R.740/S.340, Southeast Alaska Native Land Entitlement Finalization and Jobs Protection Act; H.R.818, Healthy Forest Management and Wildfire Prevention Act; H.R.1137, Joint Ventures for Bird Habitat Conservation Act of 2013; H.R.1206, Permanent Electronic Duck Stamp Act of 2013; S.19, A bill to amend the Endangered Species Act of 1973 to establish a procedure for approval of certain settlements; S.37, Forest Jobs and Recreation Act of 2013; S.89, Migratory Bird Treaty Amendment Act of 2013; S.338, Land and Water Conservation Authorization and Funding Act of 2013; S.368, Federal Land Transaction Facilitation Act Reauthorization of 2013; H.R.322/S.1505, Hunting, Fishing, and Recreational Shooting Protection Act; S.285, Valles Caldera National Preserve Management Act; H.R.1825/S.170, Recreational Fishing and Hunting Heritage and Opportunities Act; H.R.1818/S.847, Polar Bear Conservation and Fairness Act of 2013; H.R.1819, Restoration of the U.S.-Russia Polar Bear Conservation Fund Act of 2013; H.R.1866, Enhancement of Species Survival Act; H.R.1526, Restoring Healthy Forests for Healthy Communities Act; S.1335, Sportsmen's Act; H.R.3590, Sportsmen's Heritage And Recreational Enhancement Act of 2013 (SHARE Act); H.R.3962, Making Public Lands Public Access Act; S.2363, Bipartisan Sportsmen's Act of 2014; S.2587/H.R.5052, Lawful Ivory Protection Act of 2014; Issues related to international wildlife trafficking, ivory ban, conservation and hunting.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges; Expressed concern to House and Senate leadership over the expiration, at the end of FY2015, of dedicated funding for Community Health Centers, the National Health Service Corps, and Teaching Health Centers. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013; advocated in Aug. 2014 for the Medicare Advantage Participants Bill of Rights, H.R. 4998 and S. 2552, that would prevent Medicare Advantage plans from terminating physicians from Medicare Advantage plan networks without sufficient notice or cause. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases; Advocated for at least a two-year extension of the Medicaid payment parity provision beyond its 2014 expiration date, namely through the Ensuring Access to Primary Care for Women & Children Act. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations; Advocated in Aug. 2014 for the Child Nicotine Poisoning Prevention Act of 2014, which gives the U.S. Consumer Product Safety Commission the authority to require the use of child-proof packaging on liquid nicotine containers sold to consumers. Advance Care Planning: Urged the Centers for Medicare & Medicaid Services to adopt the American Medical Associations new Current Procedural Terminology Codes for advance care planning.

Client expense: $225,016 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges; Expressed concern to House and Senate leadership over the expiration, at the end of FY2015, of dedicated funding for Community Health Centers, the National Health Service Corps, and Teaching Health Centers. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013; advocated in Aug. 2014 for the Medicare Advantage Participants Bill of Rights, H.R. 4998 and S. 2552, that would prevent Medicare Advantage plans from terminating physicians from Medicare Advantage plan networks without sufficient notice or cause. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases; Advocated for at least a two-year extension of the Medicaid payment parity provision beyond its 2014 expiration date, namely through the Ensuring Access to Primary Care for Women & Children Act. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations; Advocated in Aug. 2014 for the Child Nicotine Poisoning Prevention Act of 2014, which gives the U.S. Consumer Product Safety Commission the authority to require the use of child-proof packaging on liquid nicotine containers sold to consumers. Advance Care Planning: Urged the Centers for Medicare & Medicaid Services to adopt the American Medical Associations new Current Procedural Terminology Codes for advance care planning.

Client expense: $101,504 · Firm income: Not reported

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

Undertook lobbying activities relating to the maintenance/shared use of Johnson Valley Off-highway Recreational Area and Twentynine Palms Marine Corps Base in California. Monitored S 1197, the National Defense Authorization Act (NDAA) and undertook lobbying activities to include language relative to the maintenance/shared use of the Johnson Valley Off-highway Recreational Area in the final NDAA. Supported passage of HR 3304, the National Defense Authorization Act (NDAA) Undertook lobbying activities relating to the restoration and preservation of the Bonneville Salt Flats. Undertook lobbying activities to support efforts and potential legislative proposals to include a more collaborative process in land use designations in the United States. Monitored HR 48, the Open Space Preservation Promotion Act Monitored HR 126, the Corolla Wild Horses Protection Act Monitored HR 139, the Udall-Eisenhower Arctic Wilderness Act Monitored HR 445, the National Heritage Area Act Monitored HR 576, the Save Endangered Species Act Monitored HR 638, the National Wildlife Refuge Review Act Monitored HR 758, the Utah Land Sovereignty Act Supported HR 819/S 486, the Preserving Access to Cape Hatteras National Seashore Recreation Area Opposed HR 1187, the Northern Rockies Ecosystem Protection Act Supported HR 1459, the Ensuring Public Involvement in the Creation of National Monuments Act Opposed HR 1630 and S 769, to designate millions of acres of land in Utah as Red Rock wilderness Monitored HR 1633, the Small Land Tracts Conveyance Act Supported HR 1676, to protect the Johnson Valley Off-Highway Vehicle (OHV) Area Monitored HR 1683, the Columbine-Hondo Wilderness Act Supported HR 1776, the Clear Creek National recreation Area and Conservation Act Monitored HR 1799, the Arizona Sonoran Desert Heritage Act Monitored HR 1825, the Recreational Fishing and Hunting Heritage and Opportunities Act Monitored HR 1834, the 21st Century Great Outdoors Commission Act Supported HR 1960, the National Defense Authorization Act Monitored HR 2068, the Federal Land Transaction Facilitation Act Reauthorization Monitored HR 2192, the National Monument Designation Transparency and Accountability Act Opposed HR 2490, the Rogue Wilderness Area Expansion Act Opposed HR 2491, the Devils Staircase Wilderness Act Monitored HR 2511/S 1233, the Federal Land Freedom Act Monitored HR 2808, to designate certain National Forest System land in the Uinta-Wasatch-Cache National Forest in Salt Lake County, Utah, as wilderness, to facilitate a land exchange involving certain land in such National Forest, and for other purposes. Monitored HR 3008, the conveyance of a small parcel of National Forest Service land in Los Padres National Forest. Monitored HR 3022, the National Discovery Trails Act Monitored S 1572/HR 3287, the Protecting States, Opening Natural Parks Act Monitored HR 3409, the National Wildlife Refuge Expansion Limitation Act Monitored HR 3533, the Endangered Species Management Self-Determination Act Monitored HR 3606, the Emigrant Wilderness Historical Use Preservation Act Monitored HR 3661, the Public Access to Public Land Guarantee Act Monitored HR 3704, the Sedona-Red Rock National Scenic Area Act Monitored HR 3806, the Great Smoky Mountains National Park Agreement Act Monitored HR 3922, the Wild Olympics Wilderness and Wild and Scenic Rivers Act Monitored HR 3962, the Making Public Lands Public Access Act Monitored HR 4166, the Lake Berryessa Recreation Enhancement Act Supported HR 4315, the 21st Century Endangered Species Transparency Act Supported HR 4316, the Endangered Species Recovery Transparency Act Supported HR 4317, the State, Tribal, and Local Species Transparency and Recovery Act Supported HR 4318, the Endangered Species Litigation Reasonableness Act Supported HR 4371, add National to Johnson Valley OHV Recreation Area Supported HR 4716, the Sage Grouse Protection and Conservation Act Monitored HR 4858, the San Gabriel National Recreation Area Act Supported HR 4866, the Lesser Prairie Chicken Voluntary Recovery Act Supported HR 4886, the National Forest System Trails Stewardship Act Supported HR 5204, the Federal Lands Recreation Enhancement Modernization Act Monitored HR5311, the Rocky Mountain Recreation and Wilderness Preservation Act Supported Utah Public Lands Initiative Monitored S 60, the Western States National Historic Trails Study Act Monitored S 61, the California Coastal National Monument Expansion Act Monitored S 341, the San Juan Mountains Wilderness Act Monitored S 352, the Devils Staircase Wilderness Act Monitored S 473, ensuring that Federal Register notices submitted to BLM are reviewed in a timely manner Monitored S 801, the Prairie Protection Act Monitored S 974, the Las Vegas Valley Public Land and Tule Springs Fossil Beds National Monument Act Monitored S 1054, the Gold Butte National Conservation Area Act Monitored S 1160, the Complete Americas Great Trails Act Monitored S 1167, the Elko Motocross and Tribal Conveyance Act Monitored S 1232, the Great Lakes Ecological and Economic Protection Act Monitored S 1237, the Omnibus Territories Act Monitored S 1309, a bill to withdraw and reserve certain public land under the jurisdiction of the Secretary of the Interior for military uses, and for other purposes. Monitored S 1415, the Canyon Mountain Land Conveyance Act Monitored S 1430, the Idaho wilderness water Resources Protection Act Monitored S 1520, the York River Wild and Scenic River Study Act Monitored S 1784, the Oregon and California Land Grant Act Monitored S 1794, the Browns Canyon National Monument and Wilderness Act+ Monitored S 1805, the Organ Mountains-Desert Peaks Conservation Act Monitored S 1829, to modify the boundaries of Cibola National Forest in New Mexico Monitored S 1888, the Inyo National Forest Land Exchange Act Monitored S 2289, the National Defense Authorization Act for Fiscal Year 2015 Supported S 2394, the Sage Grouse Protection and Conservation Act Supported S 2575, the Sage-Grouse Accountability and Private Conservation Act Monitored S 2623, to prohibit land management modifications relating to the Lesser Prairie Chicken Supported S 2630, a bill to amend the Endangered Species Act of 1973 Supported S 2635, the 21st Century Endangered Species Transparency Act Supported S 2677, the Lesser Prairie Chicken Voluntary Recovery Act

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

S 368, HR 2068 Federal Land Transaction Facilitation Act Reauthorization S 916, HR 1033 Revolutionary War and War of 1812 battlefields S 312, HR 663 Carson National Forest Boundary Adjustment Act HR 87 Castle Nugent NHS Establishment ActHR 1230, S 353 Molalla River Wild and Scenic Rivers Act S 338 Land and Water Conservation Authorization and Funding Act S 371, HR 706 Blackstone River Valley National Historic Park S 646 National Endowment for the Oceans HR 1021 LAND Act HR 712, S 1140 Highlands Conservation Act Extension S 618 Pacific Islands Parks Act of 2013 S 509, HR 993 Fruit Heights Land Conveyance Act HR 638 National Wildlife Refuge Review Act HR 2208, S 741 NAWCA Extension Act S 1139, HR 2636 Hudson River Valley Special Resource Study Act S 1554 HUNT Act S 1996, S 2363, S1335 Sportsmen's Act S 2604 A bill to authorize the sale of certain National Forest System land in the State of Georgia HR 4551 Forest Legacy Management Flexibility Act S 1875, HR 3992 Wildfire Disaster Funding Act HR 3962 Making Public Lands Public Access Act HR 4858 San Gabriel National Recreation Act HR 5074 Land Adjacency Notification and Disclosure Act HR 4736 North Country National Scenic Trail Route Adjustment Act HR 1351, S 360 The Public Lands Service Corps Act

Client expense: $36,416 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Army, Dept of (Corps of Engineers), Council on Environmental Quality (CEQ), Defense, Dept of (DOD), Environmental Protection Agency (EPA), Executive Office of the President (EOP), Federal Emergency Management Agency (FEMA), HOUSE OF REPRESENTATIVES, Housing & Urban Development, Dept of (HUD), Interior, Dept of (DOI), Natl Oceanic & Atmospheric Administration (NOAA), Office of Management & Budget (OMB), SENATE, Transportation, Dept of (DOT)

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013; advocated in Aug. 2014 for the Medicare Advantage Participants Bill of Rights, H.R. 4998 and S. 2552, that would prevent Medicare Advantage plans from terminating physicians from Medicare Advantage plan networks without sufficient notice or cause. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases; Advocated for at least a two-year extension of the Medicaid payment parity provision beyond its 2014 expiration date, namely through S. 2694, the Ensuring Access to Primary Care for Women & Children Act. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations; Advocated in Aug. 2014 for the Child Nicotine Poisoning Prevention Act of 2014, which gives the U.S. Consumer Product Safety Commission the authority to require the use of child-proof packaging on liquid nicotine containers sold to consumers. Medicares Prior Authorization Process for Certain Durable Medical Equipment: Commented in July 2014 to CMS on the proposed rule requesting clarification and making recommendations on changes to the Medicare benefit structure to ensure that any proposed changes not increase the administrative burden on physicians or other health care professionals.

Client expense: $270,324 · Firm income: Not reported

Government targets: Centers For Disease Control & Prevention (CDC), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), President of the U.S., SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013; advocated in Aug. 2014 for the Medicare Advantage Participants Bill of Rights, H.R. 4998 and S. 2552, that would prevent Medicare Advantage plans from terminating physicians from Medicare Advantage plan networks without sufficient notice or cause. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases; Advocated for at least a two-year extension of the Medicaid payment parity provision beyond its 2014 expiration date, namely through S. 2694, the Ensuring Access to Primary Care for Women & Children Act. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations; Advocated in Aug. 2014 for the Child Nicotine Poisoning Prevention Act of 2014, which gives the U.S. Consumer Product Safety Commission the authority to require the use of child-proof packaging on liquid nicotine containers sold to consumers. Medicares Prior Authorization Process for Certain Durable Medical Equipment: Commented in July 2014 to CMS on the proposed rule requesting clarification and making recommendations on changes to the Medicare benefit structure to ensure that any proposed changes not increase the administrative burden on physicians or other health care professionals.

Client expense: $101,924 · Firm income: Not reported

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

H.R.39, Multinational Species Conservation Funds Reauthorization Act of 2013; H.R.47, Farmland Preservation and Land Conservation Act of 2013; H.R.250, To amend the Antiquities Act of 1906 to place additional requirements on the establishment of national monuments under that Act, and for other purposes; H.R.262/S.231, Multinational Species Conservation Funds Semipostal Stamp Reauthorization Act; H.R.542, To limit restrictions on deer hunting within the Kisatchie National Forest;H.R.576, Save Endangered Species Act of 2013; H.R.432, To prohibit the further extension or establishment of national monuments in Nevada except by express authorization of Congress; H.R.596/S.279, Public Lands Renewable Energy Development Act of 2013; H.R.686, Protect our Prairies Act; H.R.740/S.340, Southeast Alaska Native Land Entitlement Finalization and Jobs Protection Act; H.R.818, Healthy Forest Management and Wildfire Prevention Act; H.R.1137, Joint Ventures for Bird Habitat Conservation Act of 2013; H.R.1206, Permanent Electronic Duck Stamp Act of 2013; S.19, A bill to amend the Endangered Species Act of 1973 to establish a procedure for approval of certain settlements; S.37, Forest Jobs and Recreation Act of 2013; S.89, Migratory Bird Treaty Amendment Act of 2013; S.338, Land and Water Conservation Authorization and Funding Act of 2013; S.368, Federal Land Transaction Facilitation Act Reauthorization of 2013; H.R.322/S.1505, Hunting, Fishing, and Recreational Shooting Protection Act; S.285, Valles Caldera National Preserve Management Act; H.R.1825/S.170, Recreational Fishing and Hunting Heritage and Opportunities Act; H.R.1818/S.847, Polar Bear Conservation and Fairness Act of 2013; H.R.1819, Restoration of the U.S.-Russia Polar Bear Conservation Fund Act of 2013; H.R.1866, Enhancement of Species Survival Act; H.R.1526, Restoring Healthy Forests for Healthy Communities Act; S.1335, Sportsmen's Act; H.R.3590, Sportsmen's Heritage And Recreational Enhancement Act of 2013 (SHARE Act); H.R.3962, Making Public Lands Public Access Act; S.2363, Bipartisan Sportsmen's Act of 2014; S.2587/H.R.5052, Lawful Ivory Protection Act of 2014; Issues related to international wildlife trafficking, ivory ban, conservation and hunting.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Undertook lobbying activities relating to the maintenance/shared use of Johnson Valley Off-highway Recreational Area and Twentynine Palms Marine Corps Base in California. Monitored S 1197, the National Defense Authroization Act (NDAA) and undertook lobbying activities to include language relative to the maintenance/shared use of the Johnson Valley Off-highway Recreational Area in the final NDAA. Supported passage of HR 3304, the National Defense Authorization Act (NDAA) Undertook lobbying activities relating to the restoration and preservation of the Bonneville Salt Flats. Undertook lobbying activities to support efforts and potential legislative proposals to include a more collaborative process in land use designations in the United States. Monitored HR 48, the Open Space Preservation Promotion Act Monitored HR 126, the Corolla Wild Horses Protection Act Monitored HR 139, the Udall-Eisenhower Arctic Wilderness Act Monitored HR 445, the National Heritage Area Act Monitored HR 576, the Save Endangered Species Act Monitored HR 638, the National Wildlife Refuge Review Act Monitored HR 758, the Utah Land Sovereignty Act Supported HR 819/S 486, the Preserving Access to Cape Hatteras National Seashore Recreation Area Opposed HR 1187, the Northern Rockies Ecosystem Protection Act Supported HR 1459, the Ensuring Public Involvement in the Creation of National Monuments Act Opposed HR 1630 and S 769, to designate millions of acres of land in Utah as Red Rock wilderness Monitored HR 1633, the Small Land Tracts Conveyance Act Supported HR 1676, to protect the Johnson Valley Off-Highway Vehicle (OHV) Area Monitored HR 1683, the Columbine-Hondo Wilderness Act Supported HR 1776, the Clear Creek National recreation Area and Conservation Act Monitored HR 1799, the Arizona Sonoran Desert Heritage Act Monitored HR 1825, the Recreational Fishing and Hunting Heritage and Opportunities Act Monitored HR 1834, the 21st Century Great Outdoors Commission Act Supported HR 1960, the National Defense Authorization Act Monitored HR 2068, the Federal Land Transaction Facilitation Act Reauthorization Monitored HR 2192, the National Monument Designation Transparency and Accountability Act Opposed HR 2490, the Rogue Wilderness Area Expansion Act Opposed HR 2491, the Devils Staircase Wilderness Act Monitored HR 2511/S 1233, the Federal Land Freedom Act Monitored HR 2808, to designate certain National Forest System land in the Uinta-Wasatch-Cache National Forest in Salt Lake County, Utah, as wilderness, to facilitate a land exchange involving certain land in such National Forest, and for other purposes. Monitored HR 3008, the conveyance of a small parcel of National Forest Service land in Los Padres National Forest. Monitored HR 3022, the National Discovery Trails Act Monitored S 1572/HR 3287, the Protecting States, Opening Natural Parks Act Monitored HR 3409, the National Wildlife Refuge Expansion Limitation Act Mintored HR 3533, the Endangered Species Management Self-Determination Act Monitored HR 3606, the Emigrant Wilderness Historical Use Preservation Act Monitored HR 3661, the Public Access to Public Land Guarantee Act Monitored HR 3704, the Sedona-Red Rock National Scenic Area Act Monitored HR 3806, the Great Smoky Mountains National Park Agreement Act Monitored HR 3922, the Wild Olympics Wilderness and Wild and Scenic Rivers Act of 2014 Monitored HR 3962, the Making Public Lands Public Access Act Monitored HR 4166, the Lake Berryessa Recreation Enhancement Act of 2014 Supported HR 4315, the 21st Century Endangered Species Transparency Act Supported HR 4316, the Endangered Species Recovery Transparency Act Supported HR 4317, the State, Tribal, and Local Species Transparency and Recovery Act Supported HR 4318, the Endangered Species Litigation Reasonableness Act Supported HR 4371, add National to Johnson Valley OHV Recreation Area Supported HR 4716, the Sage Grouse Protection and Conservation Act Supported Utah Public Lands Initiative Monitored S 60, the Western States National Historic Trails Study Act Monitored S 61, the California Coastal National Monument Expansion Act Monitored S 341, the San Juan Mountains Wilderness Act Monitored S 352, the Devils Staircase Wilderness Act Monitored S 473, ensuring that Federal Register notices submitted to BLM are reviewed in a timely manner Monitored S 801, the Prairie Protection Act Monitored S 974, the Las Vegas Valley Public Land and Tule Springs Fossil Beds National Monument Act Monitored S 1054, the Gold Butte National Conservation Area Act Monitored S 1160, the Complete Americas Great Trails Act Monitored S 1167, the Elko Motocross and Tribal Conveyance Act Monitored S 1232, the Great Lakes Ecological and Economic Protection Act Monitored S 1237, the Omnibus Territories Act Monitored S 1309, a bill to withdraw and reserve certain public land under the jurisdiction of the Secretary of the Interior for military uses, and for other purposes. Monitored S 1415, the Canyon Mountain Land Conveyance Act Monitored S 1430, the Idaho wilderness water Resources Protection Act Monitored S 1520, the York River Wild and Scenic River Study Act Monitored S 1784, the Oregon and California Land Grant Act Monitored S 1794, the Browns Canyon National Monument and Wilderness Act+ Monitored S 1805, the Organ Mountains-Desert Peaks Conservation Act Monitored S 1829, to modify the boundaries of Cibola National Forest in New Mexico Monitored S 1888, the Inyo National Forest Land Exchange Act

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S 338 Land and Water Conservation Authorization and Funding Act; HR 1021 LAND Act; HR 2208 S 741 NAWCA Extension Act; S 1554 HUNT Act; S 1996, S 2363, S 1335 Sportsmen's Act; HR 4551 Forest Legacy Management Flexibility Act; S 1875, HR 3992 Wildfire Disaster Funding Act;HR 3962 Making Public Lands Public Acess Act S 661 HR 2727 HR 3590 Sportsmen's Heritage and Recreational Enhancement Act of 2013

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

Government targets: Agriculture, Dept of (USDA), Council on Environmental Quality (CEQ), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Interior, Dept of (DOI), Office of Management & Budget (OMB), SENATE

S. 1875, Wildfire Disaster Funding Act of 2013, all provisions S. 2363, Bipartisan Sportsmen's Act of 2014, all provisions S. 2389, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industryS. 2410, Carl Levin National Defense Authorization Act for Fiscal Year 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industry S. 2437, Commerce, Justice, Science, and Related Agencies Appropriations Act, 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industry H.R. 3590, Target Practice and Marksmanship Training Support Act, all provisions H.R. 3962, Making Public Lands Public Access Act, all provisions H.R. 3992, Wildfire Disaster Funding Act of 2014, all provisions H.R. 4435, Howard P. "Buck" McKeon National Defense Authorization Act for Fiscal Year 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industry H.R. 4660, Commerce, Justice, Science, and Related Agencies Appropriations Act, 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industry H.R. 4749, To modify the definition of "antique firearm", all provisions. H.R. 4800, Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act, 2015, all provisions relating to or affecting the firearms, ammunition, hunting and the shooting sports industry H.R. 4934, Regulatory Agency Demilitarization Act, all provisions H.R. 4986, End Operation Choke Point Act of 2014, all provisions H.R. 5052, Lawful Ivory Protection Act of 2014, all provisions

Client expense: $810,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S 368, HR 2068 Federal Land Transaction Facilitation Act Reauthorization S 916, HR 1033 Revolutionary War and War of 1812 battlefields S 312, HR 663 Carson National Forest Boundary Adjustment Act HR 87 Castle Nugent NHS Establishment ActHR 1230, S 353 Molalla River Wild and Scenic Rivers Act S 338 Land and Water Conservation Authorization and Funding Act S 371, HR 706 Blackstone River Valley National Historic Park S 646 National Endowment for the Oceans HR 1021 LAND Act Chattahoochee River National Recreation Area Boundary Study Act (bill not yet introduced) HR 712, S 1140 Highlands Conservation Act Extension HR 1411, S61 California Coastal National Monument Expansion Act S 618 Pacific Islands Parks Act of 2013 S 509, HR 993 Fruit Heights Land Conveyance Act HR 638 National Wildlife Refuge Review Act HR 2208, S 741 NAWCA Extension Act S 1139, HR 2636 Hudson River Valley Special Resource Study Act S 1554 HUNT Act S 1996, S 2363, S1335 Sportsmen's Act S 2604 A bill to authorize the sale of certain National Forest System land in the State of Georgia HR 4551 Forest Legacy Management Flexibility Act S 1875, HR 3992 Wildfire Disaster Funding Act HR 3962 Making Public Lands Public Access Act HR 4858 San Gabriel National Recreation Act

Client expense: $49,879 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Army, Dept of (Corps of Engineers), Council on Environmental Quality (CEQ), Defense, Dept of (DOD), Environmental Protection Agency (EPA), Executive Office of the President (EOP), Federal Emergency Management Agency (FEMA), HOUSE OF REPRESENTATIVES, Housing & Urban Development, Dept of (HUD), Interior, Dept of (DOI), Natl Oceanic & Atmospheric Administration (NOAA), Office of Management & Budget (OMB), SENATE, Transportation, Dept of (DOT)

H.R.39, Multinational Species Conservation Funds Reauthorization Act of 2013; H.R.47, Farmland Preservation and Land Conservation Act of 2013; H.R.250, To amend the Antiquities Act of 1906 to place additional requirements on the establishment of national monuments under that Act, and for other purposes; H.R.262/S.231, Multinational Species Conservation Funds Semipostal Stamp Reauthorization Act; H.R.542, To limit restrictions on deer hunting within the Kisatchie National Forest;H.R.576, Save Endangered Species Act of 2013; H.R.432, To prohibit the further extension or establishment of national monuments in Nevada except by express authorization of Congress; H.R.596/S.279, Public Lands Renewable Energy Development Act of 2013; H.R.686, Protect our Prairies Act; H.R.740/S.340, Southeast Alaska Native Land Entitlement Finalization and Jobs Protection Act; H.R.818, Healthy Forest Management and Wildfire Prevention Act; H.R.1137, Joint Ventures for Bird Habitat Conservation Act of 2013; H.R.1206, Permanent Electronic Duck Stamp Act of 2013; S.19, A bill to amend the Endangered Species Act of 1973 to establish a procedure for approval of certain settlements; S.37, Forest Jobs and Recreation Act of 2013; S.89, Migratory Bird Treaty Amendment Act of 2013; S.338, Land and Water Conservation Authorization and Funding Act of 2013; S.368, Federal Land Transaction Facilitation Act Reauthorization of 2013; H.R.322/S.1505, Hunting, Fishing, and Recreational Shooting Protection Act; S.285, Valles Caldera National Preserve Management Act; H.R.1825/S.170, Recreational Fishing and Hunting Heritage and Opportunities Act; H.R.1818/S.847, Polar Bear Conservation and Fairness Act of 2013; H.R.1819, Restoration of the U.S.-Russia Polar Bear Conservation Fund Act of 2013; H.R.1866, Enhancement of Species Survival Act; H.R.1526, Restoring Healthy Forests for Healthy Communities Act; S.1335, Sportsmen's Act; H.R.3590, Sportsmen's Heritage And Recreational Enhancement Act of 2013 (SHARE Act); H.R.3962, Making Public Lands Public Access Act; S.2363, Bipartisan Sportsmen's Act of 2014; Issues related to international wildlife trafficking, ivory ban, conservation and hunting.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations.

Client expense: $322,966 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories.State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Advocated for the Saving Lives, Saving Costs Act (H.R. 4106), which establishes a framework for health care liability lawsuits to undergo review by independent medical review panels if health care professionals (practicing physicians or their agents or employees) allege adherence to applicable clinical practice guidelines in the provision of health care goods or services. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases. Tobacco Regulation: Expressed strong opposition to House appropriators to any amendment that would exempt any type of cigar from regulation under the Family Smoking Prevention and Tobacco Control Act, P.L. 111-31, or would impede the rulemaking process the Food and Drug Administration (FDA) has initiated to determine the appropriate level of oversight for tobacco products not currently regulated by the agency; the FDA should retain the authority to regulate all tobacco products, including cigars, and should be permitted to use a science-based process for determining those regulations.

Client expense: $98,325 · Firm income: Not reported

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

See attachedUndertook lobbying activities relating to the maintenance/shared use of Johnson Valley Off-highway Recreational Area and Twentynine Palms Marine Corps Base in California. Monitored S 1197, the National Defense Authroization Act (NDAA) and undertook lobbying activities to include language relative to the maintenance/shared use of the Johnson Valley Off-highway Recreational Area in the final NDAA. Supported passage of HR 3304, the National Defense Authorization Act (NDAA) Undertook lobbying activities relating to the restoration and preservation of the Bonneville Salt Flats. Undertook lobbying activities to support efforts and potential legislative proposals to include a more collaborative process in land use designations in the United States. Monitored HR 48, the Open Space Preservation Promotion Act Monitored HR 126, the Corolla Wild Horses Protection Act Monitored HR 139, the Udall-Eisenhower Arctic Wilderness Act Monitored HR 445, the National Heritage Area Act Monitored HR 576, the Save Endangered Species Act Monitored HR 638, the National Wildlife Refuge Review Act Monitored HR 758, the Utah Land Sovereignty Act Supported HR 819/S 486, the Preserving Access to Cape Hatteras National Seashore Recreation Area Opposed HR 1187, the Northern Rockies Ecosystem Protection Act Supported HR 1459, the Ensuring Public Involvement in the Creation of National Monuments Act Opposed HR 1630 and S 769, to designate millions of acres of land in Utah as Red Rock wilderness Monitored HR 1633, the Small Land Tracts Conveyance Act Supported HR 1676, to protect the Johnson Valley Off-Highway Vehicle (OHV) Area Monitored HR 1683, the Columbine-Hondo Wilderness Act Supported HR 1776, the Clear Creek National recreation Area and Conservation Act Monitored HR 1799, the Arizona Sonoran Desert Heritage Act Monitored HR 1825, the Recreational Fishing and Hunting Heritage and Opportunities Act Monitored HR 1834, the 21st Century Great Outdoors Commission Act Supported HR 1960, the National Defense Authorization Act Monitored HR 2068, the Federal Land Transaction Facilitation Act ReauthorizationMonitored HR 2192, the National Monument Designation Transparency and Accountability Act Opposed HR 2490, the Rogue Wilderness Area Expansion Act Opposed HR 2491, the Devils Staircase Wilderness Act Monitored HR 2511/S 1233, the Federal Land Freedom Act Monitored HR 2808, to designate certain National Forest System land in the Uinta-Wasatch-Cache National Forest in Salt Lake County, Utah, as wilderness, to facilitate a land exchange involving certain land in such National Forest, and for other purposes. Monitored HR 3008, the conveyance of a small parcel of National Forest Service land in Los Padres National Forest. Monitored HR 3022, the National Discovery Trails Act Monitored S 1572/HR 3287, the Protecting States, Opening Natural Parks Act Monitored HR 3409, the National Wildlife Refuge Expansion Limitation Act Mintored HR 3533, the Endangered Species Management Self-Determination Act Monitored HR 3606, the Emigrant Wilderness Historical Use Preservation Act Monitored HR 3661, the Public Access to Public Land Guarantee Act Monitored HR 3704, the Sedona-Red Rock National Scenic Area Act Monitored HR 3806, the Great Smoky Mountains National Park Agreement Act Monitored HR 3922, the Wild Olympics Wilderness and Wild and Scenic Rivers Act of 2014 Monitored HR 3962, the Making Public Lands Public Access Act Monitored HR 4166, the Lake Berryessa Recreation Enhancement Act of 2014 Supported HR 4315, the 21st Century Endangered Species Transparency Act Supported HR 4316, the Endangered Species Recovery Transparency Act Supported HR 4317, the State, Tribal, and Local Species Transparency and Recovery Act Supported HR 4318, the Endangered Species Litigation Reasonableness Act Suported HR 4371, the add National to Johnson Valley OHV Recreation Area Supported Utah Public Lands Initiative Monitored S 60, the Western Sates National Historic Trails Study Act Monitored S 61, the California Coastal National Monument Expansion ActMonitored S 341, the San Juan Mountains Wilderness Act Monitored S 352, the Devils Staircase Wilderness Act Monitored S 473, ensuring that Federal Register notices submitted to BLM are reviewed in a timely manner Monitored S 801, the Prairie Protection Act Monitored S 974, the Las Vegas Valley Public Land and Tule Springs Fossil Beds National Monument Act Monitored S 1054, the Gold Butte National Conservation Area Act Monitored S 1160, the Complete Americas Great Trails Act Monitored S 1167, the Elko Motocross and Tribal Conveyance Act Monitored S 1232, the Great Lakes Ecological and Economic Protection Act Monitored S 1237, the Omnibus Territories Act Monitored S 1309, a bill to withdraw and reserve certain public land under the jurisdiction of the Secretary of the Interior for military uses, and for other purposes. Monitored S 1415, the Canyon Mountain Land Conveyance Act Monitored S 1430, the Idaho wilderness water Resources Protection Act Monitored S 1520, the York River Wild and Scenic River Study Act Monitored S 1784, the Oregon and California Land Grant Act Monitored S 1794, the Browns Canyon National Monument and Wilderness Act+ Monitored S 1805, the Organ MountainsDesert Peaks Conservation Act Monitored S 1829, to modify the boundaries of Cibola National Forest in New Mexico Monitored S 1888, the Inyo National Forest Land Exchange Act

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

Government targets: Bureau of Land Management (BLM), HOUSE OF REPRESENTATIVES, SENATE, U.S. Forest Service

H.R.39, Multinational Species Conservation Funds Reauthorization Act of 2013; H.R.47, Farmland Preservation and Land Conservation Act of 2013; H.R.250, To amend the Antiquities Act of 1906 to place additional requirements on the establishment of national monuments under that Act, and for other purposes; H.R.262, Multinational Species Conservation Funds Semipostal Stamp Reauthorization Act; H.R.542, To limit restrictions on deer hunting within the Kisatchie National Forest;H.R.576, Save Endangered Species Act of 2013; H.R.432, To prohibit the further extension or establishment of national monuments in Nevada except by express authorization of Congress; H.R.596, Public Lands Renewable Energy Development Act of 2013; H.R.686, Protect our Prairies Act; H.R.740, Southeast Alaska Native Land Entitlement Finalization and Jobs Protection Act; H.R.818, Healthy Forest Management and Wildfire Prevention Act; H.R.1137, Joint Ventures for Bird Habitat Conservation Act of 2013; H.R.1206, Permanent Electronic Duck Stamp Act of 2013; S.10, Agriculture Reform, Food, and Jobs Act of 2013; S.19, A bill to amend the Endangered Species Act of 1973 to establish a procedure for approval of certain settlements; S.37, Forest Jobs and Recreation Act of 2013; S.89, Migratory Bird Treaty Amendment Act of 2013; S.170, Recreational Fishing and Hunting Heritage and Opportunities Act; S.231, Multinational Species Conservation Funds Semipostal Stamp Reauthorization Act of 2013; S.279, Public Land Renewable Energy Development Act of 2013; S.338, Land and Water Conservation Authorization and Funding Act of 2013; S.340, Southeast Alaska Native Land Entitlement Finalization and Jobs Protection Act; S.368, Federal Land Transaction Facilitation Act Reauthorization of 2013; H.R.322/S.1505, Hunting, Fishing, and Recreational Shooting Protection Act; S.285, Valles Caldera National Preserve Management Act; H.R.1825/S.170, Recreational Fishing and Hunting Heritage and Opportunities Act; S.954, Agriculture Reform, Food, and Jobs Act of 2013; H.R.2642, Federal Agriculture Reform and Risk Management Act of 2013; H.R.1818/S.847, Polar Bear Conservation and Fairness Act of 2013; H.R.1819, Restoration of the U.S.-Russia Polar Bear Conservation Fund Act of 2013; H.R.1866, Enhancement of Species Survival Act; H.R.1526, Restoring Healthy Forests for Healthy Communities Act; S.1335, Sportsmen's Act; H.R.3590, Sportsmen's Heritage And Recreational Enhancement Act of 2013 (SHARE Act); H.R.3962, Making Public Lands Public Access Act; S.1996, Bipartisan Sportsmen's Act of 2014; Issues related to international wildlife trafficking, conservation and hunting.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage: Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents.The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act.Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases. Medicare Advantage Program: Urged the Centers for Medicare & Medicaid Services (CMS) to take immediate action to ensure that Medicare beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy.

Client expense: $257,236 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014; Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system; Advocated for H.R. 4015/S.2000, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014, legislation introduced on Feb. 6, 2014 to repeal the SGR and transition to a new value-based payment and delivery system. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage; Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY2015 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage:Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents.The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act. Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases.Medicare Advantage Program: Urged the Centers for Medicare & Medicaid Services (CMS) to take immediate action to ensure that Medicare beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy.

Client expense: $107,809 · Firm income: Not reported

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

Establish and preserve accountable care organizations in California, preserve funding for certain Medicare Advantage plans; establish medical homes; establish CMS innovation center (H.R. 3962, Sec. 1301, 1302, 1907; Div. B, Title 1,Subtitle D; Affordable Health Care for America Act (H.R. 3590, Sec. 3021, 3022, 9010; Part III, Subtitle C, Patient Protection and Affordable Care Act)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014. Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system. Sequestration: Advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY 2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA) Function 550) in the FY 2014 budget resolutions. FY2014 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, the National Institutes of Health (NIH), the Centers for Disease Control (CDC), GME; Urged Congress not to terminate AHRQ. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs.Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation.Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act. Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases. Medicare Advantage Program: Urged the Centers for Medicare & Medicaid Services (CMS) to take immediate action to ensure that Medicare beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy.

Client expense: $214,639 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which was scheduled to take effect on January 1, 2014. Advocated for H.R. 2810, the SGR Repeal and Medicare Beneficiary Access Act of 2013, which would repeal the SGR and transition to a new value-based payment and delivery system. Sequestration: Advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. Advocated to protect Medicare beneficiary access to health care services by preserving existing Medicare financing for Graduate Medical Education (GME). FY 2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA) Function 550) in the FY 2014 budget resolutions. FY2014 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, the National Institutes of Health (NIH), the Centers for Disease Control (CDC), GME; Urged Congress not to terminate AHRQ. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs.Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the "Essential Health Benefits Bulletin," issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation.Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury. Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act. Medicaid Pay Parity: Advocated for extending for at least two more years, beyond 2014, the Medicaid primary care payment increase, as enacted under the Affordable Care Act, which has only recently been implemented in a majority of states, and (2) including physicians practicing obstetrics and gynecology as qualified specialties, subject to the current eligibility requirement that at least 60 percent of their Medicaid billings are the primary care services as defined by the authorizing legislation, for the purposes of qualifying for the Medicaid primary care increases. Medicare Advantage Program: Urged the Centers for Medicare & Medicaid Services (CMS) to take immediate action to ensure that Medicare beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy.

Client expense: $107,046 · Firm income: Not reported

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

Establish and preserve accountable care organizations in California, preserve funding for certain Medicare Advantage plans; establish medical homes; establish CMS innovation center (H.R. 3962, Sec. 1301, 1302, 1907; Div. B, Title I, Subtitle D; Affordable Health Care for America Act. H.R. 3590, Sec. 3021, 3022, 9010; Part III, Subtitle C, Patient Protection and Affordable Care Act)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R.3200 - America's Affordable Health Choices Act of 2009; H.R.3962 - Affordable Health Care for America Act; H.R.3590 - Patient Protection and Affordable Care Act; H.R.4872 - Health Care and Education Affordability Reconciliation Act of 2010; Health Care Reform and Medicare & Implementation. Health policy. Medicaid Funding issues.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which is scheduled to take effect on January 1, 2014. Sequestration: Advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. FY 2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA) Function 550) in the FY 2014 budget resolutions. FY2014 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA);; Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, the National Institutes of Health (NIH), the Centers for Disease Control (CDC), GME; Urged Congress not to terminate AHRQ. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services;and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury.Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act. Chronic Care Management Codes/CPT 2014 Guidelines: expressed gratitude to CMS for its support of the Complex Chronic Care Management (CCCM) services and for proposing adoption of a number of provisions included in our multispecialty proposal and the CPT 2014 guidelines; made further recommendations. Additional legislation/policy: Supported the Medical Neutrality Protection Act of 2013 (H.R. 2033) which would establish the protection of medical neutrality as a policy priority of the United States, supported the intent of the Accuracy in Medicare Physician Payment (H.R. 2545) and requested changes/clarifications to ensure that it is consistent with the original MedPAC recommendation, particularly as it relates to the RUC, advocated that tobacco control measures and tobacco products are carved out of existing and future trade agreements, including the Trans-Pacific Partnership (TPP), a 12-nation agreement currently under negotiation.

Client expense: $274,606 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.Advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which is scheduled to take effect on January 1, 2014. Sequestration: Advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. FY 2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA) Function 550) in the FY 2014 budget resolutions. FY2014 Appropriations: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA);; Supported funding to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for funding for AHRQ, the Health Resources and Services Administration (HRSA); Title VII, Section 747, Primary Care Training and Enhancement; National Health Service Corps, Community Health Centers Fund, National Health Care Workforce Commission, the Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, the National Institutes of Health (NIH), the Centers for Disease Control (CDC), GME; Urged Congress not to terminate AHRQ. Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. Advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Advocated that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage. Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services;and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Advocated to repeal the mandate that requires a prescription for over-the-counter medications purchased through a Health Savings Account. Advocated for legislation that would provide coverage under Medicare for voluntary consultations between doctors and patients to discuss advance care plans, as included in H.R. 1173, the Personalize Your Care Act of 2013. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury.Workforce: Advocated for H.R. 1201, The Training Tomorrow's Doctors Today Act, S. 577, the Resident Physician Shortage Reduction Act of 2013, H.R. 487, the Primary Care Workforce Access and Improvement Act of 2013, and legislation to permanently reauthorize the Conrad State 30 J-1 visa waiver program through S. 616, the Conrad State 30 and Physician Access Act. Chronic Care Management Codes/CPT 2014 Guidelines: expressed gratitude to CMS for its support of the Complex Chronic Care Management (CCCM) services and for proposing adoption of a number of provisions included in our multispecialty proposal and the CPT 2014 guidelines; made further recommendations. Additional legislation/policy: Supported the Medical Neutrality Protection Act of 2013 (H.R. 2033) which would establish the protection of medical neutrality as a policy priority of the United States, supported the intent of the Accuracy in Medicare Physician Payment (H.R. 2545) and requested changes/clarifications to ensure that it is consistent with the original MedPAC recommendation, particularly as it relates to the RUC, advocated that tobacco control measures and tobacco products are carved out of existing and future trade agreements, including the Trans-Pacific Partnership (TPP), a 12-nation agreement currently under negotiation.

Client expense: $112,286 · Firm income: Not reported

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

Monitor issues pertaining to the Dietary Supplement Health and Education Act (DSHEA). Affordable Health Care for America (H.R. 3962). Patient Protection and Affordable Care Act (PL 111-148). Monitor and explain impacts of NDI guidance issued by the FDA.

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

Government targets: Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, SENATE

Implementation of H.R. 3590, The Patient Protection and Affordable Care Act Sections (P.L. 111-148) Title III--Improving the Quality and Efficiency of Health Care, and H.R. 3590 provisions relating to Health Information Technology; Implementation of the American Recovery and Reinvestment Act of 2009, (P.L. 111-5) Title XIII the Health Information Technology for Economic and Clinical Health Act (HITECH Act); H.R. 3239, Safeguarding Access for Every Medicare Patient Act, all provisions;H.R. 6043, Behavioral Health Information Technology Act of 2012, all provisions; H.R. 3962, Affordable Health Care for America Act, provisions relating to Health Information Technology; H.R. 2663, To Amend the Congressional Budget Act Respecting Scoring of Prevention Health Savings; Legislation to Repeal the SGR in the Medicare Physician Payment Formula.

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

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

Establish and preserve accountable care organizations in California, preserve funding for certain Medicare Advantage plans; establish medical homes; establish CMS innovation center (H.R. 3962, Sec. 1301, 1302, 1907; Div. B Title I, Subtitle D; Affordable Health Care for America Act. H.R. 3590, Sec. 3021, 3022, 9010; Part III,Subtitle C, Patient Protection and Affordable Care Act)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Insurance Individual Market H.R. 3962: Affordable Health Care for America Act H.R. 3200: America's Affordable Healthcare Choices Act Health Care ReformTax reform Medical Loss Ratio legislation Tax provision (m) 162-tax issue

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

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

Monitor issues pertaining to the Dietary Supplement Health and Education Act (DSHEA). Affordable Health Care for America (H.R. 3962). Patient Protection and Affordable Care Act (PL 111-148). Monitor and explain impacts of NDI guidance issued by the FDA.

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

Government targets: Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, SENATE

H.R. 1063, S. 1718, The Strengthening Medicare and Repaying Taxpayers (SMART) Act; H.R. 5284, The Medicare Secondary Payer and Worker's Compensation Settlements Act of 2013; H.R. 1845, Medicare IVIG Access and Strengthening Medicare and Repaying Taxpayers Act of 2012, Title II, Strengthening Medicare Secondary Payer Rules; H.R. 3962, Affordable Health Care for America Act, provisions relating to Health Information Technology; H.R. 3590, Patient Protection and Affordable Care Act, provisions relating to health information technology.

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, Transportation Security Administration (TSA)

Implementation of H.R. 3590, The Patient Protection and Affordable Care Act Sections (P.L. 111-148) Title III--Improving the Quality and Efficiency of Health Care, and H.R. 3590 provisions relating to Health Information Technology; Implementation of the American Recovery and Reinvestment Act of 2009, (P.L. 111-5) Title XIII the Health Information Technology for Economic and Clinical Health Act (HITECH Act); H.R. 3239, Safeguarding Access For Every Medicare Patient Act, all provisions; H.R. 6043, Behavioral Health Information Technology Act of 2012, all provisions; H.R. 3962, Affordable Health Care for America Act, provisions relating to Health Information Technology.

Client expense: Not reported · Firm income: $25,000

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE, Transportation Security Administration (TSA), White House Office

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Specifically, beginning in April 2011, urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged action on legislation to provide stability and predictability for the Medicare physician payments at least through 2012; Advocated for repealing the SGR and using the Overseas Contingency Operation (OCO) funds to offset the cost. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.In July 2012 testimony; advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which is scheduled to take effect on January 1, 2014. Sequestration: October 2012 through March 2013, advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. FY2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Appropriations for FY 2013: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA)s Title VII health professions and Title VIII nursing workforce development programs in FY2013 appropriations. Supported $520 million for Title VII Health Professions and Title VIII Nursing Programs to the House and Senate Labor-HHS-Education Appropriations Subcommittees; Supported $400 million to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for a base, discretionary budget of $400 million in FY 2013 for AHRQ; Advocated for at least $7.0 billion for the Health Resources and Services Administration (HRSA); Specifically, the College supported Title VII, Section 747, Primary Care Training and Enhancement, at no less than $71 million; National Health Service Corps, $535,087,442 million in discretionary funding, in addition to the $300 million in enhanced funding through the Community Health Centers Fund; National Health Care Workforce Commission, $3 million; and Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, $574.5 million. Fund the National Institutes of Health (NIH), at $32 billion, which represents the minimum investment necessary to avoid further loss of promising research and at the same time allows the NIH's budget to keep pace with biomedical inflation. Fund the Centers for Disease Control (CDC), at $7.8 billion, which reflects the minimal amount CDC will need to fulfill its core missions for fiscal year 2013, which are essential to protect the health of the American people. Preserve funding for GME in FY 2013; Urged Congress not to terminate AHRQ. Appropriations for FY 2014: Urged appropriators to provide at least $7.0 billion for discretionary Health Resources and Services Administration programs in the FY 2014 Labor, Health and Human Services, Education, and Related Agencies Appropriations bill.Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. In January 2013, advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Further advocated in January 2013 that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage: Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act;Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country; Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Urge enactment of H.R. 5, the HEALTH Act, as initially introduced, which would set national standards for medical malpractice, including a $250,000 cap on non-economic damages. The Restoring Access to Medication Act (H.R. 2529 in the 112th Congress): Advocated for this legislation, and signed on to similar letters, that overturns the restrictions placed on tax-preferred accounts reimbursing for over-the-counter (OTC) medicines without first getting a prescription. This legislation will restore efficiencies in the healthcare system and consumer access to vital, frontline medicines that were disrupted by ACA. The Primary Care Workforce Access and Improvement Act (H.R. 3667 in the 112th Congress): Supported this legislation that would authorize the Secretary of Health and Human Services (HHS) to conduct a five year Medicare pilot project that would direct a share of Graduate Medical Education funding to medical education entities to test different models of primary care training. This legislation would give the Secretary of HHS the authority to test new models of care that demonstrate the capability of improving the quality, quantity, and distribution of primary care physicians.

Client expense: $259,678 · Firm income: Not reported

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

Preserving Access to Primary Care Services: Address the shortage of primary care physicians; designate primary care as a shortage profession; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps,provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (111th Congress). Support Implementation and Improvement of the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Establishing a new Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Creating a new Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes; Training more primary care physicians through the National Health Service Corps, Title VII health professions funding, and redistributing unused graduate medical education positions to primary care specialties facing shortages; Beginning in 2014, ensuring that nearly all Americans have access to coverage either through subsidized private health insurance offered by state health exchanges or through Medicaid, if they don't already have access to coverage through an employer, Medicare, or another public program. Medicare Physician Payment Reform: Increase Medicare Fee Schedule payments to make primary care competitive in the market with other physician career and specialty choices; create a fast track authority to develop and implement new physician payment models that better align payment with effective, efficient, patient-centered care such as the Patient Centered Medical Home; provide a voluntary shared savings program, Accountable Care Organizations, that promotes accountability for services delivered to a defined Medicare fee-for-service (FFS) patient population with the goals of increasing the quality and efficiency of services delivered; provide separate Medicare payment for specific care coordination services provided principally by primary care physicians; revise Medicare budget neutrality rules to recognize the value of primary care in reducing Medicare baseline spending; increase the accuracy of physician work relative value units under the Medicare physician fee schedule; improve the accuracy of practice expense RVUs under the Medicare Fee Schedule; increase Medicare bonus payments for primary care services provided in designated shortage areas; provide stable, positive, predictable updates under Medicares reimbursement formula; and replacing the Sustainable Growth Rate (SGR) formula with a long term solution that provides for stable, predictable updates for physicians (H.R. 3961). Specifically, beginning in April 2011, urged Congress to enact legislation that would provide stable payments for all physician specialties for at least five years while providing higher updates for undervalued evaluation and management services, require that different payment models (including Patient-Centered Medical Homes) be pilot-tested on a voluntary basis during the five year period of stable payments, and designate a specific transition period for broad adoption of the new models that have been shown to be the most effective based on the pilots. Urged action on legislation to provide stability and predictability for the Medicare physician payments at least through 2012; Advocated for repealing the SGR and using the Overseas Contingency Operation (OCO) funds to offset the cost. Urged enactment of the Medicare Physician Payment Innovation Act (H.R. 574), as introduced in Feb. 2013 by Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV). This legislation would eliminate the SGR once and for all and transition to better payment and delivery systems that are aligned with value. Specifically, H.R. 574 would repeal the SGR formula, provide more than 5 years of stable physician payments, with positive increases for all physician services, and higher payments for primary care, preventive and care coordination services, and establishes a process for practices to transition to new, more effective, models of care by 2018.In July 2012 testimony; advocated for the Patient-Centered Medical Home model should be scaled up for broad Medicare adoption, recognized, through the medical neighborhood concept, that specialty and subspecialty practices, hospitals, and other healthcare professionals and entities that provide treatment to the patient need to be recognized and provided with incentivesboth non-financial and financialfor engaging in patient-centered practices that complement and support the efforts of the PCMH to provide high quality, efficient, coordinated care; advocated for ACPs High Value, Cost-Conscious Care Initiative, which includes clinical, public policy, and educational components, designed to help physicians and patients understand the benefits, harms, and costs of an intervention and whether it provides good value, as well as to slow the unsustainable rate of health care cost increases while preserving high-value, high-quality care. Advocated for halting the nearly 25 percent cut in physician payments resulting from the flawed SGR formula, which is scheduled to take effect on January 1, 2014. Sequestration: October 2012 through March 2013, advocated strongly that Congress develop and pass a fiscally responsible, bipartisan agreement to prevent the implementation of across-the-board budget sequestration cuts that would endanger critical programs related to medical research, public health, workforce, food and drug safety, and health care for military families, as well as trigger cuts in Medicare payments to physicians and graduate medical education programs that will endanger patient access to care. Instead, policymakers should embrace an alternative approach that addresses the true cost drivers behind rising health care costs. They should work to improve the effectiveness of care provided, make necessary and appropriate changes in entitlement programs, including Medicare cost-sharing, reform payment and delivery systems, and support the proven value of primary care. Medical Education: Provide incentives to medical schools, community health centers, or hospitals, to increase the numbers of physicians choosing primary care; authorize HHS to selectively eliminate Graduate Medical Education (GME) caps for residency programs in primary care, advocated for S. 1627, which would increase the number of Medicare-supported training positions for medical residents by 15 percent (approximately 15,000 slots) over five years, requiring at least 50 percent of the new positions to be allocated to specialties facing a current shortage. FY2014 Budget: Recommended funding of $65 billion for discretionary public health and health research programs (Function 550) in the FY 2014 budget resolution; Urged the Administration to continue to prioritize investments in the nations health care workforce through Titles VII and VIII in the FY2014 budget. Appropriations for FY 2013: Advocated for the highest level of funding possible for the Labor-HHS-Education bill within the discretionary cap established by the Budget Control Act (BCA); Urged appropriators to preserve full funding for the Health Resources and Services Administration (HRSA)s Title VII health professions and Title VIII nursing workforce development programs in FY2013 appropriations. Supported $520 million for Title VII Health Professions and Title VIII Nursing Programs to the House and Senate Labor-HHS-Education Appropriations Subcommittees; Supported $400 million to "improve health care quality, enhance consumer choice, advance patient safety, improve efficiency, reduce medical errors, and broaden access to essential services; Advocated for a base, discretionary budget of $400 million in FY 2013 for AHRQ; Advocated for at least $7.0 billion for the Health Resources and Services Administration (HRSA); Specifically, the College supported Title VII, Section 747, Primary Care Training and Enhancement, at no less than $71 million; National Health Service Corps, $535,087,442 million in discretionary funding, in addition to the $300 million in enhanced funding through the Community Health Centers Fund; National Health Care Workforce Commission, $3 million; and Centers for Medicare and Medicaid Services, Operations and Management of Exchanges, $574.5 million. Fund the National Institutes of Health (NIH), at $32 billion, which represents the minimum investment necessary to avoid further loss of promising research and at the same time allows the NIH's budget to keep pace with biomedical inflation. Fund the Centers for Disease Control (CDC), at $7.8 billion, which reflects the minimal amount CDC will need to fulfill its core missions for fiscal year 2013, which are essential to protect the health of the American people. Preserve funding for GME in FY 2013; Urged Congress not to terminate AHRQ. Appropriations for FY 2014: Urged appropriators to provide at least $7.0 billion for discretionary Health Resources and Services Administration programs in the FY 2014 Labor, Health and Human Services, Education, and Related Agencies Appropriations bill.Public Health Programs and Funding: Increase funding to accomplish the core missions and activities of the major federal public health agencies, including: biomedical and behavioral research, disease prevention and health promotion, access to safety net health care services, health professions education, mental health and substance abuse, health services research, health care for American Indians and Alaska natives, food and drug safety. In January 2013, advocated to federal health agencies that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals; Further advocated in January 2013 that employers and health plans should fund programs proven to be effective in reducing obesity, stopping smoking, deterring alcohol abuse, and promoting wellness and providing coverage or subsidies for individuals to participate in such programs. Improving Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Ensure that all Americans will have access to affordable coverage: Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Regarding the Essential Health Benefits Bulletin, issued by the Department of Health and Human Services (HHS) on December 16, 2011, the College advocated for striking a balance between comprehensiveness and affordability while giving States some freedom to determine a package that best serve the needs of residents. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Essential Health Benefits: Commented on the proposed rule regarding essential benefits, actuarial value, and accreditation as issued by the U.S. Department of Health & Human Services on November 20, 2012; Advocated that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Pilot test new Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the establishing of a new CMS Innovation Center to pilot-test new payment models, such as the medical home; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. National workforce policy to ensure sufficient numbers of primary care and other physicians: Urged support for a national workforce commission to recommend national goals relating to the numbers and distribution of physicians and other health care professionals, including increasing the supply of primary care physicians; Fully fund the commission at levels authorized in the Affordable Care Act; Increase the number of Medicare-funded graduate medical education positions available each year in adult primary care specialties; Provide new loan repayment and medical school scholarship programs in exchange for primary care service in critical shortage health facilities, or in critical shortage areas of the country;Increase funding for scholarships and loan repayment programs under Title VII as well as increase funding for the National Health Service Corps (NHSC); Provide new practice-entry bonus for scholarship or loan repayment award recipients who remain in underserved communities after completion of service obligation. Reform the medical liability system and the enormous costs associated with frivolous lawsuits and defensive medicine: Impose caps on non-economic damages; and test and fund new models--like health courts, which would have cases heard by an expert panel rather than by a lay jury; Urge enactment of H.R. 5, the HEALTH Act, as initially introduced, which would set national standards for medical malpractice, including a $250,000 cap on non-economic damages. The Restoring Access to Medication Act (H.R. 2529 in the 112th Congress): Advocated for this legislation, and signed on to similar letters, that overturns the restrictions placed on tax-preferred accounts reimbursing for over-the-counter (OTC) medicines without first getting a prescription. This legislation will restore efficiencies in the healthcare system and consumer access to vital, frontline medicines that were disrupted by ACA. The Primary Care Workforce Access and Improvement Act (H.R. 3667 in the 112th Congress): Supported this legislation that would authorize the Secretary of Health and Human Services (HHS) to conduct a five year Medicare pilot project that would direct a share of Graduate Medical Education funding to medical education entities to test different models of primary care training. This legislation would give the Secretary of HHS the authority to test new models of care that demonstrate the capability of improving the quality, quantity, and distribution of primary care physicians.

Client expense: $106,421 · Firm income: Not reported

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

Establish and preserve accountable care organizations in California, preserve funding for certain Medicare Advantage plans; establish medical homes; establish CMS innovation center (H.R. 3962, Sec. 1301, 1302, 1907; Div. B. Title I, Subtitle D; Affordable Health Care for America Act. H.R. 3590, Sec. 3021, 3022, 9010; Part III, Subtitle C, Patient Protection and Affordable Care Act)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Insurance Individual Market H.R. 3962: Affordable Health Care for America Act H.R. 3200: America's Affordable Healthcare Choices Act Health Care ReformTax reform Medical Loss Ratio legislation H.R. 3590: Patient Protection & Affordable Care Act Tax provision (m) 162-tax issue

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

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

H.R.3200 - America's Affordable Health Choices Act of 2009; H.R.3962 - Affordable Health Care for America Act; H.R.3590 - Patient Protection and Affordable Care Act; H.R.4872 - Health Care and Education Affordability Reconciliation Act of 2010; health care reform and Medicare & Implemnentations, Medicare distribution of funds by state.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Monitor issues pertaining to the Dietary Supplement Health and Education Act (DSHEA). Affordable Health Care for America (H.R. 3962). Patient Protection and Affordable Care Act (PL 111-148). Monitor and explain impacts of NDI guidance issued by the FDA.

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

Government targets: Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, SENATE