Expanding the Availability of Medicare Data Act

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. S. 77, Prescription Drug and Health Improvement Act S. 557 / H.R. 1024, Medication Therapy Management Empowerment Act S.867, Medicare Prescription Drug Program Integrity and Transparency Act H.R. 2960, Medicare Prescription Drug Integrity Act of 2013 H.R. 4160, Keep the Promise to Seniors Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid; Pharmacy, and Health Care General H.R. 4418, Expanding the Availability of Medicare Data to Medicare/Medicaid

Client expense: $788,488 · Firm income: Not reported

Government targets: Administration for Children & Families (ACF), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

HR 487, Primary Care Workforce Access Improvement Act, Urge House to cosponsor bill that would create GME pilot project to train primary care doctors, urge Senate offices to sponsor bill; urge W&M offices to discuss during March 2014 budget hearing, GME reform increase primary care physician training, pilot test alternatives to GME payment to increase PCP training.HR 2305, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2810, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2867, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2969, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 3306, Telehealth Enhancement Act, Defining the home base for telehealth reimbursement to incluse family medicine offices. HR 4015, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4209, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4302, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. HR 4418, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4543, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1123, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1184, Treat and Reduce Obesity Act, Seeking House and Senate cosponsors for obesity legislation. S. 1318, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1759, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 1769, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1871, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1978, Increasing Primary Care Access Act, Family physician workforce, Teaching Health Center Reauthorization Act, Reauthorize the Teaching Health Centers Graduate Medical Education program, increase family physician workforce. S. 2000, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2110, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2122, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 2229, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 2415, Seeking House and Senate cosponsors for obesity legislation. No Bill Number, SGR Repeal and Replacement process, Advocate for SGR repeal and new physician payment system that pays for value and primary care. No Bill Number, Medicaid Primary Care Bonus, Advocate for extension of the Medicaid bonus which expires at the end of 2014. No Bill Number, Medicare Primary Care Incentive Payment, Urge Ways and Means members to discuss at annual MedPac hearing. No Bill Number, Telemedicine,advocate for AAFP policies to be included in a potential bipartisan telehealth bill. No Bill Number, Medicare Site Neutral Payments; advocate for AAFP policies to be included in conncection with MedPac hearing. No Bill Number, Extend Medicare/medicare parity for primary care services, Extend increase in Medicaid payments for primary care services to Medicare levels beyond 2015. No Bill Number, Direct Primary Care, Primary care model of retainer-based practice. No Bill Number, Medicare physician payment reform of the SGR, 2014 converstion factor. No Bill Number, Repeal SGR, Positive update and higher rate for primary care.No Bill Number, Site-neutral payment for medical services, Support site-neutral payment by CMS for medical services. No Bill Number, First Fridays Meetings, Provider outreach group for Affordable Care Act, provider and open enrollment issues.

Client expense: $627,558 · Firm income: Not reported

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

General Issues: Coordinated care for dual eligible's, Medicare payment reform, Medicare Advantage quality bonus payment program,insurer tax, Medicaid payment reform, Medicaid Managed Care, Medicare Advantage, Medicare Supplemental, fraud and abuse prevention, high cost drugs, Special Needs Plans reauthorization, Medicare Part D, appropriate use criteria, Medicare Sustainable Growth Rate, and Medicare data transparency. Specific Bills include: H.R. 4418; S. 1758; and, H.R. 4302 (became Public Law 113-93).

Client expense: $1,050,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE, Treasury, Dept of, White House Office

General Issues: Coordinated care for dual eligible's, Medicare payment reform, Medicare Advantage quality bonus payment program,insurer tax, Medicaid payment reform, Medicaid Managed Care, Medicare Advantage, Medicare Supplemental, fraud and abuse prevention, high cost drugs, Special Needs Plans reauthorization, Medicare Part D, appropriate use criteria, Medicare Sustainable Growth Rate, and Medicare data transparency. Specific Bills include: H.R. 4418; S. 1758; and, H.R. 4302.

Client expense: $1,730,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE, Treasury, Dept of, White House Office

Pub.Law 111-148 & 111-152 - Discussed implementation of health care law that would reform the health care system to provide affordable quality health care, reduce drug costs and expand access to long-term services and supports. Discussed how to implement Medicaid provisions of Affordable Care Act. (PL. 111-148)S. 374, Medicare Mental Health Inpatient Equity Act - Lobbied in support of this legislation to eliminate the 190-day lifetime limit on Medicare coverage for in-patient psychiatric hospital services (112th). Discussed improving access to care for underserved population. (no bill) Discussed importance of maintaining low income subsididies and supports in Medicare. (no bill) Discussed the importance of coordinating services for those who qualify for both Medicare and Medicaid in order to ensure that beneficiaries receive all needed benefits but there is no duplication. (no bill) Discussed whether, and under what circumstances, managed care could effectively be used to provide benefits to dual eligible beneficiaries. (no bill) Discussed additional methods for fighting fraud and waste in Health Care. (no bill) Discussed Medigap and need for guaranteed issue for all populations and need to increase medical loss ratio. Discussed durable medical equipment bidding. (no bill) Lobbied for legislation to provide Medicare beneficiaries with additional opportunities to enroll in Medicare Part B.(no bill) Lobbied against the use of the Social Security account number on Government-issued identification cards issued in connection with Medicare, Medicaid, and SCHIP benefits and for other purposes. (no bill) Discussed support to curb waste and fraud from the Medicare and Medicaid programs. (no bill) H.R. 3630, Middle Class Tax Relief and Job Creation Act of 2012 - Discussed the legislation as it pertained to SGR. Discussed Medicare Reform. (no bill) H.R. 2305/S. 1123, PRIME ACT (Preventing and Reducing Improper Medicare Expenditures) - Discussed support for bill and urged cosponsorship. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs. (no bill) H.R. 1588/S. 740, Medicare Drug Savings Act - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income befeficiaries. (no bill) Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) H.R. 1717 - Discussed Medicare DMEPOS Market Pricing Program Act. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R.3830/S.1900 - Discussed pending U.S. trade agreement negotiations and trade promotional or "fast track" authority legislation and their potential impact on Medicare and Medicaid prescription drug programs. S. 2461 - Discussed Children's Health Insurance Program (CHIP) extension and CHIP Extension Act of 2014. Discussed Part D Payment for Drugs for Beneficiaries Enrolled in Hospice - Final 2014 CMS Guidance. H.R.5294, Health Equity & Accountability Act of 2014 - Addresses health care disparities; no endorsement due to budget impact. Medicare Advantage- Answered questions from some Hill offices. (no bill) Medicare Supplemental Insurance - Stated opposition to the elimination of first dollar coverage. (no bill) Discussed LTSS issues, including financing. (no bill)Discussed Medicare Graduate Nursing Education pilot design. (no bill) Discussed Prescription Drug Affordability. (no bill) Discussed Prescription Drug Shortages. (no bill) H.R. 3342, Affordable Medicines Utilization Act of 2011 - Lobbied to encourage state Medicaid programs to use safe, effective generic medications. H.R. 2576 - Discussion to amend the Internal Revenue Code of 1986 to modify the calculation of modified adjusted gross income for purposes of determining eligibility for certain healthcare-related programs. Discussed opposition to caps on dual eligibles; discussed managed care and dual eligibles. (no bill) Discussed with CMS demonstration programs for dual eligibles and process related to the demonstrations, as well as other work of the Medicare-Medicaid Coordination Office, discussed consumer choice and continuity of care in Medicaid managed long-term services and supports programs, discussed focus groups on dual eligibles. Discussed Hospital & Critical Access Hospitals Conditions of Participation proposed regulations; requested that advanced practice registered nurses and physicians assistants be allowed the full scope of services in hospital admitting and visiting privileges. (no bill) Discussed Hospital Outpatient Therapeutic Services Final Rule underscoring that advanced practice registered nurses and physicians should be allowed to supervise such outpatient service clinics without physician oversight as long as in line with state scope of practice laws. (no bill) Discussed health disparities. (no bill) Discussed Medicaid reform, Medicare/Medicaid "dual eligibles" integration efforts and financial alignment demonstrations; and other CMS demonstration initiatives. (no bill) S. 3586, Recruiting Individuals to Drive Elders (RIDE) Act - Discussed Medicaid non-emergency transportation bill (112th). Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) Discussed extension of funding originally provided under the Medicare Improvement for Patients and Providers Act (P.L. 110-275) to State Health Insurance Assistance Programs (SHIPs), Aging and Disability Resource Centers (ADRICs), and Area Agencies on Aging (AAAs) for Medicare outreach and enrollment counseling. (no bill) Discussed the prevention of cuts to beneficiaries in the Medicare program. (no bill) Discussed the prevention of an increase in the age of eligibility in the Medicare program. (no bill) Discussed the patch to the Sustainable Growth Rate (SGR) in the Medicare program. (no bill) Discussed concerns of block granting Medicaid. (no bill) Discussed the Kansas managed long-term services and supports waiver proposals and related implementation issues. (no bill). H.R.928/S.408, the Medicare Drug Savings Act - Discussed requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed Health Disparities. (no bill) Discussed medicare demonstration project replacing standard medicare cards with Smart Card technology. (no bill) H.R. 574 - The Medicare Physician Payment Innovation Act of 2013. Discussed Medicaid expansion and estate recovery. (no bill) S. 2491, Discussed Medicare Protection Act. Discussed concern about CMS guidance on prescription drugs for medicare beneficiaries receiving hospice and coordination between hospice providers and medicare Part D sponsors. (no bill) Discussed long-term services and supports in Hill briefings. (no bill) H.R. 1173 - Discussed advance care planning, CMS payment for advance care planning, advanced illness, and Personalize Your Care Act.H.R. 1179/S.569, Improving Access to Medicare Act - Discussed support of Improving Access to Medicare Coverage Act and urged cosponsorship and advancement of the bill. Discussed CMS information regarding healthcare marketplaces. H.R. 2305/S.1123, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act. Bill reduces waste, fraud, and abuse in Medicare and Medicaid programs. Discussed Competitive bidding of durable medical equipment, prosthetics, orthotics, and supplies. (no bill) Discussed repeal of Affordable Care Act provision making prescriptions necessary for over-the-counter drugs purchased with flexible spending accounts. (no bill) Discussed Medicare supplemental coverage. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug cost. (no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) H.R. 83, Consolidated and Further Continuing Appropriations, 2015 - Lobbied to protect vital health and social services programs from enhanced reductions from the prior year baseline, and to prevent repeal of certain financial and health care-related regulation.(no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiares. (no bill) Discussed pending U.S. trade agreement negotiations, including trade promotional or 'fast track' authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) Discussed fraud, Medicare home healthcare, ways to find savings in Medicare without harming Medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). Discussed You've Earned A Say, ways to find savings in medicare without harming medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). PL.111-148 - Discussed implementation of provision to require reporting of nursing home staffing data based on payroll data and executive actions related to nursing homes, IMPACT Act, PL 113-185).. Discussed the draft legislation on Medicare fraud and abuse. Protecting the Integrity of Medicare Act. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R. 1588/S.740 - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. H.R. 3830/S. 1900 - Discussed pending U.S. trade agreement negotiations and trade promotional or "fast track" authority legislation and their potential impact on Medicare and Medicaid prescription drug programs. S. 2461 - Discussed Children's Health Insurance Program (CHIP) Extension Act of 2014. Discussed Part D Payment for Drugs for Beneficiaries Enrolled in Hospice-Final 2014 CMS Guidance. Discussed the Protecting Integrity of Medicare Act. (no bill) H.R.5435, Home Infusion Site of Care Act - Sent letter of endorsement H.R. 5958 - Discussed the ACO Improvement Act. H.J. Res. 124, Continuing Appropriations Resolution - Lobbied to protect funding levels for CMS program management under Continuing Resolution. H.R. 1179/S. 569 - Discussed observation impace on Medicare beneficiaries, counting time in observation toward Medicare's three-day inpatient hospital stay requirement for Medicare skilled nursing facility coverage, and the Improving Access to Medicare Coverage Act (CMS & MedPAC). PL. 113-295 - Responded to inquiry about Medicare offsets on Achieving a Better Life Expense Act.Discussed Medicare Advantage. (no bill) Discussed H.R. 3616, Protecting Seniors from Healthcare Fraud Act. Discussed observation care and "two-midnight rule". (no bill) H.R. 1070, the Removing Barriers to Colorectal Cancer Screening Act - Discussed and sent letter of endorsement to bill. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R. 1588/S.740, Medicaid Drug Savings Act - Discussed the requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) Discussed pending U.S. Trade agreement negotiations, including trade promotional or "fast track" authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) H.R. 2810/S.1871/H.R. 4015/S.2110 - Discussed SGR repeal and health care extender provisions, including the Qualified Individual low-income Medicare beneficiary assistance program. H.R. 4418, The Expanding Availability of Medicare Data Act - Sent letter of endorsement. Discussed Medicare data and billing transparency. (no bill) Discussed socio-economic risk adjustment. (no bill) S. 2240 - Discussed Medicare Choices Empowerment and Protection Act. H.R. 3024 - Discussed the Medicare Common Access Card Act. Discussed Medicare expansion. (no bill) Discussed Medicaid Labs Spousal Impoverishment provisions (PL. 111-198). Discussed transparency in healthcare. (no bill) Discussed Medicaid managed care regulations. (CMS, no bill) PL.111-148 - Discussed long-term services and supports broadly and Older Americans Act. Submitted comments on Medicare Physician fee schedule final rule and advance care planning (CMS - 1612-FC). Discussed Medicare enrollment and notification of eligibility. (no bill) Discussed Medicare in-office ancillary services exception. (no bill)

Client expense: $2,180,000 · Firm income: Not reported

Government targets: Administration on Aging, Agriculture, Dept of (USDA), Bureau of the Census, Centers For Medicare and Medicaid Services (CMS), Commodity Futures Trading Commission (CFTC), Congressional Budget Office (CBO), Energy, Dept of, Environmental Protection Agency (EPA), Equal Employment Opportunity Commission (EEOC), Executive Office of the President (EOP), Federal Communications Commission (FCC), Federal Highway Administration (FHA), Federal Reserve System, Federal Trade Commission (FTC), Federal Transit Administration (FTA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Housing & Urban Development, Dept of (HUD), Internal Revenue Service (IRS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Medicare Payment Advisory Commission (MedPAC), Natl Highway Traffic Safety Administration (NHTSA), Natl Institutes of Health (NIH), Office of Management & Budget (OMB), Office of Personnel Management (OPM), Office of the Comptroller of the Currency (OCC), Pension Benefit Guaranty Corporation (PBGC), SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA), Transportation, Dept of (DOT), Treasury, Dept of, Veterans Affairs, Dept of (VA), White House Office

Medicare physician payment; Medicare coverage; Medicare hospital payment; physician and hospital quality; medical liability reform; electronic health record incentive program; clinical data registries; graduate medical education; health care quality; medical imaging and prior authorization; in-office ancillary services exception. HR 2914, Promoting Integrity in Medicare Act; SGR Repeal and Beneficiary Access Improvement Act; HR 4015/S 2000, SGR Repeal and Medicare Provider Payment Modernization Act; S 2501, Hospital Readmission Accuracy and Accountability Act; S 1932/HR 3890, Better Care, Lower Cost Act; Facilitating Participation in Clinical Data Registries Act; IMPACT Act; S 2552, Medicare Advantage Participant Bill of Rights Act; HR 4282, CARE Act; HR 4930, Advancing Care for Exceptional Kids Act; S 961/HR 36, Health Care Safety Net Enhancement Act; HR 5215, to provide for recommendations for the development and use of clinical data registries; HR 5481, FLEX-IT Act; HR 4188, Establishing Beneficiary Equity in the Hospital Readmission Program Act; HR 4857, Ensuring Equal Access to Treatments Act; S 1758, Quality Data, Quality Healthcare Act; HR 4418, Expanding the Availability of Medicare Data Act; Hospital Improvements for Payment (HIP) Act of 2014; Protecting Integrity in Medicare Act of 2014 (PIMA); HR 647, ABLE Act; S 2461/HR 5364, CHIP Extension and Improvement Act of 2014.

Client expense: $410,000 · Firm income: Not reported

Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE

MMM (Medicare and Medicaid) Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Oral Health Coverage for the Medically Compromised and at Risk Populations There is sufficient data that demonstrates oral health impacts the systemic health of the patient and in doing can reduce the cost of care. Linkages that encourage patient compliance, patient education, provider education, and bi-directional referral and surveillance should be incented and compensated. Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare.

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

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), SENATE

Issues relating to insurance regulatory reform and agent compensation; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173, S. 1926, H.R. 4871, S.2244. Issues related to the implementation of the Dodd-Frank Wall Street Reform Act of 2010; H.R. 1627, H.R. 2374, H.R. 797, H.R. 4510, H.R. 5461, S. 2102, S. 2270. Issues related to the implementation of of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1926, S. 1188, H.R. 4418, H.R. 3522, S. 2808. Issues related to terrorism risk insurance; H.R. 508, H.R. 2146, H.R. 4871, S. 2244. Issues related to flood risk insurance; H.R. 3370, S. 1846, S. 1926. Issues related to the regulation of insurance competition, products with guarantees, individual and employer owned policies, and fiduciary-client relationships; H.R. 2374. Issues related to capital standards for insurance providers; H.R. 4510, H.R. 5461, S. 2102. S. 2270.

Client expense: $708,090 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Issues related to agent compensation; ; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418, H.R. 3522, S. 2808. Issues related to HSA/FSA reform; H.R. 2194, S. 1031. Issues related to the McCarran-Ferguson anti-trust exemption; H.R. 743.

Client expense: $708,090 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

S. 236, Medicare Patient Empowerment Act: Private contracting for patients and physicians S. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB) S. 577, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training S. 972, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10H.R. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB)H.R. 574, Medicare Physician Payment Innovation Act of 2013: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 969, Medical Practice Freedom Act of 2013: Medical licensure H.R. 1180, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training H.R.1201, Training Tomorrow's Doctors Today Act: Graduate medical education-residency training H.R. 1310, Medicare Patient Empowerment Act: Private contracting for patients and physicians H.R. 1333, Electronic Health Records Improvement Act: Electronic medical record penalties and incentive payments H.R.1701, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10 H.R. 2810, Medicare Patient Access and Quality Improvement Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 4302, the Protecting Access to Medicare Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R.4418: Expanding the Availability of Medicare Data Act: making Medicare data available for clinical data registries

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S. 236, Medicare Patient Empowerment Act: Private contracting for patients and physicians S. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB) S. 577, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training S. 972, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10H.R. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB)H.R. 574, Medicare Physician Payment Innovation Act of 2013: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 969, Medical Practice Freedom Act of 2013: Medical licensure H.R. 1180, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training H.R.1201, Training Tomorrow's Doctors Today Act: Graduate medical education-residency training H.R. 1310, Medicare Patient Empowerment Act: Private contracting for patients and physicians H.R. 1333, Electronic Health Records Improvement Act: Electronic medical record penalties and incentive payments H.R.1701, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10 H.R. 2810, Medicare Patient Access and Quality Improvement Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 4302, the Protecting Access to Medicare Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R.4418: Expanding the Availability of Medicare Data Act: making Medicare data available for clinical data registries

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

General Issues: Coordinated care for dual eligible's, Medicare payment reform, Medicare Advantage quality bonus payment program, insurer tax, Medicaid payment reform, Medicaid Managed Care, Medicare Advantage, Medicare Supplemental, fraud and abuse prevention, high cost drugs, Special Needs Plans reauthorization, Medicare Part D, appropriate use criteria, Medicare Sustainable Growth Rate, and Medicare data transparency.Specific Bills include: H.R. 4418; S. 1758; and, H.R. 4302 (became Public Law 113-93).

Client expense: $1,050,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE, Treasury, Dept of, White House Office

Pub.Law 111-148 & 111-152 - Discussed implementation of health care law that would reform the health care system to provide affordable quality health care, reduce drug costs and expand access to long-term services and supports. Discussed how to implement Medicaid provisions of Affordable Care Act. (PL. 111-148)S. 374, Medicare Mental Health Inpatient Equity Act - Lobbied in support of this legislation to eliminate the 190-day lifetime limit on Medicare coverage for in-patient psychiatric hospital services (112th). Discussed improving access to care for underserved population. (no bill) Discussed importance of maintaining low income subsididies and supports in Medicare. (no bill) Discussed the importance of coordinating services for those who qualify for both Medicare and Medicaid in order to ensure that beneficiaries receive all needed benefits but there is no duplication. (no bill) Discussed whether, and under what circumstances, managed care could effectively be used to provide benefits to dual eligible beneficiaries. (no bill) Discussed additional methods for fighting fraud and waste in Health Care. (no bill) Discussed Medigap and need for guaranteed issue for all populations and need to increase medical loss ratio. Discussed durable medical equipment bidding. (no bill) Lobbied for legislation to provide Medicare beneficiaries with additional opportunities to enroll in Medicare Part B.(no bill) Lobbied against the use of the Social Security account number on Government-issued identification cards issued in connection with Medicare, Medicaid, and SCHIP benefits and for other purposes. (no bill) Discussed support to curb waste and fraud from the Medicare and Medicaid programs. (no bill) H.R. 3630, Middle Class Tax Relief and Job Creation Act of 2012 - Discussed the legislation as it pertained to SGR. Discussed Medicare Reform. (no bill) H.R. 2305/S. 1123, PRIME ACT (Preventing and Reducing Improper Medicare Expenditures) - Discussed support for bill and urged cosponsorship. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs. (no bill) H.R. 1588/S. 740, Medicare Drug Savings Act - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income befeficiaries. (no bill) Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) H.R. 1717 - Discussed Medicare DMEPOS Market Pricing Program Act. Discussed implementation of regulations regarding minimum wage and overtime for home care workers and consumer-directed care. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H. R. 1588/S.740 - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. H.R.3830/S.1900 - Discussed pending U.S. trade agreement negotiations and trade promotional or "fast track" authority legislation and their potential impact on Medicare and Medicaid prescription drug programs. S. 2461 - Discussed Children's Health Insurance Program (CHIP) extension and CHIP Extension Act of 2014. Discussed Part D Payment for Drugs for Beneficiaries Enrolled in Hospice - Final 2014 CMS Guidance. H.R.5294, Health Equity & Accountability Act of 2014 - Addresses health care disparities; no endorsement due to budget impact. Medicare Advantage- Answered questions from some Hill offices. (no bill) Medicare Supplemental Insurance - Stated opposition to the elimination of first dollar coverage. (no bill)Discussed Medicare Graduate Nursing Education pilot design. (no bill) Discussed Prescription Drug Affordability. (no bill) Discussed Prescription Drug Shortages. (no bill) H.R. 3342, Affordable Medicines Utilization Act of 2011 - Lobbied to encourage state Medicaid programs to use safe, effective generic medications. H.R. 2576 - Discussion to amend the Internal Revenue Code of 1986 to modify the calculation of modified adjusted gross income for purposes of determining eligibility for certain healthcare-related programs. Discussed opposition to caps on dual eligibles; discussed managed care and dual eligibles. (no bill) Discussed with CMS demonstration programs for dual eligibles and process related to the demonstrations, as well as other work of the Medicare-Medicaid Coordination Office, discussed consumer choice and continuity of care in Medicaid managed long-term services and supports programs, discussed focus groups on dual eligibles. Discussed Hospital & Critical Access Hospitals Conditions of Participation proposed regulations; requested that advanced practice registered nurses and physicians assistants be allowed the full scope of services in hospital admitting and visiting privileges. (no bill) Discussed Hospital Outpatient Therapeutic Services Final Rule underscoring that advanced practice registered nurses and physicians should be allowed to supervise such outpatient service clinics without physician oversight as long as in line with state scope of practice laws. (no bill) Discussed health disparities. (no bill) Discussed Medicaid reform, Medicare/Medicaid "dual eligibles" integration efforts and financial alignment demonstrations; and other CMS demonstration initiatives. (no bill) S. 3586, Recruiting Individuals to Drive Elders (RIDE) Act - Discussed Medicaid non-emergency transportation bill (112th). Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) Discussed extension of funding originally provided under the Medicare Improvement for Patients and Providers Act (P.L. 110-275) to State Health Insurance Assistance Programs (SHIPs), Aging and Disability Resource Centers (ADRICs), and Area Agencies on Aging (AAAs) for Medicare outreach and enrollment counseling. (no bill) Discussed the prevention of cuts to beneficiaries in the Medicare program. (no bill) Discussed the prevention of an increase in the age of eligibility in the Medicare program. (no bill) Discussed the patch to the Sustainable Growth Rate (SGR) in the Medicare program. (no bill) Discussed concerns of block granting Medicaid. (no bill) Discussed the Kansas managed long-term services and supports waiver proposals and related implementation issues. (no bill). H.R.928/S.408, the Medicare Drug Savings Act - Discussed requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed Health Disparities. (no bill) Discussed medicare demonstration project replacing standard medicare cards with Smart Card technology. (no bill) H.R. 574 - The Medicare Physician Payment Innovation Act of 2013. Discussed Medicaid expansion and estate recovery. (no bill) Discussed Medicaid and asset transfers. (no bill) H.R.4994/S. 2553, Improving Medicare Post-Acute Care Transformation Act of 2014 - Discussed the bill and AARP support for the bill. Shared our letter of support. S. 2491, Discussed Medicare Protection Act. Discussed concern about CMS guidance on prescription drugs for medicare beneficiaries receiving hospice and coordination between hospice providers and medicare Part D sponsors. (no bill) H.R. 1179/S.569 - Submitted statement for the record for Senate Aging Committee hearing on Observation Improving Access to Medicare Coverage Act and Notice of Observation Treatment and Implication for Care Eligibility Act (H.R. 5232). Discussed aging in place, HCBS, family caregiving. (no bill)H.R. 1179/S.569, Improving Access to Medicare Act - Discussed support of Improving Access to Medicare Coverage Act and urged cosponsorship and advancement of the bill. Discussed CMS information regarding healthcare marketplaces. H.R. 2305/S.1123, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act. Bill reduces waste, fraud, and abuse in Medicare and Medicaid programs. Discussed Competitive bidding of durable medical equipment, prosthetics, orthotics, and supplies. (no bill) Discussed repeal of Affordable Care Act provision making prescriptions necessary for over-the-counter drugs purchased with flexible spending accounts. (no bill) Discussed Medicare supplemental coverage. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug cost. (no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) Discussed Recruiting Individuals to Drive Our Elders Act (RIDE) would increase state flexibility by giving states the option to receive federal assistance to reimburse their volunteer drivers for no-load miles. (no bill) Labor, Health and Human Services Appropriations Act, 2015 - Lobbied to protect vital health and social services programs from enhanced reductions from the prior year baseline, and to prevent repeal of certain financial and health care-related regulation.(no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiares. (no bill) Discussed pending U.S. trade agreement negotiations, including trade promotional or 'fast track' authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) Discussed fraud, Medicare home healthcare, ways to find savings in Medicare without harming Medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). Discussed You've Earned A Say, ways to find savings in medicare without harming medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). PL.111-148 - Discussed implementation of provision to require reporting of nursing home staffing data based on payroll data. Discussed the draft legislation on Medicare fraud and abuse. Protecting the Integrity of Medicare Act. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R. 1588/S.740 - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. H.R. 3830/S. 1900 - Discussed pending U.S. trade agreement negotiations and trade promotional or "fast track" authority legislation and their potential impact on Medicare and Medicaid prescription drug programs. S. 2461 - Discussed Children's Health Insurance Program (CHIP) Extension Act of 2014. Discussed Part D Payment for Drugs for Beneficiaries Enrolled in Hospice-Final 2014 CMS Guidance. Discussed the Protecting Integrity of Medicare Act. (no bill) H.R.5435, Home Infusion Site of Care Act - Sent letter of endorsement H.R. 5958 - Discussed the ACO Improvement Act. H.R. 5232 - Discussed and sent letter on the Notice of Observation Treatment and Implication for Care Eligibility Act. Met with Centers for Medicare and medicaid services to discuss three-day stay requirement for medicare skilled nursing coverage. H.J. Res. 124, Continuing Appropriations Resolution - Lobbied to protect funding levels for CMS program management under Continuing Resolution. Discussed coordination with hospice providers and Medicare Part D plans guidance for Medicare beneficiaries receiving hospice. (no bill) H.R. 1179/S. 569 - Discussed observation impace on Medicare beneficiaries, counting time in observation toward Medicare's three-day inpatient hospital stay requirement for Medicare skilled nursing facility coverage, and the Improving Access to Medicare Coverage Act (CMS & MedPAC). Discussed caucus for military/veteran family caregivers and support for family caregivers. (no bill) Discussed draft working paper on impact of observation on Medicare beneficiary out of pocket. (no bill)Discussed District of Columbia EPD Medicaid HCBS waiver. (no bill) H.R. 5232 - Discussed legislation and shared letter of support for the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act of 2014. Discussed Medicare Advantage. (no bill) Discussed H.R. 3616, Protecting Seniors from Healthcare Fraud Act. Discussed observation care and "two-midnight rule". (no bill) H.R. 1070, the Removing Barriers to Colorectal Cancer Screening Act - Discussed and sent letter of endorsement to bill. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R. 1588/S.740, Medicaid Drug Savings Act - Discussed the requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) Discussed pending U.S. Trade agreement negotiations, including trade promotional or "fast track" authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) H.R. 2810/S.1871/H.R. 4015/S.2110 - Discussed SGR repeal and health care extender provisions, including the Qualified Individual low-income Medicare beneficiary assistance program. H.R. 4418, The Expanding Availability of Medicare Data Act - Sent letter of endorsement. Discussed Medicare data and billing transparency. (no bill) Discussed socio-economic risk adjustment. (no bill) S. 2240 - Discussed Medicare Choices Empowerment and Protection Act. H.R. 3024 - Discussed the Medicare Common Access Card Act. H.R. 4673-Discussed the Bundling and Coordinating Post Acute Care (BACPAC) Act and shared views on post-acute care return. Discussed Medicare expansion. (no bill) Discussed Medicaid Labs Spousal Impoverishment provisions (PL. 111-198). S. 2361, Discussed Stop Schemes and cons against Medicare and seniors. Discussed transparency in healthcare. (no bill) Discussed LTSS Hill briefing series. (no bill) Met with CMS on observation status. (no bill) Submitted comment letter to CMS on the FY2015 Medicare Hospice proposed regulation. Shared comment letter with some Hill staff. H.R. 4994/S.2553 - Shared letter of support for Improving Medicare Post-Acute Care Transformation Act and discussed the status of the bill. Discussed long-term survey and supports Hill briefings. (no bill) Submitted comment letter to CMS on the FY 2015 Medicare Home Health proposed regulation. Shared draft working paper on impact of observation on Medicare beneficiary out of pocket cost. (no bill) Responded to inquiry on observation. (no bill)

Client expense: $2,380,000 · Firm income: Not reported

Government targets: Administration on Aging, Agriculture, Dept of (USDA), Bureau of the Census, Centers For Medicare and Medicaid Services (CMS), Commodity Futures Trading Commission (CFTC), Congressional Budget Office (CBO), Energy, Dept of, Environmental Protection Agency (EPA), Equal Employment Opportunity Commission (EEOC), Executive Office of the President (EOP), Federal Communications Commission (FCC), Federal Highway Administration (FHA), Federal Reserve System, Federal Trade Commission (FTC), Federal Transit Administration (FTA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Housing & Urban Development, Dept of (HUD), Internal Revenue Service (IRS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Medicare Payment Advisory Commission (MedPAC), Natl Highway Traffic Safety Administration (NHTSA), Natl Institutes of Health (NIH), Office of Management & Budget (OMB), Office of Personnel Management (OPM), Office of the Comptroller of the Currency (OCC), Pension Benefit Guaranty Corporation (PBGC), SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA), Transportation, Dept of (DOT), Treasury, Dept of, Veterans Affairs, Dept of (VA), White House Office

Issues related to agent compensation; ; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418, H.R. 3522. Issues related to HSA/FSA reform; H.R. 2194, S. 1031. Issues related to the McCarran-Ferguson anti-trust exemption; H.R. 743.

Client expense: $698,190 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Issues relating to insurance regulatory reform and agent compensation; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Dodd-Frank Wall Street Reform Act of 2010; H.R. 1627, H.R. 2374, H.R. 797, H.R. 4510, S. 2270. Issues related to the implementation of of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418, H.R. 3522.Issues related to terrorism risk insurance; H.R. 508, H.R. 2146, H.R. 4871, S. 2244. Issues related to flood risk insurance; H.R. 3370, S. 1846, S. 1926. Issues related to the regulation of insurance competition, products with guarantees, individual and employer owned policies, and fiduciary-client relationships; H.R. 2374. Issues related to capital standards for insurance providers; H.R. 5461, S. 2102.

Client expense: $698,190 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Medicare physician payment; clinical data registries; graduate medical education; health care quality; medical imaging and prior authorization; in-office ancillary services exception; HR 2914, Promoting Integrity in Medicare Act; SGR Repeal and Beneficiary Access Improvement Act of 2014; HR 4015/S 2000, SGR Repeal and Medicare Provider Payment Modernization Act; S 2501, Hospital Readmission Accuracy and Accountability Act; S 1932/HR 3890, Better Care, Lower Cost Act; IMPACT Act;S 2552, Medicare Advantage Participant Bill of Rights Act; HR 4282, CARE Act; HR 4930, Advancing Care for Exceptional Kids Act; S 961/HR 36, Health Care Safety Net Enhancement Act; Facilitating Participation in Clinical Data Registries Act; HR 4188, Establishing Beneficiary Equity in the Hospital Readmission Program Act; HR 4857, Ensuring Equal Access to Treatments Act; S 1758, Quality Data, Quality Healthcare Act; HR 4418, Expanding the Availability of Medicare Data Act.

Client expense: $850,000 · Firm income: Not reported

Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Medicare and Medicaid Services (CMS), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE

H.R. 5380 The Medicare Telehealth Parity Act of 2014 S. 2552 The Medicare Advantage Participants Bill of Rights Act H.R. 4998, The Medicare Advantage Participants Bill of Rights Act S. 2553 The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) H.R. 4994, The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) S. 1932 The Better Care, Lower Cost Act H.R. 3890, The Better Care, Lower Cost Act S. 1422 The Preventive Health Savings Act H.R. 2663, The Preventive Health Savings Act H.R. 5279, The Sugar-Sweetened Beverages Tax (SWEET) Act S.2574, The Healthy Families Act of 2014 H.R. 1024, The Medication Therapy Management Empowerment Act S. 2240, The Medicare Choices Empowerment and Protection Act S. 2000 SGR Repeal and Medicare Provider Payment Modernization Act of 2014 H.R. 4015 SGR Repeal and Medicare Provider Payment Modernization Act of 2014 HR. 4418, the Expanding the Availability of Medicare Data Act H.R. 2843 Medicare Data Access for Transparency and Accountability Act S. 1180 Medicare Data Access for Transparency and Accountability Act H.R. 3077, TELEmedicine for MEDicare (TELE-MED) Act H.R. 4190, a bill that would will allow Medicare reimbursement for Part B services performed by a pharmacist in underserved communities, among other activities. H.R.1070, Removing Barriers to Colorectal Cancer Screening Act of 2013 H.R. 1074 National Diabetes Clinical Care Commission Bill S. 539, National Diabetes Clinical Care Commission Bill

Client expense: $160,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Congressional Budget Office (CBO), Executive Office of the President (EOP), Federal Trade Commission (FTC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. S. 77, Prescription Drug and Health Improvement Act S. 557, Medication Therapy Management Empowerment Act H.R. 460, Patients Access to Treatments Act H.R. 1188, Preserving Our Hometown Independent Pharmacies Act H.R. 1367, FEHBP Prescription Drug Integrity, Transparency, and Cost Savings Act H.R. 1024, Medication Therapy Management Empowerment Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $788,458 · Firm income: Not reported

Government targets: Administration for Children & Families (ACF), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. Issues related to the compounding of certain drugs. S. 77, Prescription Drug and Health Improvement Act S. 557, Medication Therapy Management Empowerment Act H.R. 460, Patients Access to Treatments Act H.R. 1188, Preserving Our Hometown Independent Pharmacies Act H.R. 1367, FEHBP Prescription Drug Integrity, Transparency, and Cost Savings Act H.R. 1024, Medication Therapy Management Empowerment Act S.867, Medicare Prescription Drug Program Integrity and Transparency Act H.R. 2960, Medicare Prescription Drug Integrity Act of 2013 H.R. 4160, Keep the Promise to Seniors Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $788,458 · Firm income: Not reported

Government targets: Administration for Children & Families (ACF), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. S. 77, Prescription Drug and Health Improvement Act S. 557 / H.R. 1024, Medication Therapy Management Empowerment Act S.867, Medicare Prescription Drug Program Integrity and Transparency Act H.R. 2960, Medicare Prescription Drug Integrity Act of 2013 H.R. 4160, Keep the Promise to Seniors Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $788,458 · Firm income: Not reported

Government targets: Administration for Children & Families (ACF), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy which will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Oral Health Coverage for the Medically Compromised and at Risk Populations There is sufficient data that demonstrates oral health impacts the systemic health of the patient and in doing can reduce the cost of care. Linkages that encourage patient compliance, patient education, provider education, and bi-directional referral and surveillance should be incented and compensated. Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care. Meaningful Use of Health Information Technology The growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized medicine, the tailoring of medical treatments to patient characteristics, allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. This should be supported.

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

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), SENATE

Discussion of issues related to HR 4015/S 2000 the SGR Repeal and Medicare Provider Payment Modernization Act; HR 4994/S 2553 the Improving Medicare Post-Acute Care Transformation Act of 2014, HR 5183 The Value-Based Insurance Design Act of 2014, The CHIP Extension Act of 2014, and HR 4418 Expanding the Availability of Medicare Data Act.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. S. 77, Prescription Drug and Health Improvement Act S. 557, Medication Therapy Management Empowerment Act H.R. 460, Patients Access to Treatments Act H.R. 1188, Preserving Our Hometown Independent Pharmacies Act H.R. 1367, FEHBP Prescription Drug Integrity, Transparency, and Cost Savings Act H.R. 1024, Medication Therapy Management Empowerment Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid ; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $1,318,034 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. S. 77, Prescription Drug and Health Improvement Act S. 557 / H.R. 1024, Medication Therapy Management Empowerment Act S.867, Medicare Prescription Drug Program Integrity and Transparency Act H.R. 2960, Medicare Prescription Drug Integrity Act of 2013 H.R. 4160, Keep the Promise to Seniors Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid ; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $1,318,034 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Provisions of PL 111-148 and PL 111-152 impacting Medicare Part D such as formulary requirements, PBM disclosure provisions, closing the Part D coverage gap Regulatory design and coverage of pharmacy benefits in health reform exchanges and the commercial market (essential health benefits, grandfathering, value-based insurance design, e-prescribing, PBM disclosure requirements, and medical loss ratio). Regulatory and proposed legislative changes to Medicare part D including pharmacy networks, classes of clinical concern, mail-service pharmacy, EGWP waivers, MTM expansion, long term care short-term fills, recovery audit contractors. Implementation of changes to the definition of Average Manufacturer Price in Medicaid Issues related to the management of Medicaid prescription drug benefits Legislation to promote generic drugs. Regulatory Implementation of the HITECH Act. FDA issues related to the Prescription Drug User Fee Act (PDUFA) (generic user fees, pedigree, REMs); implementation of approval pathway for generic biologic drugs, 340B program. Issues related to the compounding of certain drugs. S. 77, Prescription Drug and Health Improvement Act S. 557, Medication Therapy Management Empowerment Act H.R. 460, Patients Access to Treatments Act H.R. 1188, Preserving Our Hometown Independent Pharmacies Act H.R. 1367, FEHBP Prescription Drug Integrity, Transparency, and Cost Savings Act H.R. 1024, Medication Therapy Management Empowerment Act S.867, Medicare Prescription Drug Program Integrity and Transparency Act H.R. 2960, Medicare Prescription Drug Integrity Act of 2013 H.R. 4160, Keep the Promise to Seniors Act H.R. 4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 to Medicare/Medicaid ; Pharmacy; and Health Care General H.R. 4418, Expanding the Availability of Medicare Data Act to Medicare/Medicaid

Client expense: $1,318,034 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), SENATE

Issues relating to insurance regulatory reform and agent compensation; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Dodd-Frank Wall Street Reform Act of 2010; H.R. 1627, H.R. 2374, H.R. 797, H.R. 4510, S. 2270. Issues related to the implementation of of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418.Issues related to terrorism risk insurance; H.R. 508, H.R. 2146, H.R. 4871, S. 2244. Issues related to flood risk insurance; H.R. 3370, S. 1846, S. 1926. Issues related to the regulation of insurance competition, products with guarantees, individual and employer owned policies, and fiduciary-client relationships; H.R. 2374.

Client expense: $698,190 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Issues related to agent compensation; ; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418. Issues related to HSA/FSA reform; H.R. 2194, S. 1031. Issues related to the McCarran-Ferguson anti-trust exemption; H.R. 743.

Client expense: $698,190 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

HR 487, Primary Care Workforce Access Improvement Act, Urge House to cosponsor bill that would create GME pilot project to train primary care doctors, urge Senate offices to sponsor bill; urge W&M offices to discuss during March 2014 budget hearing, GME reform increase primary care physician training, pilot test alternatives to GME payment to increase PCP training.HR 2305, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2810, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2867, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2969, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 3306, Telehealth Enhancement Act, Defining the home base for telehealth reimbursement to incluse family medicine offices. HR 4015, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4209, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4302, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. HR 4418, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4543, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1123, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1184, Treat and Reduce Obesity Act, Seeking House and Senate cosponsors for obesity legislation. S. 1318, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1759, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 1769, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1871, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1978, Increasing Primary Care Access Act, Family physician workforce, Teaching Health Center Reauthorization Act, Reauthorize the Teaching Health Centers Graduate Medical Education program, increase family physician workforce. S. 2000, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2110, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2122, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 2229, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 2415, Seeking House and Senate cosponsors for obesity legislation. No Bill Number, SGR Repeal and Replacement process, Advocate for SGR repeal and new physician payment system that pays for value and primary care. No Bill Number, Medicaid Primary Care Bonus, Advocate for extension of the Medicaid bonus which expires at the end of 2014. No Bill Number, Medicare Primary Care Incentive Payment, Urge Ways and Means members to discuss at annual MedPac hearing. No Bill Number, Telemedicine,advocate for AAFP policies to be included in a potential bipartisan telehealth bill. No Bill Number, Medicare Site Neutral Payments; advocate for AAFP policies to be included in conncection with MedPac hearing. No Bill Number, Extend Medicare/medicare parity for primary care services, Extend increase in Medicaid payments for primary care services to Medicare levels beyond 2015. No Bill Number, Direct Primary Care, Primary care model of retainer-based practice. No Bill Number, Medicare physician payment reform of the SGR, 2014 converstion factor. No Bill Number, Repeal SGR, Positive update and higher rate for primary care.No Bill Number, Site-neutral payment for medical services, Support site-neutral payment by CMS for medical services. No Bill Number, First Fridays Meetings, Provider outreach group for Affordable Care Act, provider and open enrollment issues.

Client expense: $1,257,519 · Firm income: Not reported

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

HR 487, Primary Care Workforce Access Improvement Act, Urge House to cosponsor bill that would create GME pilot project to train primary care doctors, urge Senate offices to sponsor bill; urge W&M offices to discuss during March 2014 budget hearing, GME reform increase primary care physician training, pilot test alternatives to GME payment to increase PCP training.HR 2305, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2810, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2867, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 2969, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 3306, Telehealth Enhancement Act, Defining the home base for telehealth reimbursement to incluse family medicine offices. HR 4015, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4209, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4302, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. HR 4418, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. HR 4543, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1123, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1184, Treat and Reduce Obesity Act, Seeking House and Senate cosponsors for obesity legislation. S. 1318, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1759, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 1769, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1871, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 1978, Increasing Primary Care Access Act, Family physician workforce, Teaching Health Center Reauthorization Act, Reauthorize the Teaching Health Centers Graduate Medical Education program, increase family physician workforce. S. 2000, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2110, Medicare Payment Reform, Repeal SGR. Positive update and higher rate for primary care. S. 2122, Medicare Payment Reform, Repeal SGR, Positive update and higher rate for primary care. S. 2229, Reauthorizing Teaching Health Center GME program, Teaching Health Centers Graduate Medical Education. S. 2415, Seeking House and Senate cosponsors for obesity legislation. No Bill Number, SGR Repeal and Replacement process, Advocate for SGR repeal and new physician payment system that pays for value and primary care. No Bill Number, Medicaid Primary Care Bonus, Advocate for extension of the Medicaid bonus which expires at the end of 2014. No Bill Number, Medicare Primary Care Incentive Payment, Urge Ways and Means members to discuss at annual MedPac hearing. No Bill Number, Telemedicine,advocate for AAFP policies to be included in a potential bipartisan telehealth bill. No Bill Number, Medicare Site Neutral Payments; advocate for AAFP policies to be included in conncection with MedPac hearing. No Bill Number, Extend Medicare/medicare parity for primary care services, Extend increase in Medicaid payments for primary care services to Medicare levels beyond 2015. No Bill Number, Direct Primary Care, Primary care model of retainer-based practice. No Bill Number, Medicare physician payment reform of the SGR, 2014 converstion factor. No Bill Number, Repeal SGR, Positive update and higher rate for primary care.No Bill Number, Site-neutral payment for medical services, Support site-neutral payment by CMS for medical services. No Bill Number, First Fridays Meetings, Provider outreach group for Affordable Care Act, provider and open enrollment issues.

Client expense: $1,257,519 · Firm income: Not reported

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

Pub.Law 111-148 & 111-152 - Discussed implementation of health care law that would reform the health care system to provide affordable quality health care, reduce drug costs and expand access to long-term services and supports. Discussed how to implement Medicaid provisions of Affordable Care Act. (PL. 111-148)S. 374, Medicare Mental Health Inpatient Equity Act - Lobbied in support of this legislation to eliminate the 190-day lifetime limit on Medicare coverage for in-patient psychiatric hospital services (112th). Discussed improving access to care for underserved population. (no bill) Discussed importance of maintaining low income subsididies and supports in Medicare. (no bill) Discussed the importance of coordinating services for those who qualify for both Medicare and Medicaid in order to ensure that beneficiaries receive all needed benefits but there is no duplication. (no bill) Discussed whether, and under what circumstances, managed care could effectively be used to provide benefits to dual eligible beneficiaries. (no bill) Discussed additional methods for fighting fraud and waste in Health Care. (no bill) Discussed Medigap and need for guaranteed issue for all populations and need to increase medical loss ratio. Discussed durable medical equipment bidding. (no bill) Lobbied for legislation to provide Medicare beneficiaries with additional opportunities to enroll in Medicare Part B.(no bill) Lobbied against the use of the Social Security account number on Government-issued identification cards issued in connection with Medicare, Medicaid, and SCHIP benefits and for other purposes. (no bill) Discussed support to curb waste and fraud from the Medicare and Medicaid programs. (no bill) H.R. 3630, Middle Class Tax Relief and Job Creation Act of 2012 - Discussed the legislation as it pertained to SGR. Discussed Medicare Reform. (no bill) H.R. 2305/S. 1123, PRIME ACT (Preventing and Reducing Improper Medicare Expenditures) - Discussed support for bill and urged cosponsorship. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs. (no bill) H.R. 1588/S. 740, Medicare Drug Savings Act - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income befeficiaries. (no bill) Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) H.R. 1717 - Discussed Medicare DMEPOS Market Pricing Program Act. Discussed implementation of regulations regarding minimum wage and overtime for home care workers and consumer-directed care. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H. R. 1588/S.740 - Discussed the Medicare Drug Savings Act to require drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. H.R.3830/S.1900 - Discussed pending U.S. trade agreement negotiations and trade promotional or "fast track" authority legislation and their potential impact on Medicare and Medicaid prescription drug programs. S. 2461 - Discussed Children's Health Insurance Program (CHIP) extension and CHIP Extension Act of 2014. Discussed Part D Payment for Drugs for Beneficiaries Enrolled in Hospice - Final 2014 CMS Guidance.Discussed Medicare Graduate Nursing Education pilot design. (no bill) Discussed Prescription Drug Affordability. (no bill) Discussed Prescription Drug Shortages. (no bill) H.R. 3342, Affordable Medicines Utilization Act of 2011 - Lobbied to encourage state Medicaid programs to use safe, effective generic medications. H.R. 2576 - Discussion to amend the Internal Revenue Code of 1986 to modify the calculation of modified adjusted gross income for purposes of determining eligibility for certain healthcare-related programs. Discussed opposition to caps on dual eligibles; discussed managed care and dual eligibles. (no bill) Discussed with CMS demonstration programs for dual eligibles and process related to the demonstrations, as well as other work of the Medicare-Medicaid Coordination Office, discussed consumer choice and continuity of care in Medicaid managed long-term services and supports programs, discussed focus groups on dual eligibles. Discussed Hospital & Critical Access Hospitals Conditions of Participation proposed regulations; requested that advanced practice registered nurses and physicians assistants be allowed the full scope of services in hospital admitting and visiting privileges. (no bill) Discussed Hospital Outpatient Therapeutic Services Final Rule underscoring that advanced practice registered nurses and physicians should be allowed to supervise such outpatient service clinics without physician oversight as long as in line with state scope of practice laws. (no bill) Discussed health disparities. (no bill) Discussed Medicaid reform, Medicare/Medicaid "dual eligibles" integration efforts and financial alignment demonstrations; and other CMS demonstration initiatives. (no bill) S. 3586, Recruiting Individuals to Drive Elders (RIDE) Act - Discussed Medicaid non-emergency transportation bill (112th). Discussed proposals that would establish per-capita caps under Medicaid as well as other Medicaid financing proposals including block grants and changes to the current FMAP structure. (no bill) Discussed extension of funding originally provided under the Medicare Improvement for Patients and Providers Act (P.L. 110-275) to State Health Insurance Assistance Programs (SHIPs), Aging and Disability Resource Centers (ADRICs), and Area Agencies on Aging (AAAs) for Medicare outreach and enrollment counseling. (no bill) Discussed the prevention of cuts to beneficiaries in the Medicare program. (no bill) Discussed the prevention of an increase in the age of eligibility in the Medicare program. (no bill) Discussed the patch to the Sustainable Growth Rate (SGR) in the Medicare program. (no bill) Discussed concerns of block granting Medicaid. (no bill) Discussed the Kansas managed long-term services and supports waiver proposals and related implementation issues. (no bill). H.R.928/S.408, the Medicare Drug Savings Act - Discussed requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed Health Disparities. (no bill) Discussed medicare demonstration project replacing standard medicare cards with Smart Card technology. (no bill) H.R. 574 - The Medicare Physician Payment Innovation Act of 2013. H.R. 1173 - Discussed Personalize Your Care Act. Discussed Medicaid expansion and estate recovery. (no bill) Discussed Medicaid and asset transfers. (no bill) Discussed the Improving Medicare Post-Acute Care Transformation Act of 2014 and provided feedback on the draft bill. (no bill number at the time, but later bill number was H.R. 4944/S. 2553) S. 2491, Discussed Medicare Protection Act. Submitted comment letter on FYIS Medicare Skilled Nursing Facility payment rule. (no bill) Discussed concern about CMS guidance on prescription drugs for medicare beneficiaries receiving hospice and coordination between hospice providers and medicare Part D sponsors. (no bill)H.R. 1179/S.569, Improving Access to Medicare Act - Discussed support of Improving Access to Medicare Coverage Act and urged cosponsorship and advancement of the bill. Discussed comments regarding Medicare and You handbook. (no bill) Discussed CMS information regarding healthcare marketplaces. H.R. 2305/S.1123, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act. Bill reduces waste, fraud, and abuse in Medicare and Medicaid programs. Discussed Competitive bidding of durable medical equipment, prosthetics, orthotics, and supplies. (no bill) Discussed repeal of Affordable Care Act provision making prescriptions necessary for over-the-counter drugs purchased with flexible spending accounts. (no bill) Discussed Medicare supplemental coverage. (no bill) Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug cost. (no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) Discussed Recruiting Individuals to Drive Our Elders Act (RIDE) would increase state flexibility by giving states the option to receive federal assistance to reimburse their volunteer drivers for no-load miles. (no bill) Labor, Health and Human Services Appropriations Act, 2014 - Lobbied to protect vital health and social services programs from enhanced reductions from the prior year baseline, and to prevent repeal of certain financial and health care-related regulation.(no bill) Discussed potential improvements to the Medicare Savings Programs for low-income beneficiares. (no bill) Discussed pending U.S. trade agreement negotiations, including trade promotional or 'fast track' authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) Discussed fraud, Medicare home healthcare, ways to find savings in Medicare without harming Medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). Discussed You've Earned A Say, ways to find savings in medicare without harming medicare beneficiaries (care coordination, prescription drugs, waste, fraud and abuse). PL.111-148 - Discussed implementation of provision to require reporting of nursing home staffing data based on payroll data.Discussed Medicare Advantage. (no bill) Discussed H.R. 3616, Protecting Seniors from Healthcare Fraud Act. Discussed observation care and "two-midnight rule". (no bill) H.R. 1070, the Removing Barriers to Colorectal Cancer Screening Act - Discussed and sent letter of endorsement to bill. Discussed the Medicare Part D prescription drug benefit program and changes needed to further lower prescription drug costs and related agency proposed rule changes. (no bill) H.R. 1588/S.740, Medicaid Drug Savings Act - Discussed the requirement for drug manufacturers to provide rebates for drugs provided to Medicare Part D low-income subsidy beneficiaries, including those who are dually eligible for Medicare and Medicaid. Discussed potential improvements to the Medicare Savings Programs for low-income beneficiaries. (no bill) Discussed pending U.S. Trade agreement negotiations, including trade promotional or "fast track" authority, and their potential impact on Medicare and Medicaid prescription drug programs. (no bill) H.R. 2810/S.1871/H.R. 4015/S.2110 - Discussed SGR repeal and health care extender provisions, including the Qualified Individual low-income Medicare beneficiary assistance program. H.R. 4418, The Expanding Availability of Medicare Data Act - Sent letter of endorsement. Discussed Medicare data and billing transparency. (no bill) Discussed socio-economic risk adjustment. (no bill) Discussed nursing home staffing data in meeting with CMS. (no bill) Discussed advanced care planning, Welcome to Medicare visit, and Medicare wellness visits. Discussed language access in managed long-term services and supports in meeting with the HHS Office for Civil Rights. S. 2240, Discussed Medicare Choices Empowerment and Protection Act. S. 1439, Discussed support for Care Planning Act. Discussed LTSS Scorecard and reserving a room/logistics for Hill briefing on the LTSS Scorecard. (no bill). Discussed managed LTSS and language access. (no bill) H.R. 3024, Discussed the Medicare Common Access Card Act. H.R. 9673, Discussed the Bundling and Coordinating Post Acute Care (BACPAC) Act and shared views on post-acute care return. Discussed Medicare expansion. (no bill) H.R. 1179/S. 569, Improving Access to Medicare Coverage Act - Submitted written statement for the record for the current hospital ---in the Medicare program hearings. Shared draft witness questions with some subcommittee members and committee staff. Discussed Medicaid Labs Spousal Impoverishment provisions (PL. 111-198). S. 2361, Discussed Stop Schemes and cons against Medicare and seniors. Invited Hill staff to attend the LTSS Scorecard briefing. (no bill) Participated in a roundtable discussion on long-term services and supports. (no bill) Discussed Welcome to Medicare Visit and advance care planning. (no bill) Discussed transparency in healthcare. (no bill) Discussed New York State Community first choice option and workforce issues. (no bill)

Client expense: $2,360,000 · Firm income: Not reported

Government targets: Administration on Aging, Agriculture, Dept of (USDA), Bureau of the Census, Centers For Medicare and Medicaid Services (CMS), Commodity Futures Trading Commission (CFTC), Energy, Dept of, Environmental Protection Agency (EPA), Equal Employment Opportunity Commission (EEOC), Executive Office of the President (EOP), Federal Communications Commission (FCC), Federal Highway Administration (FHA), Federal Reserve System, Federal Trade Commission (FTC), Federal Transit Administration (FTA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Housing & Urban Development, Dept of (HUD), Internal Revenue Service (IRS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Medicare Payment Advisory Commission (MedPAC), Natl Highway Traffic Safety Administration (NHTSA), Natl Institutes of Health (NIH), Office of Management & Budget (OMB), Office of Personnel Management (OPM), Office of the Comptroller of the Currency (OCC), Pension Benefit Guaranty Corporation (PBGC), SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA), Transportation, Dept of (DOT), Treasury, Dept of, Veterans Affairs, Dept of (VA), White House Office

S. 236, Medicare Patient Empowerment Act: Private contracting for patients and physicians S. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB) S. 577, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training S. 972, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10H.R. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB)H.R. 574, Medicare Physician Payment Innovation Act of 2013: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 969, Medical Practice Freedom Act of 2013: Medical licensure H.R. 1180, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training H.R.1201, Training Tomorrow's Doctors Today Act: Graduate medical education-residency training H.R. 1310, Medicare Patient Empowerment Act: Private contracting for patients and physicians H.R. 1333, Electronic Health Records Improvement Act: Electronic medical record penalties and incentive payments H.R.1701, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10 H.R. 2810, Medicare Patient Access and Quality Improvement Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 4302, the Protecting Access to Medicare Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R.4418: Expanding the Availability of Medicare Data Act: making Medicare data available for clinical data registries

Client expense: $30,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S. 236, Medicare Patient Empowerment Act: Private contracting for patients and physicians S. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB) S. 577, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training S. 972, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10H.R. 351, Protecting Seniors' Access to Medicare Act of 2013: Repeal of the Independent Payment Advisory Board (IPAB)H.R. 574, Medicare Physician Payment Innovation Act of 2013: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 969, Medical Practice Freedom Act of 2013: Medical licensure H.R. 1180, Resident Physician Shortage Reduction Act of 2013: Graduate medical education-residency training H.R.1201, Training Tomorrow's Doctors Today Act: Graduate medical education-residency training H.R. 1310, Medicare Patient Empowerment Act: Private contracting for patients and physicians H.R. 1333, Electronic Health Records Improvement Act: Electronic medical record penalties and incentive payments H.R.1701, Cutting Costly Codes Act Prohibit replacement of ICD-9 with ICD-10 H.R. 2810, Medicare Patient Access and Quality Improvement Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R. 4302, the Protecting Access to Medicare Act: Medicare physician payment-sustainable growth rate (SGR) reform H.R.4418: Expanding the Availability of Medicare Data Act: making Medicare data available for clinical data registries

Client expense: $30,000 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

General Issues: Coordinated care for dual eligible's, Medicare payment reform, Medicare Advantage quality bonus payment program, insurer tax, Medicaid payment reform, Medicaid Managed Care, Medicare Advantage, Medicare Supplemental, fraud and abuse prevention, high cost drugs, Special Needs Plans reauthorization, Medicare Part D, appropriate use criteria, Medicare Sustainable Growth Rate, and Medicare data transparency.Specific Bills include: H.R. 4418; S. 1758; and, H.R. 4302 (became Public Law 113-93).

Client expense: $1,580,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), SENATE, Treasury, Dept of, White House Office

H.R.4577, Ensuring Seniors Access to Local Pharmacies Act of 2014 HR. 4418, the Expanding the Availability of Medicare Data Act H.R. 4302, the Protecting Access to Medicare Act of 2014 S. 2491, the Medicare Protection ActH.R. 2843/S. 1180, the Medicare Data Access for Transparency and Accountability Act H.R. 3890/S.1932, the Better Care, Lower Cost Act H.R. 4302, the Protecting Access to Medicare Act of 2014 H.R. 4190 - To amend title XVIII of the Social Security Act to provide for coverage under the Medicare program of pharmacist services

Client expense: $160,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Congressional Budget Office (CBO), Executive Office of the President (EOP), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness researchImposes necessary regulations on Insurers banning rescissions and exclusions for pre-existing medical conditions limits Expands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate -- We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value -- Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health -The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.Value Based Purchasing - The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Medicare Payment Inequities - In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work - There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Transparency -- Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement - The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medicare Advantage Improvements -H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Accountable Care Organizations - The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary.The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. We recommend that CMS relax restrictions on the provision of services using telemedicine technologies to allow ACOs to increase the efficiency of services provided. Adequate Funding for CMS -The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. Telemedicine in Medicare -Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform -- The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. Dental Access and Integration with Traditional Medicine - The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists.A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Oral Health Coverage for the Medically Compromised and at Risk Populations There is sufficient data that demonstrates oral health impacts the systemic health of the patient and in doing can reduce the cost of care. Linkages that encourage patient compliance, patient education, provider education, and bi-directional referral and surveillance should be incented and compensated. Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit.

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

Government targets: Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), SENATE

Issues relating to insurance regulatory reform and agent compensation; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Dodd-Frank Wall Street Reform Act of 2010; H.R. 1627, H.R. 2374, H.R. 797. Issues related to the implementation of of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418.Issues related to terrorism risk insurance; H.R. 508, H.R. 2146. Issues related to flood risk insurance; H.R. 3370, S. 1846, S. 1926. Issues related to the regulation of insurance competition, products with guarantees, individual and employer owned policies, and fiduciary-client relationships.

Client expense: $694,328 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of

Issues related to agent compensation; ; H.R. 1155, S. 534, S. 650, H.R. 2328, S. 2175, S. 2173. Issues related to the implementation of the Patient Protection and Affordable Care Act; H.R. 544, H.R. 2995, H.R. 2575, S. 1188, H.R. 4418. Issues related to HSA/FSA reform; H.R. 2194, S. 1031. Issues related to the McCarran-Ferguson anti-trust exemption; H.R. 743.

Client expense: $694,328 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Internal Revenue Service (IRS), Labor, Dept of (DOL), SENATE, Securities & Exchange Commission (SEC), Treasury, Dept of