Medicare Rural Health Access Improvement Act of 2008

Cited source text, amounts, lobbyists, and targets

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

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

S 2786

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

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2009 · fourth_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

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

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2009 · third_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

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

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2009 · second_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

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

Show 38 more cited filings

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2009 · first_quarter · Medicare/Medicaid

NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)client→NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)

Cited source text, amounts, lobbyists, and targets

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

2008 · fourth_quarter · Health Issues

Cited source text, amounts, lobbyists, and targets

S.3: Medicare Prescription Drug Price Negotiation Act of 2007 S.158: Access to Affordable Health Care Act S. 273: Prescription Drug and Health Improvement Act of 2007 S. 290: Rural Physicians Relief Act of 2007 S. 334: Healthy Americans Act S. 397: Tax Equity and Affordability Act of 2007 S. 498: Rural Medicare Equity Act of 2007 S. 1342: HeLP America Act S. 1605: Craig Thomas Rural Hospital and Provider Equity Act of 2007 S. 1710: Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 S. 2785: Save Medicare Act of 2008 S. 2603: Medicare Fraud Prevention Act of 2008 S. 2687: Medicare Beneficiary Protection Act of 2008 S. 2786: Medicare Rural Health Access Improvement Act of 2008 H.R.4: Medicare Prescription Drug Price Negotiation Act of 2007 H.R.15: National Health Insurance Act H.R.118: To amend part D of title XVIII of the Social Security Act to authorize the Secretary of Health and Human Services to negotiate prices for part D covered drugs for Medicare beneficiaries. H.R.205: Medicare Prescription Drug Enrollment Extension Act of 2007 H.R.298: Flexible Spending Accounts Growth and Opportunities Act of 2007 HR 914: Tax Equity and Affordability Act of 2007 H.R. 1651: Rural Health Quality Advisory Commission Act of 2007 HR 2056: Medicare Part D Improvement Act of 2007 HR 2633: HeLP America Act (Introduced in House) HR 2860: Health Care Access and Rural Equity (H-CARE) Act of 2007 HR 3014: Health Equity and Accountability Act of 2007 H.R. 3043: Department of Health and Human Services Appropriations Act, 2008 HR 3163: Healthy Americans HR 4848: To extend for one year parity in the application of certain limits to mental health benefits, and for other purposes HR 1424: Paul Wellstone Mental Health and Addiction Equity Act of 2007 HR 5445: To amend part B of title XVIII of the Social Security Act to increase Medicare payments for physicians' services through December 31, 2009. H.R. 6143: Pension Protection Act ERISA Amendments of 2008 H.R. 6382: Pension Protection Technical Corrections Act of 2008 H.R. 7242: Pension Protection Act IRC Amendments of 2008

Client expense: $2,095,000 · Firm income: Not reported

S. 2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

AMERICAN HEALTH CARE ASSOCIATIONclient→AMERICAN HEALTH CARE ASSOCIATION

2008 · fourth_quarter · Medicare/Medicaid

BRUCE YARWOOD DAVID HEBERT KARL POLZER KEN PREEDE MARYANNE SAPIO MATTHEW SMYTH mrs CYNTHIA MORTON ms FRANCESCA O'REILLY

Cited source text, amounts, lobbyists, and targets

H.R. 3025 - To amend title XVII of the Social Security Act to provide comprehensive improvements to the Medicare Prescription Drug Program, and for other purposes. H.R. 4105 - To impose a moratorium on the use of recovery audit contrators under the Medicare Integrity Program. H.R. 976 - An act to amend title XXI of the Social Sercurity Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R. 1459 - To improve Medicare beneficiary access by extending the 60 percent compliance threshold to determine whether a hospital or unit is an impatient rehabilitation facility. H.R. 562 - To amend title XVIII of teh Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare Program. H.R. 3162 - To amend titles XVII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes. H.R. 1621 - To amnd title XIX of the Social Security Act to provide individuals with disabilities and older Americans with equal access to community-based attendant services and supports, and for other purposes. H.R. 1536 - To amend part D of title XVII of the Social Security Act to assist low-income individuals in obtaining subsidized prescription drug coverage under the Medicare prescription drug program by expediting the application and qualification process and by revising the resource standards used to determine eligibility for such subsidies, and for other purposes. H.R. 4541 - To amend title XVIII of the Social Security Act to provide for patient protections under the Medicare prescription drug program for residents of long term care facilities. H.R.3963 - To amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.5604 - To amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. H.R.5613 - To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009, and for other purposes. H.R.6331 - To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes. H.R.5480 - To respond to a Medicare funding warning. S.2662 - A bill to respond to a medicare funding warning. S.543 - A bill to improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility under the Medicare program. S.1107 - A bill to amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S. 2819 - A bill to preserve access to Medicaid and the State Children's Health Insurance Program during an economic downturn, and for other purposes. S. 3101 - A bill to amend titles XVII and XIX of the Social Security Act to extend expiring provisions under the Medicare program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care sub rural areas, including pharmacy access, and for other purposes. S.1893 - An original bill to amend title XXI of the Social Security Act to reauthorize the State Children's Health Insurance Program, and for other purposes. S.338 - A bill to amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare program. S.2499 - A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. S.2396 - A bill to amend title XI of the Social Security Act to modernize the quality improvement organization (QIO) program. S. 2708 - A bill to amend the Public Health Service Act to attract and retain trained health care professionals and firect care workers dedicated to providing quality care to the growing population of older Americans. S. 2705 - A bill to authorize programs to increase the number of nurses within the Armed Forces through assistance for service as nurse faculty or education as nurses, and for other purposes. S. 2786 - A bill to amend title XVIII of the Social Security Act to improve access to health care under teh Medicare program for beneficiaries residing in rural areas. H.R.5480 - To respond to a Medicare funding warning.

Client expense: $460,000 · Firm income: Not reported

S. 2786

Government targets: Bureau of Citizenship & Immigration Services (BCIS), Centers For Medicare and Medicaid Services (CMS), Commerce, Dept of (DOC), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), SENATE

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2008 · fourth_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

Provisions of the Presidents FY2008 Budget and related appropriations legislation (S Con Res 70) related to implementation of the Medicare Advantage and Prescription Drug Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, and prescription drug benefits. S 3101, and HR 6331, the Medicare Improvements for Patients and Providers Act of 2008. Supported provisions that prevent the 10.6% cut in Medicare physician payment that was called for in the November 27, 2007 CMS final rule implementing the Medicare physician fee schedule. The bill replaces the 10.6% cut with an increase through 2008, and extended the 1.0 floor on the geographic adjustor for physician work initially included in the Medicare Modernization Act of 2003 through 2008. S.2812, the Medicare Improvement Act of 2008 introduced by senator Kent Conrad. This legislation will expand the number of originating sites, the list of eligible practitioners, and provide an advisory committee to CMS and Congress on payment issues related to services provided via TeleHealth. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. Reform proposals include reimbursement updated on a market basket basis, removal of prescription drugs from the calculation of Medicare Part B costs, and rebasing Part B to reflect current rather than cumulative costs. Pay-for Reporting and Performance (Value Based Purchasing) Currently the prevailing methods of paying for health care in the US neither incent nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. In the 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 unanticipated, but now recognized effect of economically stimulating growth in the numbers of services provided by physicians. Medicare must implement quality based payments for physician services, and capture the data on performance measures utilizing available claims-based data recoverable through enhanced IT functions. In 2005, the Centers for Medicare and Medicaid Services (CMS) proposed the Physicians Voluntary Reporting Program (PVRP). In late 2006 CMS renamed PVRP the Physicians Quality Reporting Initiative. (PQRI) In the PQRI program CMS calls on physicians to report on evidence-based performance measures selected with input from the National Quality Forum, the Ambulatory Care Quality Alliance, and the National Committee for Quality Assurance, (NCQA). For reporting purposes physicians will utilize provisional G- Codes developed by CMS to indicate whether a patient received a service, did not receive the service, was not a eligible candidate to receive the service, or would not be considered a patient under the care of the physician at the time of the service. Marshfield Clinic has recommended that CMS allow medical groups to electronically report quality measures in an aggregated, periodic, statistically valid basis to PQRI; and re-focus the PQRI on high cost/high volume disease states. Marshfield Clinic supports a request for CMS authorization and funding for a multi-center demonstration project with access to vast data resources across multiple states. This proposed project will connect treatments with outcomes and develop quality metrics that reflect the realities of the care setting and the severity of the patients illness. Information Technology Under current law the capital and operating expenses of installing and maintaining an electronic medical record are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS measurement of current physician practice expenses reflect minimal expense associated with IT. Congress should provide incentives for EMR adoption, and should establish standards to facilitate the sharing and exchange of data. S. 1693, the Wired for Health Care Quality Act introduced by Senator Ted Kennedy (D-MA) and Michael Enzi (R-WY) - Amends the Public Health Service Act to establish the Office of the National Coordinator of Health Information Technology to coordinate and oversee programs and activities to develop a nationwide interoperable health information technology infrastructure. HR 6357, the Protecting Records, Optimizing Treatment and Easing Communications through Health Care Technology Act of 2008 is important legislation that promotes Health Information Technology and the protection of patients personal health information. HR 6357 codifies ONCHIT, provides grants and loans for HIT, but most importantly the bill creates new privacy and security provisions which require notification of breaches of PHI by covered entities and business associates. The bill also includes restrictions on certain disclosures of PHI allowing patients to request that their information not be released to health plans in certain circumstances. It also includes an impractical consent provision that requires additional patient consent if the PHI is utilized in operations, such as peer review, quality review, standard of care review, malpractice review, or best practices analysis. HR 6898 Health-e Information Technology Act of 2008, a bill that includes an estimated $4 billion in incentive payments to Medicare physicians and hospitals which demonstrate successful adoption and use of HIT once initial national technical standards are finalized. Support for privacy enforcement provisions. H.R.6179 the Promoting Health Information Technology Act of 2008 - provisions that encourage and facilitate the adoption of state reciprocity agreements for practitioner licensure in order to expedite the provision across state lines of telehealth services; and provisions that require the Centers of Medicare & Medicaid Services to make federally qualified health centers eligible to participate in demonstration projects related to health records and heath information technology. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: CMS should administratively revise its measurements of the costs of practice to assure the validity and fairness of payments; a payment floor could be established for practice expense; or the present variation (.705 1.501) in practice expense could be channeled into a narrower corridor of adjustment. Payment Equity Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 07 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. This payment floor should be extended indefinitely or geographic adjustment of work should be eliminated entirely. The Rural Medicare Equity Act of 2007 (S 498), introduced by Senator Russ Feingold, Amends title XVIII (Medicare) of the Social Security Act (SSA) to eliminate the geographic physician work adjustment factor from the geographic indices used to adjust payments under the physician fee schedule. Rep. Braley introduced HR 2827, the Medicare Equity and Accessibility Act, along with Rep. Adrian Smith (R-Nebraska). This bill will increase the Medicare Part B reimbursement rates in Iowa and other rural states, by making permanent the 1.0 floor on the Geographic Practice Indexes for Work and Practice Expense. Support for Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Chuck Grassley especially provisions that would extend the 1.0 work floor through December 31,2009, and would recognize the equality of physician work in all geographic areas and eliminate differing work index values by establishing a national value of 1.0, effective 2010. Also support provisions for physician practice expense that would establish a practice expense floor of 1.0 for 2009 by requiring the Secretary to increase the value of any practice expense geographic index that was below 1.0 to 1.0 for services furnished on or after January 1, 2009 and before January 1, 2010. Subsection (b) would reduce the geographic adjustment for practice expense to 50 percent of the current adjustment for employee wages and rent, effective 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 - Public Law No: 108-173: Title II: Medicare Advantage -- (Sec. 211) Revises the payment system, requiring all plans to be paid at a rate at least as high as the rate for traditional Medicare fee-for-service plans. Makes change in budget neutrality for blended payments. Increases minimum percentage increase to national growth rate. Marshfield Clinic opposes reductions to Medicare Advantage payments in low payment states. Subtitle D: Additional Reforms - (Sec. 237) Provides that Federally Qualified Health Centers (FQHCs) will receive a wrap-around payment for the reasonable costs of care provided to Medicare managed care patients served at such centers. Raises reimbursements to FQHCs in order that when they are combined with MA payments and cost-sharing payments from beneficiaries they equal 100 percent of the reasonable costs of providing such services. Extends the safe harbor to include any remuneration between a FQHC (or entity controlled by an FQHC) and an MA organization. Title IV: Rural Provisions - Subtitle B: Provisions Relating to Part B Only - (Sec. 412) Directs the Secretary to increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00 for services furnished on or after January 1, 2004, and before January 1, 2007. Since this provision expires at the end of 2006 it must be extended or revised. See Tax Relief and Health Care Act provisions below (Sec. 413) Establishes a new five percent incentive payment program designed to reward both primary care and specialist care physicians for furnishing physicians' services on or after January 1, 2005, and before January 1, 2008 in physician scarcity areas. Directs the Secretary to pay the current law ten percent Health Professional Shortage Area (HPSA) incentive payment for services furnished in full county primary care geographic area HPSAs automatically rather than having the physician identify the health professional shortage area involved. Deficit Reduction Act (Section 5102) reduced reimbursements for multiple images on contiguous body parts in 2006; the DRA provision created in statute a basis for payment reductions on the imaging of contiguous body parts that CMS implemented through the rulemaking process in 2005; the DRA also requires that payment rates for imaging services delivered in physician offices do not exceed payment rates for identical imaging services delivered in hospital outpatient departments beginning in 2007. Clinic recommends that Congress repeal Section 5102, and direct MedPAC and CMS to conduct a comprehensive study of imaging and the geographic variation in services to determine where growth in the volume of imaging services is appropriate and develop workable solutions to control inappropriate imaging utilization. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments. Regulatory clarification of Medicare anti-markup issues, and postponement of the effective date of CMS final rule regarding the applicability of the anti markup provisions with respect to: (1) the technical component of a purchased diagnostic test and (2) any anatomic pathology diagnostic testing services furnished in space that is utilized by a physician group practice as a "centralized building" for purposes of complying with the physician self-referral rules and does not qualify as a "same building".

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

S 2786

Government targets: Agency for Healthcare Research & Quality (AHRQ), Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Natl Institutes of Health (NIH), SENATE

IROQUOIS HEALTHCARE ALLIANCEclient→IROQUOIS HEALTHCARE ALLIANCE

2008 · third_quarter · Health Issues

STACY CONNORS mr GARY FITZGERALD

Cited source text, amounts, lobbyists, and targets

See attached Iroquois Healthcare Alliance Federal legislation for July 1 through September 30, 2008 Preserving Access to Healthcare (PATH) Act, S.3656/ H.R. 7241 blocks for six months implementation of both the Medicare capital IME cut and the Medicaid outpatient regulation Rural Hospital Assistance Act of 2008 S.3300 IS / H.R.6912.IH To amend title XVIII of the Social Security Act to provide for temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals and to provide for the use of the non-wage adjusted PPS rate under the Medicare-dependent hospital (MDH) program, and for other purposes. Physician Availability Act of 2008 H.R.5739.IH Physician Workforce and Graduate Medical Education Enhancement Act of 2007 HR 2583 IH To amend title VII of the Public Health Service Act to establish a loan program for eligible hospitals to establish residency training programs. Physician Workforce Enhancement Act of 2008 HR 2583 EH Nursing and Allied Health Education Preservation Act of 2008 S.3468 IS /H.R.5174.IH To amend title XVIII of the Social Security Act to continue the ability of hospitals to supply a needed workforce of nurses and allied health professionals by preserving funding for hospital operated nursing and allied health education programs. 340B Program Improvement and Integrity Act of 2007 S.1376 Resident Physician Shortage Reduction Act of 2007 S.588.IS/ H.R.1093.IH Medicare Rural Health Access Improvement Act of 2008 S.2786.IS Physician Availability Act of 2008 HR 5739 IH To assure that the services of a nonemergency department physician are available to hospital patients 24 hours a day, seven days a week in all non-Federal hospitals with at least 100 licensed beds.

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

S.2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

AMERICAN HEALTH CARE ASSOCIATIONclient→AMERICAN HEALTH CARE ASSOCIATION

2008 · third_quarter · Medicare/Medicaid

BRUCE YARWOOD DAVID HEBERT KARL POLZER KEN PREEDE MARYANNE SAPIO MATTHEW SMYTH mrs CYNTHIA MORTON ms FRANCESCA O'REILLY

Cited source text, amounts, lobbyists, and targets

H.R. 3025 - To amend title XVII of the Social Security Act to provide comprehensive improvements to the Medicare Prescription Drug Program, and for other purposes. H.R. 4105 - To impose a moratorium on the use of recovery audit contrators under the Medicare Integrity Program. H.R. 976 - An act to amend title XXI of the Social Sercurity Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R. 1459 - To improve Medicare beneficiary access by extending the 60 percent compliance threshold to determine whether a hospital or unit is an impatient rehabilitation facility. H.R. 562 - To amend title XVIII of teh Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare Program. H.R. 3162 - To amend titles XVII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes. H.R. 1621 - To amnd title XIX of the Social Security Act to provide individuals with disabilities and older Americans with equal access to community-based attendant services and supports, and for other purposes. H.R. 1536 - To amend part D of title XVII of the Social Security Act to assist low-income individuals in obtaining subsidized prescription drug coverage under the Medicare prescription drug program by expediting the application and qualification process and by revising the resource standards used to determine eligibility for such subsidies, and for other purposes. H.R. 4541 - To amend title XVIII of the Social Security Act to provide for patient protections under the Medicare prescription drug program for residents of long term care facilities. H.R.3963 - To amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.5604 - To amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. H.R.5613 - To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009, and for other purposes. H.R.6331 - To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes. H.R.5480 - To respond to a Medicare funding warning. S.2662 - A bill to respond to a medicare funding warning. S.543 - A bill to improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility under the Medicare program. S.1107 - A bill to amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S. 2819 - A bill to preserve access to Medicaid and the State Children's Health Insurance Program during an economic downturn, and for other purposes. S. 3101 - A bill to amend titles XVII and XIX of the Social Security Act to extend expiring provisions under the Medicare program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care sub rural areas, including pharmacy access, and for other purposes. S.1893 - An original bill to amend title XXI of the Social Security Act to reauthorize the State Children's Health Insurance Program, and for other purposes. S.338 - A bill to amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare program. S.2499 - A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. S.2396 - A bill to amend title XI of the Social Security Act to modernize the quality improvement organization (QIO) program. S. 2708 - A bill to amend the Public Health Service Act to attract and retain trained health care professionals and firect care workers dedicated to providing quality care to the growing population of older Americans. S. 2705 - A bill to authorize programs to increase the number of nurses within the Armed Forces through assistance for service as nurse faculty or education as nurses, and for other purposes. S. 2786 - A bill to amend title XVIII of the Social Security Act to improve access to health care under teh Medicare program for beneficiaries residing in rural areas. H.R.5480 - To respond to a Medicare funding warning.

Client expense: $390,000 · Firm income: Not reported

S. 2786

NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)client→NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)

2008 · third_quarter · Health Issues

Cited source text, amounts, lobbyists, and targets

S.3: Medicare Prescription Drug Price Negotiation Act of 2007 S.158: Access to Affordable Health Care Act S. 273: Prescription Drug and Health Improvement Act of 2007 S. 290: Rural Physicians Relief Act of 2007 S. 334: Healthy Americans Act S. 397: Tax Equity and Affordability Act of 2007 S. 498: Rural Medicare Equity Act of 2007 S. 1342: HeLP America Act S. 1605: Craig Thomas Rural Hospital and Provider Equity Act of 2007 S. 1710: Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 S. 2785: Save Medicare Act of 2008 S. 2603: Medicare Fraud Prevention Act of 2008 S. 2687: Medicare Beneficiary Protection Act of 2008 S. 2786: Medicare Rural Health Access Improvement Act of 2008 H.R.4: Medicare Prescription Drug Price Negotiation Act of 2007 H.R.15: National Health Insurance Act H.R.118: To amend part D of title XVIII of the Social Security Act to authorize the Secretary of Health and Human Services to negotiate prices for part D covered drugs for Medicare beneficiaries. H.R.205: Medicare Prescription Drug Enrollment Extension Act of 2007 H.R.298: Flexible Spending Accounts Growth and Opportunities Act of 2007 HR 914: Tax Equity and Affordability Act of 2007 H.R. 1651: Rural Health Quality Advisory Commission Act of 2007 HR 2056: Medicare Part D Improvement Act of 2007 HR 2633: HeLP America Act (Introduced in House) HR 2860: Health Care Access and Rural Equity (H-CARE) Act of 2007 HR 3014: Health Equity and Accountability Act of 2007 H.R. 3043: Department of Health and Human Services Appropriations Act, 2008 HR 3163: Healthy Americans HR 4848: To extend for one year parity in the application of certain limits to mental health benefits, and for other purposes HR 1424: Paul Wellstone Mental Health and Addiction Equity Act of 2007 HR 5445: To amend part B of title XVIII of the Social Security Act to increase Medicare payments for physicians' services through December 31, 2009. H.R. 6143: Pension Protection Act ERISA Amendments of 2008 H.R. 6382: Pension Protection Technical Corrections Act of 2008 H.R. 7242: Pension Protection Act IRC Amendments of 2008

Client expense: $1,113,000 · Firm income: Not reported

S. 2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2008 · third_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

Provisions of the Presidents FY2008 Budget and related appropriations legislation (S Con Res 70) related to implementation of the Medicare Advantage and Prescription Drug Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, and prescription drug benefits. S 3101, and HR 6331, the Medicare Improvements for Patients and Providers Act of 2008. Supported provisions that prevent the 10.6% cut in Medicare physician payment that was called for in the November 27, 2007 CMS final rule implementing the Medicare physician fee schedule. The bill replaces the 10.6% cut with an increase through 2008, and extended the 1.0 floor on the geographic adjustor for physician work initially included in the Medicare Modernization Act of 2003 through 2008. S.2812, the Medicare Improvement Act of 2008 introduced by senator Kent Conrad. This legislation will expand the number of originating sites, the list of eligible practitioners, and provide an advisory committee to CMS and Congress on payment issues related to services provided via TeleHealth. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. Reform proposals include reimbursement updated on a market basket basis, removal of prescription drugs from the calculation of Medicare Part B costs, and rebasing Part B to reflect current rather than cumulative costs. Support for S.2785, the Save Medicare Access Act of 2008, introduced by Sen. Debbie Stabenow. It would avert the 10.6% cut to physician payments scheduled to take effect in July and the additional cut of 5% or more scheduled in January 09. Payments would continue at their current rate through the remainder of 2008 and then would rise by 1.8% in 2009. The current work GPCI floor and physician scarcity bonus would also be continued through the end of 2009. Pay-for Reporting and Performance Currently the prevailing methods of paying for health care in the US neither incent nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. In the 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 unanticipated, but now recognized effect of economically stimulating growth in the numbers of services provided by physicians. Medicare must implement quality based payments for physician services, and capture the data on performance measures utilizing available claims-based data recoverable through enhanced IT functions. In 2005, the Centers for Medicare and Medicaid Services (CMS) proposed the Physicians Voluntary Reporting Program (PVRP). In late 2006 CMS renamed PVRP the Physicians Quality Reporting Initiative. (PQRI) In the PQRI program CMS calls on physicians to report on evidence-based performance measures selected with input from the National Quality Forum, the Ambulatory Care Quality Alliance, and the National Committee for Quality Assurance, (NCQA). For reporting purposes physicians will utilize provisional G- Codes developed by CMS to indicate whether a patient received a service, did not receive the service, was not a eligible candidate to receive the service, or would not be considered a patient under the care of the physician at the time of the service. Marshfield Clinic has recommended that CMS allow medical groups to electronically report quality measures in an aggregated, periodic, statistically valid basis to PQRI; and re-focus the PQRI on high cost/high volume disease states. Marshfield Clinic supports a request for CMS authorization and funding for a multi-center demonstration project with access to vast data resources across multiple states. This proposed project will connect treatments with outcomes and develop quality metrics that reflect the realities of the care setting and the severity of the patients illness. Information Technology Under current law the capital and operating expenses of installing and maintaining an electronic medical record are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS measurement of current physician practice expenses reflect minimal expense associated with IT. Congress should provide incentives for EMR adoption, and should establish standards to facilitate the sharing and exchange of data. S. 1693, the Wired for Health Care Quality Act introduced by Senator Ted Kennedy (D-MA) and Michael Enzi (R-WY) - Amends the Public Health Service Act to establish the Office of the National Coordinator of Health Information Technology to coordinate and oversee programs and activities to develop a nationwide interoperable health information technology infrastructure. HR 6357, the Protecting Records, Optimizing Treatment and Easing Communications through Health Care Technology Act of 2008 is important legislation that promotes Health Information Technology and the protection of patients personal health information. HR 6357 codifies ONCHIT, provides grants and loans for HIT, but most importantly the bill creates new privacy and security provisions which require notification of breaches of PHI by covered entities and business associates. The bill also includes restrictions on certain disclosures of PHI allowing patients to request that their information not be released to health plans in certain circumstances. It also includes an impractical consent provision that requires additional patient consent if the PHI is utilized in operations, such as peer review, quality review, standard of care review, malpractice review, or best practices analysis. HR 6898 Health-e Information Technology Act of 2008, a bill that includes an estimated $4 billion in incentive payments to Medicare physicians and hospitals which demonstrate successful adoption and use of HIT once initial national technical standards are finalized. Support for privacy enforcement provisions. H.R.6179 the Promoting Health Information Technology Act of 2008 - provisions that encourage and facilitate the adoption of state reciprocity agreements for practitioner licensure in order to expedite the provision across state lines of telehealth services; and provisions that require the Centers of Medicare & Medicaid Services to make federally qualified health centers eligible to participate in demonstration projects related to health records and heath information technology. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: CMS should administratively revise its measurements of the costs of practice to assure the validity and fairness of payments; a payment floor could be established for practice expense; or the present variation (.705 1.501) in practice expense could be channeled into a narrower corridor of adjustment. Payment Equity Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 07 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. This payment floor should be extended indefinitely or geographic adjustment of work should be eliminated entirely. The Rural Medicare Equity Act of 2007 (S 498), introduced by Senator Russ Feingold, Amends title XVIII (Medicare) of the Social Security Act (SSA) to eliminate the geographic physician work adjustment factor from the geographic indices used to adjust payments under the physician fee schedule. Rep. Braley introduced HR 2827, the Medicare Equity and Accessibility Act, along with Rep. Adrian Smith (R-Nebraska). This bill will increase the Medicare Part B reimbursement rates in Iowa and other rural states, by making permanent the 1.0 floor on the Geographic Practice Indexes for Work and Practice Expense. Support for Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Chuck Grassley especially provisions that would extend the 1.0 work floor through December 31,2009, and would recognize the equality of physician work in all geographic areas and eliminate differing work index values by establishing a national value of 1.0, effective 2010. Also support provisions for physician practice expense that would establish a practice expense floor of 1.0 for 2009 by requiring the Secretary to increase the value of any practice expense geographic index that was below 1.0 to 1.0 for services furnished on or after January 1, 2009 and before January 1, 2010. Subsection (b) would reduce the geographic adjustment for practice expense to 50 percent of the current adjustment for employee wages and rent, effective 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 - Public Law No: 108-173: Title II: Medicare Advantage -- (Sec. 211) Revises the payment system, requiring all plans to be paid at a rate at least as high as the rate for traditional Medicare fee-for-service plans. Makes change in budget neutrality for blended payments. Increases minimum percentage increase to national growth rate. Marshfield Clinic opposes reductions to Medicare Advantage payments in low payment states. Subtitle D: Additional Reforms - (Sec. 237) Provides that Federally Qualified Health Centers (FQHCs) will receive a wrap-around payment for the reasonable costs of care provided to Medicare managed care patients served at such centers. Raises reimbursements to FQHCs in order that when they are combined with MA payments and cost-sharing payments from beneficiaries they equal 100 percent of the reasonable costs of providing such services. Extends the safe harbor to include any remuneration between a FQHC (or entity controlled by an FQHC) and an MA organization. Title IV: Rural Provisions - Subtitle B: Provisions Relating to Part B Only - (Sec. 412) Directs the Secretary to increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00 for services furnished on or after January 1, 2004, and before January 1, 2007. Since this provision expires at the end of 2006 it must be extended or revised. See Tax Relief and Health Care Act provisions below (Sec. 413) Establishes a new five percent incentive payment program designed to reward both primary care and specialist care physicians for furnishing physicians' services on or after January 1, 2005, and before January 1, 2008 in physician scarcity areas. Directs the Secretary to pay the current law ten percent Health Professional Shortage Area (HPSA) incentive payment for services furnished in full county primary care geographic area HPSAs automatically rather than having the physician identify the health professional shortage area involved. Deficit Reduction Act (Section 5102) reduced reimbursements for multiple images on contiguous body parts in 2006; the DRA provision created in statute a basis for payment reductions on the imaging of contiguous body parts that CMS implemented through the rulemaking process in 2005; the DRA also requires that payment rates for imaging services delivered in physician offices do not exceed payment rates for identical imaging services delivered in hospital outpatient departments beginning in 2007. Clinic recommends that Congress repeal Section 5102, and direct MedPAC and CMS to conduct a comprehensive study of imaging and the geographic variation in services to determine where growth in the volume of imaging services is appropriate and develop workable solutions to control inappropriate imaging utilization. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments. Regulatory clarification of Medicare anti-markup issues, and postponement of the effective date of CMS final rule regarding the applicability of the anti markup provisions with respect to: (1) the technical component of a purchased diagnostic test and (2) any anatomic pathology diagnostic testing services furnished in space that is utilized by a physician group practice as a "centralized building" for purposes of complying with the physician self-referral rules and does not qualify as a "same building".

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

S 2786

FEDERATION OF AMERICAN HOSPITALSclient→FEDERATION OF AMERICAN HOSPITALS

2008 · second_quarter · Medicare/Medicaid

CHARLES KAHN iii JAYNE CHAMBERS JEFFREY MICKLOS KAREN SMITH STEVE SPEIL mr JEFFREY COHEN

Cited source text, amounts, lobbyists, and targets

H.R. 4105 - Medicare Recovery Audit Contractor Program Moratorium Act of 2007 A bill to impose a moratorium on the use of recovery audit contractors under the Medicare Integrity Program. S. 2819 Economic Recovery in Health Care Act Legislation to enact moratoria on the Medicaid and CHIP regulations issued by the Administration over the last year and to provide targeted state fiscal relief. HR 5613 - Protecting the Medicaid Safety Net Act of 2008 To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009. HR 2642 - Supplemental Appropriations Act, 2008 Making appropriations for military construction, the Department of Veterans Affairs, and related agencies for the fiscal year ending September 30, 2008, and for other purposes. This bill included provisions related to a moratorium on Medicaid funding cuts. HR 6331 - Medicare Improvements for Patients and Providers Act of 2008 To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes. HR 3533 - Public and Teaching Hospital Preservation Act To extend by one year the moratorium on implementation of a rule relating to the Federal-State financial partnership under Medicaid and the State Children's Health Insurance Program and on finalization of a Medicaid rule regarding graduate medical education. S. 1605 - Craig Thomas Rural Hospital and Provider Equity Act of 2007 A bill to amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program, and for other purposes. HR 2860 - Health Care Access and Rural Equity (H-CARE) Act of 2007 To amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare Program, and for other purposes. S. 2786 - Medicare Rural Health Access Improvement Act of 2008 A bill to amend title XVIII of the Social Security Act to improve access to health care under the Medicare program for beneficiaries residing in rural areas.

Client expense: $435,000 · Firm income: Not reported

S. 2786

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

NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)client→NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)

2008 · second_quarter · Health Issues

Cited source text, amounts, lobbyists, and targets

S.3: Medicare Prescription Drug Price Negotiation Act of 2007 S.158: Access to Affordable Health Care Act S. 273: Prescription Drug and Health Improvement Act of 2007 S. 290: Rural Physicians Relief Act of 2007 S. 334: Healthy Americans Act S. 397: Tax Equity and Affordability Act of 2007 S. 498: Rural Medicare Equity Act of 2007 S. 1342: HeLP America Act S. 1605: Craig Thomas Rural Hospital and Provider Equity Act of 2007 S. 1710: Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 S. 2785: Save Medicare Act of 2008 S. 2603: Medicare Fraud Prevention Act of 2008 S. 2687: Medicare Beneficiary Protection Act of 2008 S. 2786: Medicare Rural Health Access Improvement Act of 2008 H.R.4: Medicare Prescription Drug Price Negotiation Act of 2007 H.R.15: National Health Insurance Act H.R.118: To amend part D of title XVIII of the Social Security Act to authorize the Secretary of Health and Human Services to negotiate prices for part D covered drugs for Medicare beneficiaries. H.R.205: Medicare Prescription Drug Enrollment Extension Act of 2007 H.R.298: Flexible Spending Accounts Growth and Opportunities Act of 2007 HR 914: Tax Equity and Affordability Act of 2007 H.R. 1651: Rural Health Quality Advisory Commission Act of 2007 HR 2056: Medicare Part D Improvement Act of 2007 HR 2633: HeLP America Act (Introduced in House) HR 2860: Health Care Access and Rural Equity (H-CARE) Act of 2007 HR 3014: Health Equity and Accountability Act of 2007 H.R. 3043: Department of Health and Human Services Appropriations Act, 2008 HR 3163: Healthy Americans HR 4848: To extend for one year parity in the application of certain limits to mental health benefits, and for other purposes HR 1424: Paul Wellstone Mental Health and Addiction Equity Act of 2007 HR 5445: To amend part B of title XVIII of the Social Security Act to increase Medicare payments for physicians' services through December 31, 2009.

Client expense: $1,251,000 · Firm income: Not reported

S. 2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

AMERICAN HEALTH CARE ASSOCIATIONclient→AMERICAN HEALTH CARE ASSOCIATION

2008 · second_quarter · Medicare/Medicaid

BRUCE YARWOOD DAVID HEBERT KARL POLZER KEN PREEDE MARYANNE SAPIO MATTHEW SMYTH mrs CYNTHIA MORTON ms FRANCESCA O'REILLY

Cited source text, amounts, lobbyists, and targets

HR 3025 - To amend title XVII of the Social Security Act to provide comprehensive improvements to the Medicare Prescription Drug Program, and for other purposes. HR 1459 - To improve Medicare beneficiary access by extending the 60 percent compliance threshold d to determie whether a hospital or unit is an impatient rehabilitation facility. H.R.976 - An act to amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.562 - To amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare Program. H.R.4105 - To impose a moratorium on the use of recovery audit contractors under the Medicare Integrity Program. H.R.3162 - To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes. H.R.1621 - To amend title XIX of the Social Security Act to provide individuals with disabilities and older Americans with equal access to community-based attendant services and supports, and for other purposes. H.R.1536 - To amend part D of title XVIII of the Social Security Act to assist low-income individuals in obtaining subsidized prescription drug coverage under the Medicare prescription drug program by expediting the application and qualification process and by revising the resource standards used to determine eligibility for such subsidies, and for other purposes. H.R.4541 - To amend title XVIII of the Social Security Act to provide for patient protections under the Medicare prescription drug program for residents of long term care facilities. H.R.3963 - To amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.5604 - To amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.543 - A bill to improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility under the Medicare program. S.1107 - A bill to amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.1893 - An original bill to amend title XXI of the Social Security Act to reauthorize the State Children's Health Insurance Program, and for other purposes. S.338 - A bill to amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare program. S.2499 - A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. S.2396 - A bill to amend title XI of the Social Security Act to modernize the quality improvement organization (QIO) program. S.2708 - A bill to amend the Public Health Service Act to attract and retain trained health care professionals and direct care workers dedicated to providing quality care to the growing population of older Americans. S.2705 - A bill to authorize programs to increase the number of nurses within the Armed Forces through assistance for service as nurse faculty or education as nurses, and for other purposes. S.2786 - A bill to amend title XVIII of the Social Security Act to improve access to health care under the Medicare program for beneficiaries residing in rural areas. H.R.5613 - To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009. S.2819 - A bill to preserve access to Medicaid and the State Children's Health Insurance Program during an economic downturn, and for other purposes. H.R.6331- To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes. S.3101 - A bill to amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes.

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

S.2786

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

IOWA HOSPITAL ASSOCIATIONclient→ABIGAIL STORK

2008 · second_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

HR 5613: Protecting the Medicaid Safety Net Act, all provisions relating to hospitals. HR 2419: To provide for the continuation of agricultural programs through fiscal year 2012, and for other purposes; focusing on physician referral to hospitals. S2819: The Economic Recovery in Health Care Act of 2008; provisions relating to moratoria on Medicaid rules. S3101: A bill to amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes; provisions relating to hospitals, including Section 131, physician payment update, Section 149, payment for clinical laboratory tests furnished by critical access hospitals. S2786: A bill to amend title XVIII of the Social Security Act to improve access to health care under the Medicare program for beneficiaries residing in rural areas; all provisions relating to hospitals including, Section 104, low-volume adjustment for hospitals, and Section 204, payment for clinical laboratory tests furnished by critical access hospitals. S3118: A bill to amend titles XVIII and XIX of the Social Security Act to preserve beneficiary access to care by preventing a reduction in the Medicare physician fee schedule, to improve the quality of care by advancing value based purchasing, electronic health records, and electronic prescribing, and to maintain and improve access to care in rural areas, and for other purposes; provisions relating to hospitals, including Section 101, low-volume adjustment for hospitals, and Section 107, payment for clinical laboratory tests furnished by critical access hospitals, Section 125, value-based purchasing, Section 131, physician payment update. HR 6331: To amend titles XVIII and XIX of the Social Security Act to extend expiring provisions under the Medicare Program, to improve beneficiary access to preventive and mental health services, to enhance low-income benefit programs, and to maintain access to care in rural areas, including pharmacy access, and for other purposes; provisions relating to hospitals including Section 131, physician payment update, and Section 148, payment for clinical laboratory tests furnished by critical access hospitals. HR 1424: To amend section 712 of the Employee Retirement Income Security Act of 1974, section 2705 of the Public Health Service Act, section 9812 of the Internal Revenue Code of 1986 to require equity in the provision of mental health and substance-related disorder benefits under group health plans, to prohibit discrimination on the basis of genetic information with respect to health insurance and employment, and for other purposes; focusing on Section 106, physician referrals for hospitals. Other Issues: Low-volume adjustment for Tweener hospitals. Value-Based Purchasing. Medicare reimbursement for hospice and the proposed changes to the wage index. CMS proposed rule for the FY 2009 inpatient PPS: proposals relating to hospitals, including proposal relating to change the budget neutrality adjustment to the rural floor of the wage index, including Murphy letter to House Ways and Means Committee.

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

S2786

ABIGAIL STORK

Government targets: HOUSE OF REPRESENTATIVES, SENATE

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2008 · second_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

Provisions of the Presidents FY2008 Budget and related appropriations legislation (S Con Res 70) related to implementation of the Medicare Advantage and Prescription Drug Programs, the provision of Medicare and Medicaid services and benefits to patients, incentives to promote electronic health records for all Americans, and prescription drug benefits. S 3101, and HR 6331, the Medicare Improvements for Patients and Providers Act of 2008. Supported provisions that prevent the 10.6% cut in Medicare physician payment that was called for in the November 27, 2007 CMS final rule implementing the Medicare physician fee schedule. The bill replaces the 10.6% cut with an increase through 2008, and extended the 1.0 floor on the geographic adjustor for physician work initially included in the Medicare Modernization Act of 2003 through 2008. S.2812, the Medicare Improvement Act of 2008 introduced by senator Kent Conrad. This legislation will expand the number of originating sites, the list of eligible practitioners, and provide an advisory committee to CMS and Congress on payment issues related to services provided via TeleHealth. The Physician Payment Sunshine Act, S. 2029, introduced by Senator Kohl with Senator Grassley to create accountability among physicians and the manufacturers of drugs and devices that physicians utilize and prescribe for their patients. This legislation would require manufacturers of pharmaceutical drugs, medical devices, and biologics to disclose the amount of money they give to doctors through payments, gifts, honoraria, travel and other means. The Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Grassley to mitigate current inequities in Medicare reimbursement, improve access to health services in rural and underserved areas, and will begin to close the gap between Medicare reimbursement and the cost of providing services in predominantly rural areas. The legislation establishes a 1.0 floor for physician work and practice expense adjustments. It also revises the work and practice expense formulas to reduce payment differences and more accurately compensate physicians in rural areas for their true practice costs. The bill also extends the five percent incentive payments for primary care and specialty physicians in scarcity areas. Marshfield Clinic nominated Dr. Douglas Reding for an open position on the Medicare Payment Advisory Commission, and sought the endorsement of the Wisconsin delegation, and other Senators and Representatives that serve on the Committees with jurisdiction over the Medicare program. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. Reform proposals include reimbursement updated on a market basket basis, removal of prescription drugs from the calculation of Medicare Part B costs, and rebasing Part B to reflect current rather than cumulative costs. Support for S.2785, the Save Medicare Access Act of 2008, introduced by Sen. Debbie Stabenow. It would avert the 10.6% cut to physician payments scheduled to take effect in July and the additional cut of 5% or more scheduled in January 09. Payments would continue at their current rate through the remainder of 2008 and then would rise by 1.8% in 2009. The current work GPCI floor and physician scarcity bonus would also be continued through the end of 2009. Pay-for Reporting and Performance Currently the prevailing methods of paying for health care in the US neither incent nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. In the 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 unanticipated, but now recognized effect of economically stimulating growth in the numbers of services provided by physicians. Medicare must implement quality based payments for physician services, and capture the data on performance measures utilizing available claims-based data recoverable through enhanced IT functions. In 2005, the Centers for Medicare and Medicaid Services (CMS) proposed the Physicians Voluntary Reporting Program (PVRP). In late 2006 CMS renamed PVRP the Physicians Quality Reporting Initiative. (PQRI) In the PQRI program CMS calls on physicians to report on evidence-based performance measures selected with input from the National Quality Forum, the Ambulatory Care Quality Alliance, and the National Committee for Quality Assurance, (NCQA). For reporting purposes physicians will utilize provisional G- Codes developed by CMS to indicate whether a patient received a service, did not receive the service, was not a eligible candidate to receive the service, or would not be considered a patient under the care of the physician at the time of the service. Marshfield Clinic has recommended that CMS allow medical groups to electronically report quality measures in an aggregated, periodic, statistically valid basis to PQRI; and re-focus the PQRI on high cost/high volume disease states. Marshfield Clinic supports a request for CMS authorization and funding for a multi-center demonstration project with access to vast data resources across multiple states. This proposed project will connect treatments with outcomes and develop quality metrics that reflect the realities of the care setting and the severity of the patients illness. Information Technology Under current law the capital and operating expenses of installing and maintaining an electronic medical record are assumed to be part of the overhead expense of a medical practice. Since no more than 5 10% of the physician population has installed EMRs, CMS measurement of current physician practice expenses reflect minimal expense associated with IT. Congress should provide incentives for EMR adoption, and should establish standards to facilitate the sharing and exchange of data. S. 1693, the Wired for Health Care Quality Act introduced by Senator Ted Kennedy (D-MA) and Michael Enzi (R-WY) - Amends the Public Health Service Act to establish the Office of the National Coordinator of Health Information Technology to coordinate and oversee programs and activities to develop a nationwide interoperable health information technology infrastructure. HR 6357, the Protecting Records, Optimizing Treatment and Easing Communications through Health Care Technology Act of 2008 is important legislation that promotes Health Information Technology and the protection of patients personal health information. HR 6357 codifies ONCHIT, provides grants and loans for HIT, but most importantly the bill creates new privacy and security provisions which require notification of breaches of PHI by covered entities and business associates. The bill also includes restrictions on certain disclosures of PHI allowing patients to request that their information not be released to health plans in certain circumstances. It also includes an impractical consent provision that requires additional patient consent if the PHI is utilized in operations, such as peer review, quality review, standard of care review, malpractice review, or best practices analysis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Alternatives: CMS should administratively revise its measurements of the costs of practice to assure the validity and fairness of payments; a payment floor could be established for practice expense; or the present variation (.705 1.501) in practice expense could be channeled into a narrower corridor of adjustment. Payment Equity Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 07 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. This payment floor should be extended indefinitely or geographic adjustment of work should be eliminated entirely. The Rural Medicare Equity Act of 2007 (S 498), introduced by Senator Russ Feingold, Amends title XVIII (Medicare) of the Social Security Act (SSA) to eliminate the geographic physician work adjustment factor from the geographic indices used to adjust payments under the physician fee schedule. Rep. Braley introduced HR 2827, the Medicare Equity and Accessibility Act, along with Rep. Adrian Smith (R-Nebraska). This bill will increase the Medicare Part B reimbursement rates in Iowa and other rural states, by making permanent the 1.0 floor on the Geographic Practice Indexes for Work and Practice Expense. Support for Medicare Rural Health Access Improvement Act, S 2786, introduced by Senator Chuck Grassley especially provisions that would extend the 1.0 work floor through December 31,2009, and would recognize the equality of physician work in all geographic areas and eliminate differing work index values by establishing a national value of 1.0, effective 2010. Also support provisions for physician practice expense that would establish a practice expense floor of 1.0 for 2009 by requiring the Secretary to increase the value of any practice expense geographic index that was below 1.0 to 1.0 for services furnished on or after January 1, 2009 and before January 1, 2010. Subsection (b) would reduce the geographic adjustment for practice expense to 50 percent of the current adjustment for employee wages and rent, effective 2010. Support for Rep. Ron Kinds concept of a not yet introduced MEDICARE EFFICIENCY BILL that would amend the CHAMP Act (H.R. 3162) 304 in whole, by establishing that the 5% bonus payment would be expanded to the top 10% of efficient counties; and a corresponding 5% efficiency penalty for physicians in the bottom 10% of efficient counties. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 - Public Law No: 108-173: Title II: Medicare Advantage -- (Sec. 211) Revises the payment system, requiring all plans to be paid at a rate at least as high as the rate for traditional Medicare fee-for-service plans. Makes change in budget neutrality for blended payments. Increases minimum percentage increase to national growth rate. Marshfield Clinic opposes reductions to Medicare Advantage payments in low payment states. Subtitle D: Additional Reforms - (Sec. 237) Provides that Federally Qualified Health Centers (FQHCs) will receive a wrap-around payment for the reasonable costs of care provided to Medicare managed care patients served at such centers. Raises reimbursements to FQHCs in order that when they are combined with MA payments and cost-sharing payments from beneficiaries they equal 100 percent of the reasonable costs of providing such services. Extends the safe harbor to include any remuneration between a FQHC (or entity controlled by an FQHC) and an MA organization. Title IV: Rural Provisions - Subtitle B: Provisions Relating to Part B Only - (Sec. 412) Directs the Secretary to increase the work geographic index to 1.00 for any locality for which such work geographic index is less than 1.00 for services furnished on or after January 1, 2004, and before January 1, 2007. Since this provision expires at the end of 2006 it must be extended or revised. See Tax Relief and Health Care Act provisions below (Sec. 413) Establishes a new five percent incentive payment program designed to reward both primary care and specialist care physicians for furnishing physicians' services on or after January 1, 2005, and before January 1, 2008 in physician scarcity areas. Directs the Secretary to pay the current law ten percent Health Professional Shortage Area (HPSA) incentive payment for services furnished in full county primary care geographic area HPSAs automatically rather than having the physician identify the health professional shortage area involved. Subtitle C: Other Provisions - (Sec. 626) Provides that in FY 2004, starting April 1, 2004, the ambulatory surgery center (ASC) update will be the Consumer Price Index for all urban consumers (U.S. city average) as estimated as of March 31, 2003, minus 3.0 percentage points. Provides that in FY 2005, the last quarter of calendar year 2005, and each of calendar years 2006 through 2009, the ASC update will be zero percent. Provides that subject to recommendations by the General Accounting Office, the Secretary will implement a revised payment system for payment of surgical services furnished in ASCs. Requires the new system to be implemented so that it is first effective on or after January 1, 2006, and not later than January 1, 2008. (Sec. 628) Provides that there will be no updates to the clinical diagnostic laboratory test fee schedule for 2004 through 2008. Subtitle D: Additional Demonstrations, Studies, and Other Provisions - (Sec. 649) Directs the Secretary to establish a pay-for-performance demonstration program with physicians to meet the needs of eligible beneficiaries through the adoption and use of health information technology and evidence-based outcomes measures Deficit Reduction Act (Section 5102) reduced reimbursements for multiple images on contiguous body parts in 2006; the DRA provision created in statute a basis for payment reductions on the imaging of contiguous body parts that CMS implemented through the rulemaking process in 2005; the DRA also requires that payment rates for imaging services delivered in physician offices do not exceed payment rates for identical imaging services delivered in hospital outpatient departments beginning in 2007. Clinic recommends that Congress repeal Section 5102, and direct MedPAC and CMS to conduct a comprehensive study of imaging and the geographic variation in services to determine where growth in the volume of imaging services is appropriate and develop workable solutions to control inappropriate imaging utilization. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term. Also supports efforts to eliminate the 2% threshold for payments and the 5% limitation on payments. Ambulatory Surgical Center Medicare Payment Modernization Act of 2007 H.R.1823 Ambulatory Surgical Center Medicare Payment Modernization Act of 2007 introduced by Rep. Wally Herger and Kendrick Meek - Amends title XVIII (Medicare) of the Social Security Act to revise the requirements and the formula for payments for services, including an implantable medical device, furnished to individuals in ambulatory surgical centers. Regulatory clarification of Medicare anti-markup issues, and postponement of the effective date of CMS final rule regarding the applicability of the anti markup provisions with respect to: (1) the technical component of a purchased diagnostic test and (2) any anatomic pathology diagnostic testing services furnished in space that is utilized by a physician group practice as a "centralized building" for purposes of complying with the physician self-referral rules and does not qualify as a "same building".

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

S 2786

Government targets: Centers For Medicare and Medicaid Services (CMS), Congressional Budget Office (CBO), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Medicare Payment Advisory Commission (MedPAC), Natl Institutes of Health (NIH), SENATE

SSM HEALTH CAREclient→SSM HEALTH CARE

2008 · first_quarter · Medicare/Medicaid

JIMMY DURANT MICHAEL HEIFETZ STEPHEN HOVEN mr DAVID DURBIN

Cited source text, amounts, lobbyists, and targets

H.R.1459 and S.543, "To improve Medicare beneficiary to inpatient rehabilitation facilities," specifically to establish the criteria in HCFA Ruling 85-2, of July 31, 1985 (50 Fed. Reg. 31040), as the sole standard for determining the medical necessity of services for inpatient rehabilitation. H.R.4105, "To impose a moratorium on the use of recovery audit contractors under the Medicare Integrity Program," while supporting initiatives to ensure accountability in the Medicare program, the processes used by CMS and its contractors need to be reviewed to be sure that those processes are accurately identifying inappropriate claims No bill number at this time, support legislation that would enhance the Ethics in Patient Referrals Act of 1989 (the "Stark" law) to include physician ownership in a "whole" hospital S.458 and H.R. 1105, "physician pathology services under the Medicare program," specifically to extend the authority, currently expiring on June 30, 2008, to make direct payments to independent labs for the technical component of pathology services. H.R. 1177, "to extend and improve protections for sole community hospitals under the Medicare Program," specifically to extend the outpatient prospective payment system hold harmless provision and to permit the use of a more current cost reporting year to allow redetermination of hospital target amounts. S.630 and H.R. 2159, "to provide for a minimum payment rate by Medicare Advantage organizations for services furnished by a critical access hospital and a rural health clinic under the Medicare program," specifically to allow critical access hospitals to receive at least 101 percent of their costs for inpatient, swing-bed and outpatient hospital services S.2786, "Medicare Rural Health Access Improvement," specifically to extend th 5 percent bonus payment to physicians practicing in provider scarcity areas (critical access, sole community provider, and Medicare dependent or low-volume areas). H.R. 1845 and S.1428, "to assure access to durable medical equipment under the Medicare Program," specifically to adopt language that would allow hospital owned durable medical equipment companies that are willing to accept the competitive bid rate to provide durable medical equipment to patients upon discharge. S.1595, "flexibility in the manner in which beds are counted for purposes of determining whether a hospital may be designated as a critical access hospital under the Medicare program" specifically in favor of such increased flexibility.

Client expense: $35,000 · Firm income: Not reported

S.2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

AMERICAN HEALTH CARE ASSOCIATIONclient→AMERICAN HEALTH CARE ASSOCIATION

2008 · first_quarter · Medicare/Medicaid

BRUCE YARWOOD DAVID HEBERT KARL POLZER KEN PREEDE MARYANNE SAPIO MATTHEW SMYTH mrs CYNTHIA MORTON ms FRANCESCA O'REILLY

Cited source text, amounts, lobbyists, and targets

HR 3025 - To amend title XVII of the Social Security Act to provide comprehensive improvements to the Medicare Prescription Drug Program, and for other purposes. HR 1459 - To improve Medicare beneficiary access by extending the 60 percent compliance threshold d to determie whether a hospital or unit is an impatient rehabilitation facility. H.R.976 - An act to amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.562 - To amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare Program. H.R.4105 - To impose a moratorium on the use of recovery audit contractors under the Medicare Integrity Program. H.R.3162 - To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes. H.R.1621 - To amend title XIX of the Social Security Act to provide individuals with disabilities and older Americans with equal access to community-based attendant services and supports, and for other purposes. H.R.1536 - To amend part D of title XVIII of the Social Security Act to assist low-income individuals in obtaining subsidized prescription drug coverage under the Medicare prescription drug program by expediting the application and qualification process and by revising the resource standards used to determine eligibility for such subsidies, and for other purposes. H.R.4541 - To amend title XVIII of the Social Security Act to provide for patient protections under the Medicare prescription drug program for residents of long term care facilities. H.R.3963 - To amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.5604 - To amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.543 - A bill to improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility under the Medicare program. S.1107 - A bill to amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.1893 - An original bill to amend title XXI of the Social Security Act to reauthorize the State Children's Health Insurance Program, and for other purposes. S.338 - A bill to amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare program. S.2499 - A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. S.2396 - A bill to amend title XI of the Social Security Act to modernize the quality improvement organization (QIO) program. S.2708 - A bill to amend the Public Health Service Act to attract and retain trained health care professionals and direct care workers dedicated to providing quality care to the growing population of older Americans. S.2705 - A bill to authorize programs to increase the number of nurses within the Armed Forces through assistance for service as nurse faculty or education as nurses, and for other purposes. S.2786 - A bill to amend title XVIII of the Social Security Act to improve access to health care under the Medicare program for beneficiaries residing in rural areas. H.R.5613 - To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009.

Client expense: $420,000 · Firm income: Not reported

S.2786

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

NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)client→NATIONAL RURAL ELECTRIC COOPERATIVE ASSOCIATION (NRECA)

2008 · first_quarter · Health Issues

Cited source text, amounts, lobbyists, and targets

S.3: Medicare Prescription Drug Price Negotiation Act of 2007 S.158: Access to Affordable Health Care Act S. 273: Prescription Drug and Health Improvement Act of 2007 S. 290: Rural Physicians Relief Act of 2007 S. 334: Healthy Americans Act S. 397: Tax Equity and Affordability Act of 2007 S. 498: Rural Medicare Equity Act of 2007 S. 1342: HeLP America Act S. 1605: Craig Thomas Rural Hospital and Provider Equity Act of 2007 S. 1710: Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008 S. 2785: Save Medicare Act of 2008 S. 2603: Medicare Fraud Prevention Act of 2008 S. 2687: Medicare Beneficiary Protection Act of 2008 S. 2786: Medicare Rural Health Access Improvement Act of 2008 H.R.4: Medicare Prescription Drug Price Negotiation Act of 2007 H.R.15: National Health Insurance Act H.R.118: To amend part D of title XVIII of the Social Security Act to authorize the Secretary of Health and Human Services to negotiate prices for part D covered drugs for Medicare beneficiaries. H.R.205: Medicare Prescription Drug Enrollment Extension Act of 2007 H.R.298: Flexible Spending Accounts Growth and Opportunities Act of 2007 HR 914: Tax Equity and Affordability Act of 2007 H.R. 1651: Rural Health Quality Advisory Commission Act of 2007 HR 2056: Medicare Part D Improvement Act of 2007 HR 2633: HeLP America Act (Introduced in House) HR 2860: Health Care Access and Rural Equity (H-CARE) Act of 2007 HR 3014: Health Equity and Accountability Act of 2007 H.R. 3043: Department of Health and Human Services Appropriations Act, 2008 HR 3163: Healthy Americans HR 4848: To extend for one year parity in the application of certain limits to mental health benefits, and for other purposes HR 1424: Paul Wellstone Mental Health and Addiction Equity Act of 2007 HR 5445: To amend part B of title XVIII of the Social Security Act to increase Medicare payments for physicians' services through December 31, 2009.

Client expense: $1,006,000 · Firm income: Not reported

S. 2786

Government targets: HOUSE OF REPRESENTATIVES, SENATE

AMERICAN ACADEMY OF FAMILY PHYSICIANSclient→AMERICAN ACADEMY OF FAMILY PHYSICIANS

2008 · first_quarter · Medicare/Medicaid

KEVIN BURKE MARK CRIBBEN ROSEMARIE SWEENEY SUSAN HILDEBRANDT TERESA BAKER

Cited source text, amounts, lobbyists, and targets

S. 558, Paul Wellstone Mental Health and Addiction Equity Act, This helps the patients of family physicians whose health insurance does not cover mental health conditions. S. 1544, Medicare Quality Enhancement Act, To assure that the data that the bill requires is from an accurate source. S. 2785, Medicare physician payment reform to prevent 10.6 percent cut from taking effect on July 1, 2008, Repeal Medicare Sustainable Growth Rate, provide positive annual updates for Medicare physician payments. S. 2786, Medicare Rural Health Access Improvement Act, To encourage physicians to practice in rural areas. H.R. 493, Genetic Information Nondiscrimination Act, To prevent insurance and employment discrimination of the patients of family physicians. H.R. 1424, Paul Wellstone Mental Health and Addiction Equity Act, This helps the patients of family physicians whose health insurance does not cover mental health conditions. H.R. 3162, Medicare physician payment reform to prevent 10.6 percent cut from taking effect on July 1, 2008, Repeal Medicare Sustainable Growth Rate, provide positive annual updates for Medicare physician payments. H.R. 3370, Medicare Quality Enhancement Act, To assure that the data that the bill requires is from an accurate source. H.R. 3963, Children's Health Insurance Program Reauthorization Act, This includes revisions to physician payment system in Medicare. H.R. 5140, Recovery Rebates and Economic Stimulus for the American People Act, To ask Congress to attach the physician payment provisions. No Bill, AMA Strategy Session on Medicare and Antitrust. No Bill, Contact with GAO Staff, Medicare physician payment; Title VII. No Bill, Health Professions Shortage Areas, To make sure the revisions to the designation process are fair. No Bill, Increased funding for Rural Health Programs in FY 2009, Adequate funding for HHS Rural Health programs. No Bill, Increased funding for Title VII Health professions Grants for Primary Care Medicine Training FY2009 Appropriations, Adequate funding for HRSA's Title VII grants. No Bill, Medicare and Medicaid Graduate Medical Education reform for primary care health professions workforce education, Protect GME payments needed to train primary care physicians. No Bill, Medicare - Non-physician Providers, To expand Medicare to cover incident to services by non-physician providers (NPP). No Bill, Medicare physician payment reform; Title VII health professions grants, Repeal Medicare Sustainable Growth Rate formula, provide positive update for Medicare physicians payments; Promote Title VII health professions grants for primary care training. No Bill, Medicare physician payment (SGR), To continue the Medicare payment rate to physicians for 18 months. No Bill, Medicare quality reporting (PQRI program), To continue the program as a voluntary bonus payment one. No Bill, Patient-Centered Medical Home, To introduce federal government to this model of primary care. No Bill, Physician Payment reform and PCMH, To introduce federal government to this model of primary care. No Bill, Prevent cuts in funding to National Health Service Corps in FY 2009 Appropriations, Adequate funding for NHSC. No Bill, RUC and Medicare medical home demo, To influence CMS and legislative enhance the demo.

Client expense: $673,563 · Firm income: Not reported

S. 2786

Government targets: Centers For Medicare and Medicaid Services (CMS), Congressional Budget Office (CBO), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), SENATE

AMERICAN ACADEMY OF FAMILY PHYSICIANSclient→AMERICAN ACADEMY OF FAMILY PHYSICIANS

2008 · first_quarter · Health Issues

JEROME CONNOLLY KEVIN BURKE MARK CRIBBEN ROSEMARIE SWEENEY SUSAN HILDEBRANDT TERESA BAKER

Cited source text, amounts, lobbyists, and targets

S.Con.Res. 70, Increase Discretionary Health Spending under F. 550 of the House and Senate Budget Resolutions, Adequate funding for HHS agencies: HRSA, AHRQ, Rural Health, NIH. S. 400, Michelle's Law, Health care coverage for all. S. 558, Paul Wellstone Mental Health and Addiction Equity Act, This helps the patients of family physicians whose health insurance does not cover mental health conditions. S. 1642, Higher Education Act Reauthorization, Make primary care physicians eligible for loan forgiveness available to those employed in areas of national need and reinstate 20/220 debt-to-income ratio to loan deferment. S. 2408, Health Information Technology; electronic health records; electronic prescribing, To educate Congress on the value, cost and obstacles associated with health information technology in family practices, as well as provisions that will make the adoption of HIT less onerous and expensive. S. 2785, Medicare physician payment reform to prevent 10.6 percent cut from taking effect on July 1, 2008, Repeal Medicare Sustainable Growth Rate, Provide positive annual updates for Medicare physician payments. S. 2786, Medicare Rural Health Access Improvement Act, To encourage physicians to practice in rural areas. H.Con.Res. 312, Increase Discretionary Health Spending under F. 550 of the House and Senate Budget Resolutions, Adequate funding for HHS agencies: HRSA, AHRQ, Rural Health, NIH. H.R. 493, Genetic Information Nondiscrimination Act, To prevent insurance and employment discrimination of the patients of family physicians. H.R. 1424, Paul Wellstone Mental Health and Addiction Equity Act, This helps the patients of family physicians whose health insurance does not cover mental health conditions. H.R. 2851, Michelle's Law, Health care coverage for all. H.R. 3162, Medicare physician payment reform to prevent 10.6 percent cut from taking effect on July 1, 2008, Repeal Medicare Sustainable Growth Rate, Provide positive annual updates for Medicare physician payments. H.R. 3825, Newborn Screening Saves Lives Act, To make sure appropriate infant testing is called for. H.R. 4137, Higher Education Act Reauthorization, Make primary care physicians eligible for loan forgiveness available to those employed in areas of national need and reinstate 20/220 debt-to-income ratio to loan deferment. H.R. 4296, Health Information Technology; electronic health records; electronic prescribing, To educate Congress on the value, cost and obstacles associated with health information technology in family practices, as well as provisions that will make the adoption of HIT less onerous and expensive. H.R. 5449, No discrimination in Health Insurance Act of 2008, Health care coverage for all. No Bill, Graduate medical education; volunteer preceptor, To review regulation of and lessen the burden on voluntary preceptor and continue GME funding. No Bill, Growth of health care spending, To make sure Congress understands how primary care can help curtail these costs. No Bill, Health care access, To promote additional support for improved access to health care. No Bill, Increased funding for Agency for Healthcare Research and Quality (AHRQ) FY 2009 Appropriations, Adequate funding for Health Information Technology and Comparable Effectiveness Research. No Bill, Increased funding for Rural Health Programs in FY 2009 Appropriations, Adequate funding for HHS Rural Health Programs. No Bill, Increased funding for Title VII Health Professions Grants for Primary Care Medicine Training FY 2009 Appropriations, Adequate funding for HRSA's Title VII Grants. No Bill, Medicare Advantage, To make sure Congress understands how these costly plans (esp PFFS) lead to beneficiary confusion and providers underpayment. No Bill, Medicare and Medicaid Graduate Medical Education reform for primary care health professions workforce education, Protect GME payments needed to train primary care physicians. No Bill, Medicare physician payment reform; Title VII health professions grants, Repeal Medicare Sustainable Growth Rate formula, provide positive update for Medicare physicians payments; Promote Title VII health professions grants for primary care training. No Bill, Participated in AMA Antitrust Work Group, Allow physicians to bargain collectively; remove antitrust barriers on physicians; reform Federal Trade Commission regulation. No Bill, Patient-Centered Medical Home, To introduce federal government to this model of primary care. No Bill, Physician Quality Reporting Initiative; Value-based purchasing, To continue this bonus payment for reporting program as a voluntary program. No Bill, Prevent cuts in funding to National Health Service Corps in FY 2009 Appropriations, Adequate funding for NHSC. No Bill, Title VII Health Professions Grants for Primary Care Medicine Training Reauthorization, Promote Title VII Health Professions Grants for Primary Care Training programs.

Client expense: $673,563 · Firm income: Not reported

S. 2786

Government targets: Centers For Medicare and Medicaid Services (CMS), Congressional Budget Office (CBO), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), SENATE

AMERICAN HEALTH CARE ASSOCIATIONclient→AMERICAN HEALTH CARE ASSOCIATION

2008 · first_quarter · Medicare/Medicaid

BRUCE YARWOOD DAVID HEBERT KARL POLZER KEN PREEDE MARYANNE SAPIO MATTHEW SMYTH mrs CYNTHIA MORTON ms FRANCESCA O'REILLY

Cited source text, amounts, lobbyists, and targets

H.R.3025 - To amend title XVIII of the Social Security Act to provide comprehensive improvements to the Medicare Prescription Drug Program, and for other purposes. H.R.1459 - To improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility. H.R.562 - To amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare Program. H.R.4105 - To impose a moratorium on the use of recovery audit contractors under the Medicare Integrity Program. H.R.3162 - To amend titles XVIII, XIX, and XXI of the Social Security Act to extend and improve the children's health insurance program, to improve beneficiary protections under the Medicare, Medicaid, and the CHIP program, and for other purposes. H.R.1621 - To amend title XIX of the Social Security Act to provide individuals with disabilities and older Americans with equal access to community-based attendant services and supports, and for other purposes. H.R.1536 - To amend part D of title XVIII of the Social Security Act to assist low-income individuals in obtaining subsidized prescription drug coverage under the Medicare prescription drug program by expediting the application and qualification process and by revising the resource standards used to determine eligibility for such subsidies, and for other purposes. H.R.4541 - To amend title XVIII of the Social Security Act to provide for patient protections under the Medicare prescription drug program for residents of long term care facilities. H.R.3963 - To amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes. H.R.5604 - To amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.543 - A bill to improve Medicare beneficiary access by extending the 60 percent compliance threshold used to determine whether a hospital or unit of a hospital is an inpatient rehabilitation facility under the Medicare program. S.1107 - A bill to amend title XVIII of the Social Security Act to reduce cost-sharing under part D of such title for certain non-institutionalized full-benefit dual eligible individuals. S.1893 - An original bill to amend title XXI of the Social Security Act to reauthorize the State Children's Health Insurance Program, and for other purposes. S.338 - A bill to amend title XVIII of the Social Security Act to ensure and foster continued patient quality of care by establishing facility and patient criteria for long-term care hospitals and related improvements under the Medicare program. S.2499 - A bill to amend titles XVIII, XIX, and XXI of the Social Security Act to extend provisions under the Medicare, Medicaid, and SCHIP programs, and for other purposes. S.2396 - A bill to amend title XI of the Social Security Act to modernize the quality improvement organization (QIO) program. S.2708 - A bill to amend the Public Health Service Act to attract and retain trained health care professionals and direct care workers dedicated to providing quality care to the growing population of older Americans. S.2705 - A bill to authorize programs to increase the number of nurses within the Armed Forces through assistance for service as nurse faculty or education as nurses, and for other purposes. S.2786 - A bill to amend title XVIII of the Social Security Act to improve access to health care under the Medicare program for beneficiaries residing in rural areas. H.R.5613 - To extend certain moratoria and impose additional moratoria on certain Medicaid regulations through April 1, 2009. H.R.976 - An act to amend title XXI of the Social Security Act to extend and improve the Children's Health Insurance Program, and for other purposes.

Client expense: $420,000 · Firm income: Not reported

S.2786

IOWA HOSPITAL ASSOCIATIONclient→ABIGAIL STORK

2008 · first_quarter · Medicare/Medicaid

Cited source text, amounts, lobbyists, and targets

--S. 1277: To amend title XVIII of the Social Security Act to clarify the treatment of payment under the Medicare program for clinical laboratory tests furnished by critical access hospitals, provisions relating to clinical lab procedures and critical access hospitals. --HR 3162, Section 651, Limitation on Exception to the Prohibition on Certain Physician Referrals for Hospitals. --HR 1424, Paul Wellstone Mental Health and Addiction Equity Act of 2007, provisions relating to self-referral to physician-owned hospitals. --S 2786: Medicare Rural Health Access Improvement Act of 2008, all provisions relating to hospitals. --HR 5613: Protecting the Medicaid Safety Net Act of 2008, all provisions relating to hospitals. --HR 4105: Medicare Recovery Audit Contractor Program Moratorium Act of 2007, all provisions relating to hospitals. --S 2745: A bill to extend agricultural programs beyond March 15, 2008, to suspend permanent price support authorities beyond that date, and for other purposes, all provisions relating to hospitals. --HR 2419: To provide for the continuation of agricultural programs through fiscal year 2012, and for other purposes, all provisions relating to hospitals, including Section 6006: Rural Hospital Loans and Loan Guarantees. Other Specific Issues: --Critical Access Hospital Relocation Rules: involving CMS' interpretation of the relocation rules and revised guidelines. --Low-volume payment adjustment for Tweener Hospitals. --Medicare payment programs, including Medicare DSH program, Medicare Dependent Hospitals, Sole Community Hospitals. --Medicare Wage Index. --Value-Based Purchasing Program. --Self-referral to physician-owned hospitals, including Altmire-Klein Letter. --Physician fix, involving Medicare reimbursement and payment cuts to physicians.

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

S 2786

ABIGAIL STORK

Government targets: HOUSE OF REPRESENTATIVES, SENATE

MARSHFIELD CLINIC HEALTH SYSTEMclient→MARSHFIELD CLINIC HEALTH SYSTEM

2008 · first_quarter · Medicare/Medicaid