Rural Hospital Access Act of 2015

Support for provisions in 21st Century Cures Act (H.R. 34), including establishment of a socio-economic status (SES) risk adjuster for the Medicare Readmissions Reduction Program; changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) and flexibility in implementation of Section 603 of the law; non-enforcement of the direct supervision rules for CAHs; NIH, mental health, and opioid crisis provisions and funding Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for changes to liver transplant allocation system Urging modifications to Hospital Compare Star Rating System Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Addressing concerns related to the Physician Quality Reporting System (PQRS) and reporting mechanisms Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Urging further flexibility in proposed rule [CMS-5517-P] to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Opposition to redistribution of Medicare DSH payments proposed in FFY 2017 Inpatient Prospective Payment System (IPPS) rule [CMS-1655-P] Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227) Support for emergency funding to address Zika outbreak Encouraging Administration to engage hospital and health system field in discussions to address cybersecurity challenges.

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

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

Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and to extend non-enforcement for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibility: advocating for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program,that Stage 3 not begin until no sooner than 2019 and that meaningful use requirements for hospitals and CAHs align with those for eligible clinicians in MACRA; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support S 629 and H.R. 1784, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Urged limitations on Recovery Audit Contractors (RACs)that includes financial penalties for inaccurate audit decisions; Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 976 and HR 2513 Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process; Support S. 2141 Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act, a bill for improved transparency of information about certified EHRs; Advocate to improve interoperability of electronic health records; Letter to CMS urging use of existing authority to bring flexibility to the EHR Incentive Program and discussion about needed flexibility; Support H.R. 5164, Rural Hospital Regulatory Relief Act, a bill to extend the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals; Support S. 3129/H.R. 5613, legislation to extend through CY2016, the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals.

H.R. 2513 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Oppose any effort to lower such payments. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. Oppose any reductions to such payments. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose any additional site neutral cuts. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. H.R. 5273 "Helping Hospitals Improve Patient Care Act of 2016" - Advocated for targeted, appropriate Hospital Outpatient Department under development language in the House Ways and Means package including LTCH provision. Advocated for Medicaid expansion and the role hospitals have in caring for patients in Medicaid populations. Part B Demo - Opposed administration's proposed Part B Drug Demo. Advocated for limits to CMMI Pilots. H.R. 6226 "Pre-Claims Undermine Seniors Health Act" - Support delay of pre-claim review for home health services. H.R. 1343/S. 688 "Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015" - SES risk adjustment for hospital payment and readmissions. H.R. 3298 "Medicare Post-Acute Care Value-Based Purchasing Act of 2015" - Provided comments on Medicare Post-Acute Care Value-Based Purchasing Act of 2015. Advocated for restoration of hospital Medicare cuts if Affordable Care Act is repealed.

Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and to extend non-enforcement for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibility: advocating for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program,that Stage 3 not begin until no sooner than 2019 and that meaningful use requirements for hospitals and CAHs align with those for eligible clinicians in MACRA; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support S 629 and H.R. 1784, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Urged limitations on Recovery Audit Contractors (RACs)that includes financial penalties for inaccurate audit decisions; Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 976 and HR 2513 Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process; Support S. 2141 Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act, a bill for improved transparency of information about certified EHRs; Advocate to improve interoperability of electronic health records; Letter to CMS urging use of existing authority to bring flexibility to the EHR Incentive Program and discussion about needed flexibility; Support H.R. 5164, Rural Hospital Regulatory Relief Act, a bill to extend the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals; Support S. 3129/H.R. 5613, legislation to extend through CY2016, the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals.

Funding for 340B Drug Pricing Program Critical Access Hospital Relief Act (S. 258; H.R. 169) Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) and flexibility in implementation of Section 603 of the law. Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Urging further flexibility in proposed rule [CMS-5517-P] to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two-Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082)

Client expense: Not reported · Firm income: Not reported

Two Midnight Rule Socioeconomic adjustment of the hospital readmission reduction program (H.R. 1343/S. 688, H.R. 5273) Medicare audit contractor program reforms (H.R. 2156, S. 2368) Rural hospital policies (H.R. 663 / S. 332, H.R. 169/S. 258, H.R. 1611/S. 257, S. 1461/H.R. 2878, H.R. 5164, H.R. 5613, CAH cost-based reimbursement) Telehealth, interoperability, health information technology (H.R. 6, S. 2511, S. 2484/H.R. 4442) Post-Acute Care policies (H.R. 3298), home health prior authorization S. 2108, H.R. 5713 Graduate Medical Education policy (H.R. 2124, S. 1148, H.R 3292) HR 976, HR 2513 DSH payment Bundled payment programs Clinical lab payment policy MACRA implementation NOTICE Act implementation Sec 603 Bipartisan Budget Act / site neutral payment policies (H.R. 5273) Stark Law reforms H.R. 4428 Star Ratings Medicare Part B drug payment model Medicare Advantage

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Mental Health Reform Health Care Reform Implementation Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) CMS Home Health Pre-Claim Demonstration

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

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

Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) and flexibility in implementation of Section 603 of the law. Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for changes to liver transplant allocation system 21st Century Cures Act (H.R. 6) and Senate HELP Committee provisions related to interoperability and information blocking Urging modifications to Hospital Compare Star Rating System Support for National Institutes of Health funding Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Addressing concerns related to the Physician Quality Reporting System (PQRS) and reporting mechanisms Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Urging further flexibility in proposed rule [CMS-5517-P] to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Opposition to redistribution of Medicare DSH payments proposed in FFY 2017 Inpatient Prospective Payment System (IPPS) rule [CMS-1655-P] Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) and inclusion of similar provision in Helping Hospitals Improve Patient Care Act (H.R. 5273) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227) Support for emergency funding to address Zika outbreak Support for authorization of new programs as well as increased funding to improve and expand access to mental health treatment services and substance use disorders. Encouraging Administration to engage hospital and health system field in discussions to address cybersecurity challenges.

Mental Health Reform Health Care Reform Implementation Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) CMS Home Health Pre-Claim Demonstration

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

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

H.R. 2513 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Oppose any effort to lower such payments. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. Oppose any reductions to such payments. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose any additional site neutral cuts. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. H.R. 5273 "Helping Hospitals Improve Patient Care Act of 2016" - Advocated for targeted, appropriate Hospital Outpatient Department under development language in the House Ways and Means package including LTCH provision. Advocated for Medicaid expansion and the role hospitals have in caring for patients in Medicaid populations. Part B Demo - Opposed administration's proposed Part B Drug Demo. H.R. 6226 "Pre-Claims Undermine Seniors Health Act" - Support delay of pre-claim review for home health services. Hospital Stars Rating - Support for delay in the CMS Hospitals Stars Program data release. DSH/S-10 - Advocate for delay and reform of the Administration's DSH/S-10 proposal. H.R. 1343/S. 688 "Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015" - SES risk adjustment for hospital payment and readmissions. Stark - Provided comments to Senate Finance Committee regarding reform of Stark physician self-referral law and Medicare anti-kickback statute. H.R. 3298 "Medicare Post-Acute Care Value-Based Purchasing Act of 2015" - Provided comments on Medicare Post-Acute Care Value-Based Purchasing Act of 2015.

Critical Access Hospital (CAH) Relief Act of 2015 (S. 258/H.R. 169) Protecting Access to Rural Therapy Services (PARTS) Act (S. 257/H.R. 1611) Rural Hospital Access Act of 2015 (S. 332/H.R. 663) Community Hospital Demonstration Extension Act of 2015 (S. 607/H.R. 672) Act to Reform Recover Audit Contractors (RACs) (H.R. 2156) Rural Emergency Acute Care Hospital (REACH) Act (S. 1648) Save Rural Hospitals Act (H.R. 3225) Critical Access and Rural Equity (CARE) Act (H.R. 4553) Direct Supervision 2016 Extension of Moratorium (S.3129/H.R. 5613); and H.R. 5614 for permanent moratorium Rural Hospital Regulatory Relief Act (H.R. 5164) Critical Access and Rural Equity (CARE) Act (H.R. 4553) Helping Hospitals Improve Patient Care Act of 2016 (H.R. 5273) Proposed rule on implementation of MACRA Proposed FY2017 Hospice Wage Index Comments regarding the HHS budget proposal to change payment of CAH from 101% to 100% of costs Concerns with implementation of Sec. 603 site-neutral reductions to Iowa hospitals and the CMS interpretation of the legislation in the outpatient prospective payment system proposed rule Concern with Hospital star ratings, and Hospital Quality Rating Transparency Act of 2016 (HR 5927) Significant concerns with Iowa's proposed transition to Medicaid managed care Medicare reduction proposals in President Obama's budget released 2015 MedPAC recommendations for cuts to hospital payments avoiding site-neutral cuts recovery audit contractor (RAC) program and needed transparency and changes protecting critical access hospital funding and necessary provider status rural hospitals and access to care in Iowa encouraging value-based purchasing hospital acquired conditions and other quality measures Medicare formula and Iowa's payment compared to payments to other states Iowa hospital's economic impact to communities and the state beneficiary access throughout Iowa and threats from regulatory burdens and changes importance of 340B program to Iowa's hospitals Changes to the definition of patient in the 340B guidance and impact on Iowa hospitals Extension of sequestration against Medicare and the inclusion of the "site neutral" hospital outpatient department payment change in H.R.1314 - Bipartisan Budget Act of 2015 Hospital outpatient department grandfathering provision to include currently planned facilities and acquisitions at time of enactment of H.R.1314 - Bipartisan Budget Act of 2015 Concerns about processing and preauthorization, access to care issues with the Veteran's Choice program.

Critical Access Hospital (CAH) Relief Act of 2015 (S. 258/H.R. 169) Protecting Access to Rural Therapy Services (PARTS) Act (S. 257/H.R. 1611) Rural Hospital Access Act of 2015 (S. 332/H.R. 663) Community Hospital Demonstration Extension Act of 2015 (S. 607/H.R. 672) Act to Reform Recover Audit Contractors (RACs) (H.R. 2156) Rural Emergency Acute Care Hospital (REACH) Act (S. 1648) Save Rural Hospitals Act (H.R. 3225) Critical Access and Rural Equity (CARE) Act (H.R. 4553) Direct Supervision 2016 Extension of Moratorium (S.3129/H.R. 5613) Rural Hospital Regulatory Relief Act (H.R. 5164) Critical Access and Rural Equity (CARE) Act (H.R. 4553) Proposed rule on implementation of MACRA Proposed FY2017 Hospice Wage Index Comments regarding the HHS budget proposal to change payment of CAH from 101% to 100% of costs Significant concerns with Iowa's proposed transition to Medicaid managed care Medicare reduction proposals in President Obama's budget released 2015 MedPAC recommendations for cuts to hospital payments avoiding site-neutral cuts recovery audit contractor (RAC) program and needed transparency and changes protecting critical access hospital funding and necessary provider status rural hospitals and access to care in Iowa encouraging value-based purchasing hospital acquired conditions and other quality measures Medicare formula and Iowa's payment compared to payments to other states Iowa hospital's economic impact to communities and the state beneficiary access throughout Iowa and threats from regulatory burdens and changes importance of 340B program to Iowa's hospitals sustainable growth rate fix and impact on hospitals in Iowa Meaningful use in EHR Changes to the definition of patient in the 340B guidance and impact on Iowa hospitals Extension of sequestration against Medicare and the inclusion of the "site neutral" hospital outpatient department payment change in H.R.1314 - Bipartisan Budget Act of 2015 Clarifying amendment to hospital outpatient department grandfathering provision to include currently planned facilities and acquisitions at time of enactment of H.R.1314 - Bipartisan Budget Act of 2015 Concerns about processing and preauthorization, access to care issues with the Veteran's Choice program.

Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and to extend non-enforcement for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibility: advocating for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program,that Stage 3 not begin until no sooner than 2019 and that meaningful use requirements for hospitals and CAHs align with those for eligible clinicians in MACRA; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support S 629 and H.R. 1784, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Urged limitations on Recovery Audit Contractors (RACs)that includes financial penalties for inaccurate audit decisions; Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 976 and HR 2513 Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process; Support S. 2141 Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act, a bill for improved transparency of information about certified EHRs; Advocate to improve interoperability of electronic health records; Letter to CMS urging use of existing authority to bring flexibility to the EHR Incentive Program and discussion about needed flexibility; Support H.R. 5164, Rural Hospital Regulatory Relief Act, a bill to extend the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals; Support S. 3129/H.R. 5613, legislation to extend through CY2016, the enforcement moratorium on CMS direct supervision policy for CAHs and small, rural hospitals.

Opposing Medicare and Medicaid Payment reductions, including those to Graduate Medical Education (H.R. 3292, the Medicare IME Pool Act of 2015), bad debt payments, post-acute care payments, Disproportionate Share Hospital (DSH) payments, CAH payments, IPPS coding offset, rural hospital payments, hospital outpatient department (HOPD) clinics, and sequestration. Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) and flexibility in implementation of Section 603 of the law. Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for changes to liver transplant allocation system 21st Century Cures Act (H.R. 6) and Senate HELP Committee provisions related to interoperability and information blocking Urging release of funding for Ebola preparedness and treatment Urging modifications to Hospital Compare Star Rating System Support for National Institutes of Health funding Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Addressing concerns related to the Physician Quality Reporting System (PQRS) and reporting mechanisms Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Urging further flexibility in proposed rule [CMS-5517-P] to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Opposition to redistribution of Medicare DSH payments proposed in FFY 2017 Inpatient Prospective Payment System (IPPS) rule [CMS-1655-P] Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) and inclusion of similar provision in Helping Hospitals Improve Patient Care Act (H.R. 5273) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227) Support for emergency funding to address Zika outbreak Support for authorization of new programs as well as increased funding to improve and expand access to mental health treatment services and substance use disorders. Encouraging Administration to engage hospital and health system field in discussions to address cybersecurity challenges.

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impacts the 1115 waiver renewal as well as the safety net in the state. Provided education to members of Congress and their staff about the importance of adequate funding for the Hospital Preparedness Program. Worked with members of Congress and staff on proposals for combating the Zika virus and encouraged adequate funding of these plans. H.R. 2646 - Helping Families in Mental Health Crisis Act of 2016 - Would make a variety of sweeping changes to the mental health infrastructure and while also reforming provider outreach, community-based treatment options, and justice system reform. - Discussed with staff how THA support the overall direction this bill would take the mental health system, and encouraged the use of community care in reforming the way we address mental health issues. Encouraged congressional staff to approve the bill, but expressed concern for lack of funding. Without adequate funding, states cannot properly implement the programs in the legislation. S.524 Comprehensive Addiction and Recovery Act (CARA) - wound enact policies intended to re-engineer how health care providers, communities and the criminal justice system coordinates care to treat addiction. - Expressed support for the overall goals of the bill and the programs to be established by the legislation, but THA is concerned with the lack of funding in the legislation. Without funding, states and localities cannot adequately address and combat the opioid addiction crisis. H.R.5273 - Helping Hospitals Improve Patient Care Act of 2016 - Would provide some relief to hospitals in site-neutral payments, readmissions adjustments and other polices. Discussed with congressional staff about the bills limited impact to Texas hospitals in relation to hospital outpatient departments. Encouraged additional work in the Senate to help a broader range of hospitals who had their payment structure changed without notice. H.R.2745 - Standard Merger and Acquisition Reviews Through Equal Rules Act of 2015 - Would standardize the merger review process for the Department of Justice (DOJ) and Federal Trade Commission (FTC). Met with congressional staff on how the merger review process impacts hospital mergers and how this legislation would eliminate disparities between the two reviewing agencies. H.R. 2124, Resident Physician Shortage Reduction Act -- Would prevent a looming doctor shortage by ensuring additional residency slots are available for teaching hospitals. Educated members of congress and staff on Graduate Medical Education and why we must increase residency slots to meet the growing demand by medical students and to help counteract the ever-growing physician shortage . Teaching hospitals and academic medical centers rely on support from the GME program to fulfill their mission of training physicians for the public good, furnishing highly-specialized care to the most medically complex patients, and delivering essential health care services to the community. H.R.4428 - Fair Medicare Hospital Payments Act of 2016 - would establish a national minimum of 0.874 for the Medicare Area Wage Index for Hospital Inpatient Services (Medicare Part A) and the Medicare Area Wage Adjustment Factor for Hospital Outpatient Department Services (Medicare Part B). Discussed with congressional staff the importance of leveling the Area Wage Index playing field for hospitals across the nation. Dozens of hospitals in Texas are negatively impacted by low AWI. While he AWI is designed so the average AWI is 1.0, Texas does not contain a single CBSA with an AWI at 1.0 or greater. H.R. 3119 - Palliative Care and Hospice Education and Training Act - Would authorize grants to improve the training of health professionals in palliative care. H.R.1343/S.688 - Would require CMS to take into account patients' sociodemographic status when imposing financial penalties for excessive hospital readmissions for Medicare patients. - Met with congressional staff on how socioeconomic status impacts health and the importance of this legislation, especially to large safety net hospitals. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225.

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impacts the 1115 waiver renewal as well as the safety net in the state. Discussed with members of Congress and staff the implications, concerns with and the misguided policies in the proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. H.R.5273 - Helping Hospitals Improve Patient Care Act of 2016 - Would provide some relief to hospitals in site-neutral payments, readmissions adjustments and other polices. Discussed with congressional staff about the bills limited impact to Texas hospitals in relation to hospital outpatient departments. Encouraged additional work in the Senate to help a broader range of hospitals that had their payment structure changed without notice. H.R.4428 - Fair Medicare Hospital Payments Act of 2016 - would establish a national minimum of 0.874 for the Medicare Area Wage Index for Hospital Inpatient Services (Medicare Part A) and the Medicare Area Wage Adjustment Factor for Hospital Outpatient Department Services (Medicare Part B). Discussed with congressional staff the importance of leveling the Area Wage Index playing field for hospitals across the nation. Dozens of hospitals in Texas are negatively impacted by low AWI. While he AWI is designed so the average AWI is 1.0, Texas does not contain a single CBSA with an AWI at 1.0 or greater. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. H.R. 2124, Resident Physician Shortage Reduction Act -- Would prevent a looming doctor shortage by ensuring additional residency slots are available for teaching hospitals. Educated members of congress and staff on Graduate Medical Education and why we must increase residency slots to meet the growing demand by medical students and to help counteract the ever-growing physician shortage . Teaching hospitals and academic medical centers rely on support from the GME program to fulfill their mission of training physicians for the public good, furnishing highly-specialized care to the most medically complex patients, and delivering essential health care services to the community. H.R. 3119 - Palliative Care and Hospice Education and Training Act - Would authorize grants to improve the training of health professionals in palliative care. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

H.R. 2513 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Oppose any effort to lower such payments. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. oppose any reductions to such payments. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose any additional site neutral cuts. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. H.R. 2156 "Medicare Audit Improvement Act of 2015" supports legislation to improve Medicare audits and provided comments to Senate Finance Committee to improve draft legislation. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. S. 2822 "Flexibility in Electronic Health Record Reporting Act" - Advocate for 90 day reporting under meaningful use program requirements as part of the EHR Incentive Program. H.R. 5273 "Helping Hospitals Improve Patient Care Act of 2016" - Advocated for targeted, appropriate Hospital Outpatient Department under development language in the House Ways and Means package including LTCH provision. Advocated for Medicaid expansion and the role hospitals have in caring for patients in Medicaid populations. Medicaid Provider Tax - Oppose efforts to limit states ability to use Medicaid provider taxes. Commented on potential policy changes to both the Hospital Acquired Conditions Program and the Readmissions Program. Part B Demo - Opposed administration's proposed Part B Drug Demo. Home Health Prior Authorization - Oppose home health prior authorization proposed demonstration project. Hospital Stars Rating - Support for delay in the CMS Hospitals Stars Program data release. DSH/S-10 - Advocate for delay and reform of the Administration's DSH/S-10 proposal. H.R. 1343/S. 688 "Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015" - SES risk adjustment for hospital payment and readmissions.

Mental Health Reform Health Care Reform Implementation Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663)

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

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

Two Midnight Rule Socioeconomic adjustment of the hospital readmission reduction program (H.R. 1343/S. 688, H.R. 5273) Medicare audit contractor program reforms (H.R. 2156, S. 2368) Rural hospital policies (H.R. 663 / S. 332, H.R. 169/S. 258, H.R. 1611/S. 257, S. 1461/H.R. 2878, H.R. 5164) Telehealth, interoperability, health information technology (H.R. 6, S. 2511, S. 2484/H.R. 4442) Post-Acute Care policies, home health prior authorization Graduate Medical Education policy (H.R. 2124, S. 1148, H.R 3292) DSH payment Clinical lab payment policy MACRA implementation NOTICE Act implementation Sec 603 Bipartisan Budget Act / site neutral payment policies (H.R. 5273) Stark Law reforms H.R. 4428 Star Ratings Medicaid Managed Care rule Medicare Part B drug payment model Medicare Advantage

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Save Rural Hospitals Act (H.R.3225) Funding for 340B Drug Pricing Program Critical Access Hospital Relief Act (S. 258; H.R. 169) Support for Medicare and Medicaid Payment reductions, including Graduate Medical Education Support for Resident Physician Shortage Act of 2015 (S. 1148; H.R. 2124) Opposing Medicare and Medicaid Payment reductions, including those to Graduate Medical Education (H.R. 3292, the Medicare IME Pool Act of 2015), bad debt payments, post-acute care payments, Disproportionate Share Hospital (DSH) payments, CAH payments, IPPS coding offset, rural hospital payments, hospital outpatient department (HOPD) clinics, and sequestration. Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) and flexibility in implementation of Section 603 of the law. Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) and inclusion of similar provision in Helping Hospitals Improve Patient Care Act (H.R. 5273) Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Addressing concerns related to the Physician Quality Reporting System (PQRS) and reporting mechanisms Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Urging further flexibility in proposed rule [CMS-5517-P] to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Opposition to redistribution of Medicare DSH payments proposed in FFY 2017 Inpatient Prospective Payment System (IPPS) rule [CMS-1655-P] Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two-Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082)

Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and to extend non-enforcement for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibility: advocating for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program and that Stage 3 not begin until 75 percent of EHs, CAHs and EPs attain Stage 2.; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support S 629 and H.R. 1784, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Urged limitations on Recovery Audit Contractors (RACs)that includes financial penalties for inaccurate audit decisions; Support ICD-10 delay and advocate to maintain the Oct. 1, 2015 transition date for ICD-10; Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 976 and HR 2513 Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process; Support S. 2141 Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act, a bill for improved transparency of information about certified EHRs; Advocate to improve interoperability of electronic health records.

Health Care Reform Implementation Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) Resident Physician Shortage Reduction Act of 2015, S. 1148/HR 2124

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

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

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impacts the 1115 waiver renewal as well as the safety net in the state. Provided education to members of Congress and their staff about the importance of adequate funding for the Hospital Preparedness Program. Worked with members of Congress and staff on proposals for combating the Zika virus and encouraged adequate funding of these plans. H.R.2745 - Standard Merger and Acquisition Reviews Through Equal Rules Act of 2015 - Would standardize the merger review process for the Department of Justice (DOJ) and Federal Trade Commission (FTC). Met with congressional staff on how the merger review process impacts hospital mergers and how this legislation would eliminate disparities between the two reviewing agencies. H.R. 2124, Resident Physician Shortage Reduction Act -- Would prevent a looming doctor shortage by ensuring additional residency slots are available for teaching hospitals. Educated members of congress and staff on Graduate Medical Education and why we must increase residency slots to meet the growing demand by medical students and to help counteract the ever-growing physician shortage . Teaching hospitals and academic medical centers rely on support from the GME program to fulfill their mission of training physicians for the public good, furnishing highly-specialized care to the most medically complex patients, and delivering essential health care services to the community. H.R.4428 - Fair Medicare Hospital Payments Act of 2016 - would establish a national minimum of 0.874 for the Medicare Area Wage Index for Hospital Inpatient Services (Medicare Part A) and the Medicare Area Wage Adjustment Factor for Hospital Outpatient Department Services (Medicare Part B). Discussed with congressional staff the importance of leveling the Area Wage Index playing field for hospitals across the nation. Dozens of hospitals in Texas are negatively impacted by low AWI. While he AWI is designed so the average AWI is 1.0, Texas does not contain a single CBSA with an AWI at 1.0 or greater. H.R. 953 Comprehensive Addiction and Recovery Act - Discussed with congressional staff how hospitals are involved with treating and caring for opioid and other substance abuse patients. Discussed limitations and flexibility within current law and congressional proposals. S.2002 - Mental Health and Safe Communities Act of 2015 - Talked with Senate staff about the importance of adequate funding and coordination of care across multiple disciplines, including hospitals, law enforcement, judicial system, outpatient clinics, community-based treatment and more. H.R. 3119 - Palliative Care and Hospice Education and Training Act - Would authorize grants to improve the training of health professionals in palliative care. H.R.1343/S.688 - Would require CMS to take into account patients' sociodemographic status when imposing financial penalties for excessive hospital readmissions for Medicare patients. - Met with congressional staff on how socioeconomic status impacts health and the importance of this legislation, especially to large safety net hospitals. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. H.R. 2646 - Helping Families in Mental Health Crisis Act of 2015 - Would make a variety of sweeping changes to the mental health infrastructure and while also reforming provider outreach, community-based treatment options, and justice system reform. - Discussed with staff how THA support the overall direction this bill would take the mental health system, and encouraged the use of community care in reforming the way we address mental health issues. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impacts the 1115 waiver renewal as well as the safety net in the state. H.R.4428 - Fair Medicare Hospital Payments Act of 2016 - would establish a national minimum of 0.874 for the Medicare Area Wage Index for Hospital Inpatient Services (Medicare Part A) and the Medicare Area Wage Adjustment Factor for Hospital Outpatient Department Services (Medicare Part B). Discussed with congressional staff the importance of leveling the Area Wage Index playing field for hospitals across the nation. Dozens of hospitals in Texas are negatively impacted by low AWI. While he AWI is designed so the average AWI is 1.0, Texas does not contain a single CBSA with an AWI at 1.0 or greater. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. H.R. 2124, Resident Physician Shortage Reduction Act -- Would prevent a looming doctor shortage by ensuring additional residency slots are available for teaching hospitals. Educated members of congress and staff on Graduate Medical Education and why we must increase residency slots to meet the growing demand by medical students and to help counteract the ever-growing physician shortage . Teaching hospitals and academic medical centers rely on support from the GME program to fulfill their mission of training physicians for the public good, furnishing highly-specialized care to the most medically complex patients, and delivering essential health care services to the community. H.R. 3119 - Palliative Care and Hospice Education and Training Act - Would authorize grants to improve the training of health professionals in palliative care. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

Two Midnight Rule Socioeconomic adjustment of the hospital readmission reduction program (H.R. 1343/S. 688) Medicare audit contractor program reforms (H.R. 2156, S. 2368) Rural hospital policies (H.R. 663 / S. 332, H.R. 169/S. 258, H.R. 1611/S. 257, S. 1461/H.R. 2878) Telehealth, interoperability, health information technology (H.R. 6, S. 2511, S. 2484/H.R. 4442) Physician self-referral (H.R. 2027, H.R. 976) Hospital Improvements for Payment Act (H.R. 3291) Post-Acute Care policies (H.R. 1458, H.R. 3298) Graduate Medical Education policy reforms (H.R. 2124, S. 1148, H.R 3292) DSH payment (H.R. 3288) H.R. 4428 Clinical lab payment policy Discharge planning MACRA implementation NOTICE Act implementation Sec 603 Bipartisan Budget Act / site neutral payment policies Stark Law reforms

Client expense: $83,731 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 2513 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose the lowering of Medicare outpatient site neutral rates. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. Provided guidance on Medicare hospital payment reform legislative drafts: Medicare Crosswalk Hospital Code Development Act of 2015, Strengthening DSH and Medicare Through Subsidy Recapture and Payment Reform Act of 2015, Medicare Crosswalk IME Pool Act of 2015, and the Medicare Post-Acute Care Value-Based Purchasing Act of 2015-under consideration by the House Ways and Means Committee. H.R. 2156, "Medicare Audit Improvement Act of 2015" supports legislation to improve Medicare audits and provided comments to Senate Finance Committee to improve draft legislation. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. Meaningful Use - Advocate for reasonable Stage 3 meaningful use requirements as part of the EHR Incentive Program. Worked to restore funding for AHRQ and CMMI in the House Labor-HHS Appropriations Bill, H.R. 3020. Chronic Care - provided comments and policy suggestions on Senate Finance Committee efforts to improve chronic care outcomes and treatments. Under Development - Advocate for technical change to the HOPD policy in the BBA15 (H.R. 1314/P.L. 114-74) to allow for an under development exception. Ensure appropriate implementation of exempt off-campus provider-based emergency departments from the hospital outpatient site neutral policy. Advocated for Medicaid expansion and the role hospitals have in caring for patients in Medicaid populations. Advocated for Medicaid Supplemental Payments, to support an adequate Medicaid payment rate. Commented on potential policy changes to both the Hospital Acquired Conditions Program and the Readmissions Program.

Opposing Medicare and Medicaid Payment reductions, including those to Graduate Medical Education (H.R. 3292, the Medicare IME Pool Act of 2015), bad debt payments, post-acute care payments, Disproportionate Share Hospital (DSH) payments, CAH payments, IPPS coding offset, rural hospital payments, hospital outpatient department (HOPD) clinics, and sequestration. Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for changes to liver transplant allocation system 21st Century Cures Act (H.R. 6) and Senate HELP Committee provisions related to interoperability and information blocking Urging release of funding for Ebola preparedness and treatment Urging modifications to Hospital Compare Star Rating System Support for National Institutes of Health funding Support for Standard Merger and Acquisition Reviews Through Equal Rules (SMARTER) Act (H.R. 2745) Addressing concerns related to the Physician Quality Reporting System (PQRS) and reporting mechanisms Encouraging Committees of jurisdiction to examine overlap in Merit-based Incentive Payment System and Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227)

Critical Access Hospital (CAH) Relief Act of 2015 (S. 258/H.R. 169) Protecting Access to Rural Therapy Services (PARTS) Act (S. 257/H.R. 1611) Rural Hospital Access Act of 2015 (S. 332/H.R. 663) Community Hospital Demonstration Extension Act of 2015 (S. 607/H.R. 672) Act to Reform Recover Audit Contractors (RACs) (H.R. 2156) Rural Emergency Acute Care Hospital (REACH) Act (S. 1648) Save Rural Hospitals Act (H.R. 3225) Critical Access and Rural Equity (CARE) Act (H.R. 4553) Significant concerns with Iowa's proposed transition to Medicaid managed care Medicare reduction proposals in President Obama's budget released 2015 MedPAC recommendations for cuts to hospital payments avoiding site-neutral cuts recovery audit contractor (RAC) program and needed transparency and changes protecting critical access hospital funding and necessary provider status rural hospitals and access to care in Iowa encouraging value-based purchasing hospital acquired conditions and other quality measures Medicare formula and Iowa's payment compared to payments to other states Iowa hospital's economic impact to communities and the state beneficiary access throughout Iowa and threats from regulatory burdens and changes importance of 340B program to Iowa's hospitals sustainable growth rate fix and impact on hospitals in Iowa Meaningful use in EHR Changes to the definition of patient in the 340B guidance and impact on Iowa hospitals Extension of sequestration against Medicare and the inclusion of the "site neutral" hospital outpatient department payment change in H.R.1314 - Bipartisan Budget Act of 2015 Clarifying amendment to hospital outpatient department grandfathering provision to include currently planned facilities and acquisitions at time of enactment of H.R.1314 - Bipartisan Budget Act of 2015 Concerns about processing and preauthorization, access to care issues with the Veteran's Choice program.

Provided education to Members of Congress and staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Educated members of congress and staff on the Medicare Area Wage Index. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. H.R.2156 - Medicare Audit Improvement Act of 2015 - Would replace the Recovery Audit Contractor (RAC) contingency fee structure with a flat fee to reduce the financial incentive for overzealous auditing practices; lowers payments for poor RAC performance; allows hospitals to rebill claims when appropriate; and requires RACs to base their inpatient claims decisions on only the information the physician had when treating the patient. - Discussed with congressional staff the burden the RACs put on hospitals and how RAC reform is necessary to improve efficiency and fairness. H.R. 2513 - PACE Act of 2015 - Would remove the prohibition on expansion of physician-owned hospitals. - Met with staff on the role these facilities play in the health care infrastructure compared to general acute care hospitals (treating healthier patients and less Medicare and Medicaid populations) and how physician-owned hospitals raise ethical concerns for cherry-picking patients and physician self-referral. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impact the 1115 waiver renewal as well as the safety net in the state. Provided information to members of Congress and their staff on physician-owned hospitals. Provided education to members of Congress and their staff about the importance of adequate funding for the Hospital Preparedness Program. H.R.1343/S.688 - Would require CMS to take into account patients' sociodemographic status when imposing financial penalties for excessive hospital readmissions for Medicare patients. - Met with congressional staff on how socioeconomic status impacts health and the importance of this legislation, especially to large safety net hospitals. Educated members of congress and staff on the Medicare Area Wage Index. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. S.2425 - Patient Access and Medicare Protection Act - would allow CMS to create a blanket hardship exemption from 2015 electronic health record meaningful use requirements and related payment adjustments to all providers who ask for it. The penalties would have been assessed in 2017. H.R. 2513 - PACE Act of 2015 - Would remove the prohibition on expansion of physician-owned hospitals. - Met with staff on the role these facilities play in the health care infrastructure compared to general acute care hospitals (treating healthier patients and less Medicare and Medicaid populations) and how physician-owned hospitals raise ethical concerns for cherry-picking patients and physician self-referral. H.R. 2646 - Helping Families in Mental Health Crisis Act of 2015 - Would make a variety of sweeping changes to the mental health infrastructure and while also reforming provider outreach, community-based treatment options, and justice system reform. - Discussed with staff how THA support the overall direction this bill would take the mental health system, and encouraged the use of community care in reforming the way we address mental health issues. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

HALO letter sent to Congress about the Medicare Sustainable Growth Rate (SGR) for physician payment; Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs and to extend non-enforcement for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibility: advocating for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program and that Stage 3 not begin until 75 percent of EHs, CAHs and EPs attain Stage 2.; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support HR 2, Medicare Access and CHIP Reauthorization Act of 2015, a bill to amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and strengthen Medicare access by improving physician payments and making other improvements, to reauthorize the Childrens Health Insurance Program; Support HR 1470, SGR Repeal and Medicare Provider Payment Modernization Act of 2015, a bill to amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and improve Medicare payments for physicians and other professionals; Support S 629, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Oppose Recovery Audit Contracts (RACs)Section 3 that imposes financial penalties on RACs; Support ICD-10 delay and advocate to maintain the Oct. 1, 2015 transition date for ICD-10; Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 1295, Trade Preferences Extension Act of 2015because the inclusion of the Medicare sequestration offset; Oppose HR 976 and HR 2513Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process; Support S. 2141 Transparent Ratings on Usability and Security to Transform Information Technology (TRUST IT) Act, a bill for improved transparency of information about certified EHRs; Advocate to improve interoperability of electronic health records.

Opposing Medicare and Medicaid Payment reductions, including those to Graduate Medical Education (H.R. 3292, the Medicare IME Pool Act of 2015), bad debt payments, post-acute care payments, Disproportionate Share Hospital (DSH) payments, CAH payments, IPPS coding offset, rural hospital payments, hospital outpatient department (HOPD) clinics, and sequestration. Support for changes to site-neutral payment provision of Bipartisan Budget Act of 2015 (P.L. 114-74) Protecting 340B Drug Pricing Program in regulatory and legislative proposals Support for finalizing Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) 2015-2017 Modifications Rule; support for delaying of Stage 3 Rule Urging Release of New York State Medicaid Vital Access Provider Program Funding Support for changes to liver transplant allocation system 21st Century Cures Act (H.R. 6) and Senate HELP Committee provisions related to interoperability and information blocking Urging release of funding for Ebola preparedness and treatment Support for National Institutes of Health funding Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) Support for Flexibility in Health IT Reporting Act of 2015 (H.R. 270) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227)

H.R. 2513 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose the lowering of Medicare outpatient site neutral proposal rates. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. Provided guidance on Medicare hospital payment reform legislative drafts: Medicare Crosswalk Hospital Code Development Act of 2015, Strengthening DSH and Medicare Through Subsidy Recapture and Payment Reform Act of 2015, Medicare Crosswalk IME Pool Act of 2015, and the Medicare Post-Acute Care Value-Based Purchasing Act of 2015-under consideration by the House Ways and Means Committee. H.R. 2156, "Medicare Audit Improvement Act of 2015" supports legislation to improve Medicare audits and provided comments to Senate Finance Committee to improve draft legislation. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. CMS "2 Midnight" Policy - advocate for policy to allow for physician judgment on whether a patient should be considered inpatient or outpatient status, and other modifications to the policy. Meaningful Use - Advocate for reasonable Stage 3 meaningful use requirements as part of the EHR Incentive Program. Worked to restore funding for AHRQ and CMMI in the House Labor-HHS Appropriations Bill, H.R. 3020. Chronic Care - provided comments and policy suggestions on Senate Finance Committee efforts to improve chronic care outcomes and treatments. Under Development - Advocate for technical change to the HOPD policy in the BBA15 (H.R. 1314/P.L. 114-74) to allow for an under development exception. H.R. 1314 "Balanced Budget Act of 2015" - Advocated to exempt off-campus provider-based emergency departments from the hospital outpatient site neutral policy. Advocated for Medicaid expansion and the role hospitals have in caring for patients in Medicaid populations. Advocated for Medicaid Supplemental Payments, to support an adequate Medicaid payment rate.

Health Care Reform Implementation Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) Resident Physician Shortage Reduction Act of 2015, S. 1148/HR 2124

Client expense: $60,000 · Firm income: Not reported

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

Two Midnight Rule Socioeconomic adjustment of the hospital readmission reduction program (H.R. 1343/ S. 688) Medicare audit contractor program reforms (H.R. 2156, AFIRM Act) Health information technology (H.R. 270, H.R. 3309, H.R. 3940, S. 2425) Medicare Access and CHIP Reauthorization Act (H.R. 2) Patient status notification (H.R. 876, S. 1349) Rural hospital policies (H.R. 663 / S. 332, H.R. 169 / S. 258, H.R. 1611 / S. 257, S. 1461 / H.R. 2878) Telehealth, interoperability (H.R. 6) Physician self-referral (H.R. 2027, H.R. 976) Hospital Improvements for Payment Act (H.R. 3291) Post-Acute Care policies (H.R. 1458, H.R. 3298) Graduate Medical Education policy reforms (H.R. 2124, S. 1148, H.R 3292) DSH payment (H.R. 3288) Bipartisan Budget Act (H.R. 1314) Clinical lab payment policy

Client expense: $73,623 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Care Reform Implementation 21st Century Cures Act, H.R. 6 Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) H.R. 270, Flexibility in Health IT Reporting (Flex-IT) Act of 2015

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Internal Revenue Service (IRS), SENATE

Critical Access Hospital (CAH) Relief Act of 2015 (S. 258/H.R. 169) Protecting Access to Rural Therapy Services (PARTS) Act (S. 257/H.R. 1611) Rural Hospital Access Act of 2015 (S. 332/H.R. 663) Community Hospital Demonstration Extension Act of 2015 (S. 607/H.R. 672) Act to Reform Recover Audit Contractors (RACs) (H.R. 2156) Rural Emergency Acute Care Hospital (REACH) Act (S. 1648) Save Rural Hospitals Act (H.R. 3225) Significant concerns with Iowa's proposed transition to Medicaid managed care Medicare reduction proposals in President Obama's budget released 2015 MedPAC recommendations for cuts to hospital payments avoiding site-neutral cuts recovery audit contractor (RAC) program and needed transparency and changes protecting critical access hospital funding and necessary provider status rural hospitals and access to care in Iowa encouraging value-based purchasing hospital acquired conditions and other quality measures Medicare formula and Iowa's payment compared to payments to other states Iowa hospital's economic impact to communities and the state beneficiary access throughout Iowa and threats from regulatory burdens and changes importance of 340B program to Iowa's hospitals sustainable growth rate fix and impact on hospitals in Iowa Meaningful use in EHR Changes to the definition of patient in the 340B guidance and impact on Iowa hospitals Extension of sequestration against Medicare and the inclusion of the "site neutral" hospital outpatient department payment change in H.R.1314 - Bipartisan Budget Act of 2015 Clarifying amendment to hospital outpatient department grandfathering provision to include currently planned facilities and acquisitions at time of enactment of H.R.1314 - Bipartisan Budget Act of 2015 Support for the Bay State fix in the Continuing Resolution

Client expense: $65,000 · Firm income: Not reported

HALO letter sent to Congress about the Medicare Sustainable Growth Rate (SGR) for physician payment; Support HR 672 and S 607, Rural Community Hospital (RCH) Demonstration Extension Act of 2015, a bill that will extend the demonstration for five more years, will ensure that RCH continues to help Americas communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need. Also enables hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement. Affects 23 small, rural hospitals nationwide. Demo included in MMA, extended and expanded in ACA and Budget neutral; Support HR 663 and S 332, Rural Hospital Access Act of 2015, a bill that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for prospective payment system (PPS) hospitals, which are vital programs for rural hospitals and the patients and communities they serve; Support S 257 and HR 1611, Protecting Access to Rural Therapy Services (PARTs)Act of 2015, a bill that would provide hospitals relief from the Centers for Medicare & Medicaid Services (CMS) regulations with respect to direct supervision of outpatient therapeutic services; Support HR 270,Flexibility in Health IT Reporting (Flex-IT) Act of 2015, a bill that requires the Centers for Medicare & Medicaid Services (CMS) to make a necessary adjustment to how it implements the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, which provide incentives and penalties to encourage meaningful use of EHRs by hospitals and physicians and to extend non-enforcement instruction for the Medicare direct supervision requirement for therapeutic hospital outpatient services for CAHs and rural hospitals ; Meaningful use flexibilityadvocate for a shorter meaningful use reporting period and other flexibilities that would increase hospitals ability to meet Stage 2 and move forward with the program; Support S. 377 and HR 745, Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2015, a bill to amend title XVIII of the Social Security Act to increase access to ambulance services under the Medicare program and to reform payments for such services under such program; Support S. 688 and HR 1343, Establishing Beneficiary Equity in the Hospital Readmission Program Act of 2015, a bill to amend title XVIII of the Social Security Act to adjust the Medicare hospital readmission reduction program to respond to patient disparities; Support HR 2, Medicare Access and CHIP Reauthorization Act of 2015, a bill to amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and strengthen Medicare access by improving physician payments and making other improvements, to reauthorize the Childrens Health Insurance Program; Support HR 1470, SGR Repeal and Medicare Provider Payment Modernization Act of 2015, a bill to amend title XVIII of the Social Security Act to repeal the Medicare sustainable growth rate and improve Medicare payments for physicians and other professionals; Support S 629, Making the Education of Nurses Dependable for Schools Act, a bill to enable hospital-based nursing programs that are affiliated with a hospital to maintain payments under the Medicare program to hospitals for the costs of such programs; Oppose Recovery Audit Contracts (RACs)Section 3 that imposes financial penalties on RACs; Support ICD-10 delay and advocate to maintain the Oct. 1, 2015 transition date for ICD-10; Discussions to oppose site neutral payments. Provide input to CMS on implementation of quality measures required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014; Analyze and develop suggested changes to the Personalize Your Care Act of 2015, a bill that would provide coverage of voluntary advance care planning consultation under Medicare and Medicaid; Oppose HR 2895, Medicare Patient Access to Cancer Treatment Act of 2015, a bill that would establish parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting; Oppose HR 1295, Trade Preferences Extension Act of 2015because the inclusion of the Medicare sequestration offset; Oppose HR 976 and HR 2513Promoting Access, Competition, and Equity Act of 2015(PACE) Act of 2015, a bill to allow an increase in, and expansion of, physician-owned hospitals eligible for Medicare reimbursement; Support S 1148 and HR 2124Resident Physician Shortage Reduction Act of 2015, a bill to increase the number of Medicare-supported physician residency slots; Urged SFC Chronic Care Working Group to consider expanding access to telehealth, removing legal barriers to clinical integration, and better engaging beneficiaries in their health and health care;Testified at the Observation status, Improving competition in Medicare and Prompt payment hearings; Support HR 2156, Medicare Audit Improvement Act of 2015, a bill to amend title XVIII of the Social Security Act to reform the practices of recovery audit contractors under the Medicare program; Discuss S. 861, Preventing and Reducing Improper Medicare and Medicaid Expenditures Act of 2015 or the PRIME Act of 2015 with the Senate Finance Committee to reform the Medicare audits and appeals process.

Two Midnight Rule Socioeconomic adjustment of the hospital readmission reduction program (H.R. 1343/ S. 688) Medicare audit contractor program reforms (H.R. 2156, AFIRM Act) Flexibility in Health IT (H.R. 270, H.R. 3309) Medicare Access and CHIP Reauthorization Act (H.R. 2) Patient status notification (H.R. 876, S. 1349) Rural hospital policies (H.R. 663 / S. 332, H.R. 169 / S. 258, H.R. 1611 / S. 257, S. 1461 / H.R. 2878) Telehealth, interoperability (H.R. 6) Medicare Advantage (H.R. 2505, H.R. 2506, H.R. 2507, H.R. 2579, H.R. 2581) Physician self-referral (H.R. 2027, H.R. 976) Hospital Improvements for Payment Act (H.R. 3291) Post-Acute Care policies (H.R. 1458, H.R. 3298) Graduate Medical Education policy reforms (H.R. 2124, S. 1148, H.R 3292) DSH payment (H.R. 3288) ICD-10

Client expense: $67,490 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

21st Century Cures Act (H.R. 6) and Senate HELP Committee provisions related to interoperability and information blocking Urging release of funding for Ebola preparedness and treatment Support for Protecting Seniors Access to Medicare Act of 2015 (H.R. 1190 and S.141) Support for Rural Hospital Access Act of 2015 (H.R. 663/S. 332) Support for Critical Access Hospital Relief Act of 2015 (H.R. 169/S. 258) Support for Protecting Access to Rural Therapies Act (H.R. 1611/S. 257) Support for Establishing Beneficiary Equity in the Hospital Readmission Program Act (H.R. 1343/S. 688) Support for Flexibility in Health IT Reporting Act of 2015 (H.R. 270) Support for Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/ S. 1148) Support for Medicare Audit Improvement Act of 2015 (H.R. 2156) Support for Two Midnight Rule Delay Act (H.R. 3698)/Two-Midnight Rule Coordination and Improvement Act of 2014 (S. 2082) Support for Craig Thomas Rural Hospital and Provider Equity Act (S. 2359) Support for Making the Education of Nurses Dependable for Schools (MEND) Act (H.R. 5227) Protecting 340B Drug Pricing Program in regulatory and legislative proposals Opposing Medicare and Medicaid Payment reductions, including those to Graduate Medical Education, bad debt payments, post-acute care payments, Disproportionate Share Hospital (DSH) payments, CAH payments, IPPS coding offset, rural hospital payments, hospital outpatient department (HOPD) clinics, and sequestration. Support for finalizing Medicare and Medicaid Electronic Health Record Incentive Payment Programs (Meaningful Use) 2015-2017 Modifications Rule; support for delaying of Stage 3 Rule Urging Release of New York State Medicaid Vital Access Provider Program Funding Support for changes to liver transplant allocation system

Client expense: $200,000 · Firm income: Not reported

H.R. 2513/S. 1099 "PACE Act of 2015" - Oppose efforts to repeal certain provisions relating to the limitation on the Medicare exception to the prohibition on certain physician referrals for hospitals and to transparency reports and reporting of physician ownership or investment interests. Bad Debt Payments to Hospitals - Lawmakers have proposed lowering the amount of Medicare Bad Debt payments to hospitals for Medicare beneficiaries who fail to pay their cost-sharing obligations for treatments provided by the hospital. Direct and Indirect Graduate Medical Education Payments - Lawmakers have proposed changes to the way that hospitals are reimbursed for the costs of training physicians and other medical professionals. H.R. 663/S.332 "Rural Hospital Access Act of 2015" - Advocate for the extension the Medicare Dependent Hospital (MDH) and current Low-Volume Hospital (LVH) programs. Oppose the lowering of Medicare outpatient site neutral proposal rates. Oppose the proposal of lowering Medicare reimbursements to Inpatient Rehabilitation Facilities. Sequestration - against extending the Medicare Sequester and oppose Medicare sequester increase and extension as an offset. Provided guidance on Medicare hospital payment reform legislative drafts: Medicare Crosswalk Hospital Code Development Act of 2015, Strengthening DSH and Medicare Through Subsidy Recapture and Payment Reform Act of 2015, Medicare Crosswalk IME Pool Act of 2015, and the Medicare Post-Acute Care Value-Based Purchasing Act of 2015-under consideration by the House Ways and Means Committee. H.R. 2156, "Medicare Audit Improvement Act of 2015" supports legislation to improve Medicare audits and provided comments to Senate Finance Committee to improve draft legislation. Price Transparency - advocate for meaningful price transparency for consumers by ensuring they have access to out of pocket price information. CMS "2 Midnight" Policy - advocate for policy to allow for physician judgment on whether a patient should be considered inpatient or outpatient status, and other modifications to the policy. Meaningful Use - Advocate for reasonable Stage 3 meaningful use requirements as part of the EHR Incentive Program. Provided advocacy comments regarding a House Ways and Means discussion draft, the Hospital Improvements for Payment Act of 2014 concerning hospital payment, self-referral, quality, accreditation and data release issue. Worked to restore funding for AHRQ and CMMI in the House Labor-HHS Appropriations Bill, H.R. 3020. Chronic Care -- provided comments and policy suggestions on Senate Finance Committee efforts to improve chronic care outcomes and treatments.

Critical Access Hospital (CAH) Relief Act of 2015 (S. 258/H.R. 169) Protecting Access to Rural Therapy Services (PARTS) Act (S. 257/H.R. 1611) Rural Hospital Access Act of 2015 (S. 332/H.R. 663) Community Hospital Demonstration Extension Act of 2015 (S. 607/H.R. 672) Act to Reform Recover Audit Contractors (RACs) (H.R. 2156) Rural Emergency Acute Care Hospital (REACH) Act (S. 1648) Save Rural Hospitals Act (H.R. 3225) Significant concerns with Iowa's proposed transition to Medicaid manged care Medicare reduction proposals in President Obama's budget released 2015 MedPAC recommendations for cuts to hospital payments avoiding site-neutral cuts recovery audit contractor (RAC) program and needed transparency and changes protecting critical access hospital funding and necessary provider status rural hospitals and access to care in Iowa encouraging value-based purchasing hospital acquired conditions and other quality measures Medicare formula and Iowa's payment compared to payments to other states Iowa hospital's economic impact to communities and the state beneficiary access throughout Iowa and threats from regulatory burdens and changes importance of 340B program to Iowa's hospitals sustainable growth rate fix and impact on hospitals in Iowa Meaningful use in EHR

Client expense: $65,000 · Firm income: Not reported

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

Health Care Reform Implementation 21st Century Cures Act, H.R. 6 Site Neutral payments Rural Hospital Access Act (S. 332/H.R. 663) H.R. 270, Flexibility in Health IT Reporting (Flex-IT) Act of 2015

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Internal Revenue Service (IRS), SENATE

S. 332, Rural Emergency Acute Care Hospital Act. H.R.3018, Code-FLEX Act of 2015. CMS-2390-P, Medicaid and Childrens Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability; Proposed Rule, June 1, 2015. CMS-1633-P, Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Proposed Rule (Vol. 80, No. 130), July 8, 2015. CMS-5516-P, Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services; Proposed Rule (Vol. 80, No. 134), July 14, 2015. CMS-1631-P, Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016 Proposed Rule, Federal Register (Vol. 80, No. 135), July 15, 2015. CMS-1625-P; Medicare Program; Home Health Prospective Payment System Proposed Rule Calendar Year 2016. Compounding Regulations, Notice of Proposed Modifications, Articles 4.5, 7 and 7.5 of Division 17 of Title 16 California Code of Regulations, Section 1735 et seq., 1751 et seq.,1752, 1753, and 1754. Emergency Regulation, Provider Network Adequacy, Filed January 20, 2015 OAL Emergency File Number: 2015-0120-03E Department of Insurance File Number: ER-2015-00001. Emergency Regulation, Provider Network Adequacy, Filed January 20, 2015 OAL Emergency File Number: 2015-0120-03E Department of Insurance File Number: ER-2015-00001.

Client expense: $259,400 · Firm income: Not reported

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. Provided data to Members of the Texas congressional delegation and their staff on the number of uninsured individuals in each district and statewide. Provided information on the uncompensated care burden in the state and how that impact the 1115 waiver renewal as well as the safety net in the state. Provided information to members of Congress and their staff on physician-owned hospitals. Provided education to members of Congress and their staff about the importance of adequate funding for the Hospital Preparedness Program. Provided education to Members of Congress and their staff about health insurance coverage expansion options in the state of Texas. 340B Drug Pricing Program - Educated staff on the 340B Drug Pricing Program and how hospitals are involved. Discussed recently released guidance from HRSA on the program and how changes to the definition of patient and qualified entity, are of concern to the hospitals in Texas, especially in relation to the states ban on the corporate practice of medicine. Trade Adjustment Assistance Program -Discussed with staff how THA cannot support the use of Medicare to pay for the trade adjustment assistance program, as was proposed in the trade promotion authority legislation. H.R.1343/S.688 - Would require CMS to take into account patients' sociodemographic status when imposing financial penalties for excessive hospital readmissions for Medicare patients. - Met with congressional staff on how socioeconomic status impacts health and the importance of this legislation, especially to large safety net hospitals. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. H.R. 2513 - PACE Act of 2015 - Would remove the prohibition on expansion of physician-owned hospitals. - Met with staff on the role these facilities play in the health care infrastructure compared to general acute care hospitals (treating healthier patients and less Medicare and Medicaid populations) and how physician-owned hospitals raise ethical concerns for cherry-picking patients and physician self-referral. H.R.3291 - Medicare Crosswalk Hospital Code Development Act of 2015 - Would create a Healthcare Common Procedure Classification System (HCPCS) version of MS-DRGs that will serve as a guide to connecting the inpatient and outpatient coding and payment systems for implementing site-neutral payments. - Educated staff on why the hospital industry cannot support site-neutral payments, as these policies do not take in to account a variety of factors that influence why a procedure is performed in a specific setting. H.R. 2646 - Helping Families in Mental Health Crisis Act of 2015 - Would make a variety of sweeping changes to the mental health infrastructure and while also reforming provider outreach, community-based treatment options, and justice system reform. - Discussed with staff how THA support the overall direction this bill would take the mental health system, and encouraged the use of community care in reforming the way we address mental health issues. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225

Provided education to Members of Congress and their staff about renewal of a Texas Medicaid 1115 demonstration waiver, the impact of Delivery System Reform Improvement Projects across the state and the role of hospitals in the waiver. Also provided information on the states 1115 waiver renewal application submitted to CMS in September and the timeline for negotiation over the next year. H.R.1343/S.688 - Would require CMS to take into account patients' sociodemographic status when imposing financial penalties for excessive hospital readmissions for Medicare patients. - Met with congressional staff on how socioeconomic status impacts health and the importance of this legislation, especially to large safety net hospitals. H.R.1479 - Repeal of the Obamacare Bay State Boondoogle Act - Would amend title XVIII of the Social Security Act to apply budget neutrality on a State-specific basis in the calculation of the Medicare hospital wage index floor for non-rural areas. - Discussed with congressional staff and members of Congress that provisions related to how the current Medicare Area Wage Index impacts hospitals in Texas, and how the implementation of a rural floor would help rural hospitals across the state and country. H.R.2156 - Medicare Audit Improvement Act of 2015 - Would replace the Recovery Audit Contractor (RAC) contingency fee structure with a flat fee to reduce the financial incentive for overzealous auditing practices; lowers payments for poor RAC performance; allows hospitals to rebill claims when appropriate; and requires RACs to base their inpatient claims decisions on only the information the physician had when treating the patient. - Discussed with congressional staff the burden the RACs put on hospitals and how RAC reform is necessary to improve efficiency and fairness. H.R. 2513 - PACE Act of 2015 - Would remove the prohibition on expansion of physician-owned hospitals. - Met with staff on the role these facilities play in the health care infrastructure compared to general acute care hospitals (treating healthier patients and less Medicare and Medicaid populations) and how physician-owned hospitals raise ethical concerns for cherry-picking patients and physician self-referral. H.R.3288 - Strengthening DSH and Medicare Through Subsidy Recapture and Payment Reform Act of 2015 - Would shift disproportionate share hospital (DSH) program payments to a lump sum, rather than per discharge add-on payments and increases DSH in states that have not expanded Medicaid. - Explained to congressional staff and members of Congress that hospitals would benefit from the bi-weekly payments proposed in this bill because there would be less delay in cash flow, but also expressed concerns for the offset proposed for the DHS pool for non-expansion states. This ACA subsidy recapture offset is an easy target to be cut in the future when Congress needs to find savings or a means to pay for another program in the future. H.R.3291 - Medicare Crosswalk Hospital Code Development Act of 2015 - Would create a Healthcare Common Procedure Classification System (HCPCS) version of MS-DRGs that will serve as a guide to connecting the inpatient and outpatient coding and payment systems for implementing site-neutral payments. - Educated staff on why the hospital industry cannot support site-neutral payments, as these policies do not take in to account a variety of factors that influence why a procedure is performed in a specific setting. H.R.3292 - Medicare IME Pool Act of 2015 - Would give teaching hospital a lump-sum payment to reimburse indirect medical education (IME) costs, instead of paying the hospital an additional percentage based on each inpatient case. - Discussed with congressional staff how the methodology proposed in HR3292 is redistributive and could benefit some hospitals in Texas while hurting others. Rural Hospital Issues: Discussed a variety of issues impacting rural and critical access hospitals with members of congress and their staff. Rural hospitals would greatly benefit from the passage of several pieces of legislation that would relieve onerous burdens and help the facilities better serve their communities. Specific legislation discussed includes: H.R.1479, S.1648, S.332, H.R.169/S.258, H.R.3225