Medicare Prescription Drug Price Negotiation Act of 2017

issues pertaining to Medicare and Medicaid. H.Res.215 Expressing the fact that the House of Representatives supports the system for prescription drug coverage provided under part D of the Medicare program and believes that changes to such system should not be part of the American Health Care Act of 2017;H.R.259 To prevent the territories of the United States from losing current Medicaid funding; S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family-Based Care Services Act of 2017;H.R.2263 - Medicaid and CHIP Territory Transparency and Information Act; HR 5685 Medicare Opiod Safety Ed Act 2018;HR 5686 Medicare Clear Health Options Enrollees Act 2018; HR 6341 Protect Seniors Medicare Act 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

issues pertaining to Medicare and Medicaid.S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family Based Care Act of 2017; HR 2263 Medicaid and CHIP Territory Transparency and Information Act;HR 3172 Medicare IVIG Demonstration Extension Act of 2017; HR3920 Medicare Demonstration Program to reduce Medicare hospital part A bad debt claims; HR 5685 Medicare Opiod Safety Education Act 2018; HR 5686 Medicare Clear Healthcare Options in Care for Enrollees Act 2018; HR 6341 Protect Seniors Act 2018; HRH.R.5942 Health Equity and Accountability Act of 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

HR 676 Expanded & Improved Medicare for All Act (all sections of full text) HR 1156 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) S 1133 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) Monitored Protecting Patients from Surprise Medical Bills Act (proposed legislation) Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S. 469, Affordable and Safe Prescription Drug Importation Act; H.R. 1245, Affordable and Safe Prescription Drug Importation Act; H.R. 1776, Improving Access to Affordable Prescription Drugs Act; S. 771, Improving Access to Affordable Prescription Drugs Act; H.R. 242, Medicare Prescription Drug Price Negotiation Act of 2017; S. 41, Medicare Prescription Drug Price Negotiation Act of 2017; Drug Pricing Transparency

Client expense: $240,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Centers For Medicare and Medicaid Services (CMS), Defense, Dept of (DOD), Drug Enforcement Administration (DEA), Environmental Protection Agency (EPA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), Office of Natl Drug Control Policy (NDCP), Office of Personnel Management (OPM), SENATE, Small Business Administration (SBA), Substance Abuse & Mental Health Services Administration (SAMHSA), White House Office

S. 870 - Chronic Care S. 251 - Protecting Medicare from Executive Action of 2017 H.R. 849/S. 260 - Protecting Seniors' Access to Medicare Act of 2017 H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017 S. 348 - Prescription Drug and Health Improvement Act of 2017 H.R. 1316 - Prescription Drug Price Transparency Act H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 3921 - Healthy Kids Act S. 1827 - Kids Act of 2017 ***, no specific bill(s), Medicare and Medicaid Drug Reimbursement, Medicaid Rebate, dual eligibles, Sunshine, discount cards, MedPAC, biosimilars, Alternative Payment Models, Value based Purchasing, coding, CMMI, Part B, Part D, non-interference, IPAB, donut hole, Part D cliff, prescription drug access and affordability

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

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

discount programs, pipeline, biosimilars, Part B demonstration, Part D, Noninterference, donut hole, Part D cliff, Rebates, CMM1 S. 251 - Protecting Medicare from Executive Action of 2017 S. 260/H.R. 849 - Protecting Seniors' Access to Medicare Act of 2017 H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017

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

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

HR 676 Expanded & Improved Medicare for All Act (all sections of full text) HR 1156 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) S 1133 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) Monitored Protecting Patients from Surprise Medical Bills Act (proposed legislation) Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S 41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

Client expense: Not reported · Firm income: $130,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

MR 695 - Appropriations legislation (provisions related to Medicaid) HR - 1148 Furthering Access to Stroke Telemedicine Act of 2017: To amend title XVIII of the Social Security Act to expand access to telehealth-eligible stroke services under the Medicare program. Griffith (R-VA) HR - 3178 Medicare Part B Improvement Act of 2017: To amend title XVIII of the Social Security Act to improve the delivery of home infusion therapy and dialysis and the application of the Stark rule under the Medicare program, and for other purposes. Brady (R-TX) HR - 3727 To amend title XVIII of the Social Security Act to include additional telehealth services for purposes of MA organization bids, and for other purposes. Black (R-TN). HR - 242 and S 41 - Medicare Prescription Drug Price Negotiation Act of 2017: To amend part D of title XVIII of the Social Security Act to require the Secretary of Health and Human Services to negotiate covered part D drug prices on behalf of Medicare beneficiaries. Welch (D-VT) & Klobuchar (D-MN). HR - 908 Medicare Advantage Quality Payment Relief Act of 2017: To amend title XVIII of the Social Security Act to eliminate a provision under the Medicare Advantage program that inadvertently penalizes Medicare Advantage plans for providing high quality care to Medicare beneficiaries. Kelly (R-PA) HR - 1995 To amend title XVIII of the Social Security to provide for national testing of a model of Medicare Advantage value-based insurance design to meet the needs of chronically ill Medicare Advantage enrollees. Black (R-TN) S 870 Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017: A bill to amend title XVIII of the Social Security Act to implement Medicare payment policies designed to improve management of chronic disease, streamline care coordination, and improve quality outcomes without adding to the deficit. No Sponsor Listed HR - 3636 Local Coverage Determination Clarification Act of 2018 S 2553 Know the Lowest Price Act S 3497 Medicare Advantage Quality Payment Relief Act

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

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

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided; Advocated with Congress on the need for adequate funding for the VHA for FY2019 and the long-term. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Health Information Technology (HIT): The College provided feedback on the Centers for Disease Control and Prevention (CDC) Request for Information (RFI) Regarding a National Test Collaborative (NTC), which sought approaches for developing a NTC that would allow for the field testing of health information technology (HIT) in a live clinical setting; expressed concern that building an entirely new testing network will be prohibitively difficult and execution could go wrong unless it is carefully designed, piloted, and tested. Emailing and conference calling with every level of every organization is labor intensive and getting participants engaged in this process will be an enormous effort; urged the need to address the patient privacy issues associated with production settings. These privacy issues may cause concern amongst hospitals and may prevent them from wanting to participate unless addressed; recommended that CDC consider building a CDC-Vendor-End User communication methodology that may be a more manageable undertaking utilizing existing infrastructures. Such a system could allow for CDC to notify EHR vendors who would notify product users when they receive an alert or guidance from CDC, using a process similar to how software updates are released. This approach does not require the sharing of protected health information nor does it require direct access into the production system. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians. 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP): Commented on CMS final rule on the 2019 PFS and QPP including - Urged additional refinements are needed to the final E/M documentation and payment policies to provide for immediate documentation relief, ensure the needs of complex patients are appropriately addressed, and avert negative downstream consequences; supports separate payment for technology-based communication services but urges the Agency to reconsider patient cost sharing and burdensome consent polices which may prevent uptake of these critical services; appreciates the burden relief that will result from allowing physicians to delegate Appropriate Use Criteria (AUC) consultations to appropriate clinical staff, but reiterates need to reimburse clinicians for the additional time required to conduct these consultations and pilot testing AUC in limited clinical priority areas before deploying on a larger scale to prevent widespread payment disruptions. With regard to QPP, urged greater simplifying of MIPS scoring by basing point values for individual measures on their relative value to the total MIPS score, taking every opportunity to award cross category credit, and instituting a consistent minimum 90-day reporting period across all categories; develop more Advanced APMs, particularly for small and specialty practices; opposes the use of cost measures that are deemed unreliable or inaccurate and urges CMS not to increase the weight of the Cost Category until every measure meets rigorous reliability and accuracy standards; reduce overall number of quality measures and use only those deemed valid, relevant, and reliable, such as those recommended by ACPs Performance Measurement Committee. Public Charge: The College provided comments on the Department of Homeland Securitys Notice of Proposed Rulemaking: Inadmissibility on Public Charge Grounds (DHS Docket No. USCIS-2010-0012). ACP oppose the DHS proposed rule on public charge because if finalized it would put the health of millions of children and families at risk. The proposed changes would expand the number of programs that the federal government would consider in public charge determinations to include Medicaid, the Medicare Part D Low-Income Subsidy Program, the Supplemental Nutrition Assistance Program, and potentially the Childrens Health Insurance Program (CHIP), among others. By widening public charge determinations in this way, the proposed rule would make it much more likely that lawfully present immigrants and those seeking to lawfully immigrate to the U.S. could be denied lawful permanent resident status, be denied visas, or even be deported, merely on the basis of seeking essential health, nutrition, and housing services for themselves or their families. The proposed rule would undermine the physician-patient relationship and disrupt care continuity, and it is antithetical to the Colleges mission to ensure meaningful access to health care for our patients. Immigrant Children and Pregnant Women in U.S. Custody: The College commented to the U.S. Department of Homeland Security that conditions in the U.S. Customs and Border Protection (CBP) custody are inconsistent with evidence-based recommendations for appropriate care and treatment of children and pregnant women. As such, they are not appropriate for children or pregnant women. ACP calls for a full, transparent, and public investigation of Jakelin Caal Maquins (from Guatemala) death and the circumstances surrounding it, as well as any other deaths that may have occurred in CBP or Immigration and Customs Enforcement custody. The College strongly urges the Department of Homeland Security (DHS) to implement specific meaningful steps to ensure that all children and pregnant women in CBP custody receive appropriate medical and mental health screening and necessary follow-up care by trained providers.

Client expense: $249,755 · Firm income: Not reported

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

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided; Advocated with Congress on the need for adequate funding for the VHA for FY2019 and the long-term. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Health Information Technology (HIT): The College provided feedback on the Centers for Disease Control and Prevention (CDC) Request for Information (RFI) Regarding a National Test Collaborative (NTC), which sought approaches for developing a NTC that would allow for the field testing of health information technology (HIT) in a live clinical setting; expressed concern that building an entirely new testing network will be prohibitively difficult and execution could go wrong unless it is carefully designed, piloted, and tested. Emailing and conference calling with every level of every organization is labor intensive and getting participants engaged in this process will be an enormous effort; urged the need to address the patient privacy issues associated with production settings. These privacy issues may cause concern amongst hospitals and may prevent them from wanting to participate unless addressed; recommended that CDC consider building a CDC-Vendor-End User communication methodology that may be a more manageable undertaking utilizing existing infrastructures. Such a system could allow for CDC to notify EHR vendors who would notify product users when they receive an alert or guidance from CDC, using a process similar to how software updates are released. This approach does not require the sharing of protected health information nor does it require direct access into the production system. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians. 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP): Commented on CMS final rule on the 2019 PFS and QPP including - Urged additional refinements are needed to the final E/M documentation and payment policies to provide for immediate documentation relief, ensure the needs of complex patients are appropriately addressed, and avert negative downstream consequences; supports separate payment for technology-based communication services but urges the Agency to reconsider patient cost sharing and burdensome consent polices which may prevent uptake of these critical services; appreciates the burden relief that will result from allowing physicians to delegate Appropriate Use Criteria (AUC) consultations to appropriate clinical staff, but reiterates need to reimburse clinicians for the additional time required to conduct these consultations and pilot testing AUC in limited clinical priority areas before deploying on a larger scale to prevent widespread payment disruptions. With regard to QPP, urged greater simplifying of MIPS scoring by basing point values for individual measures on their relative value to the total MIPS score, taking every opportunity to award cross category credit, and instituting a consistent minimum 90-day reporting period across all categories; develop more Advanced APMs, particularly for small and specialty practices; opposes the use of cost measures that are deemed unreliable or inaccurate and urges CMS not to increase the weight of the Cost Category until every measure meets rigorous reliability and accuracy standards; reduce overall number of quality measures and use only those deemed valid, relevant, and reliable, such as those recommended by ACPs Performance Measurement Committee. Public Charge: The College provided comments on the Department of Homeland Securitys Notice of Proposed Rulemaking: Inadmissibility on Public Charge Grounds (DHS Docket No. USCIS-2010-0012). ACP oppose the DHS proposed rule on public charge because if finalized it would put the health of millions of children and families at risk. The proposed changes would expand the number of programs that the federal government would consider in public charge determinations to include Medicaid, the Medicare Part D Low-Income Subsidy Program, the Supplemental Nutrition Assistance Program, and potentially the Childrens Health Insurance Program (CHIP), among others. By widening public charge determinations in this way, the proposed rule would make it much more likely that lawfully present immigrants and those seeking to lawfully immigrate to the U.S. could be denied lawful permanent resident status, be denied visas, or even be deported, merely on the basis of seeking essential health, nutrition, and housing services for themselves or their families. The proposed rule would undermine the physician-patient relationship and disrupt care continuity, and it is antithetical to the Colleges mission to ensure meaningful access to health care for our patients. Immigrant Children and Pregnant Women in U.S. Custody: The College commented to the U.S. Department of Homeland Security that conditions in the U.S. Customs and Border Protection (CBP) custody are inconsistent with evidence-based recommendations for appropriate care and treatment of children and pregnant women. As such, they are not appropriate for children or pregnant women. ACP calls for a full, transparent, and public investigation of Jakelin Caal Maquins (from Guatemala) death and the circumstances surrounding it, as well as any other deaths that may have occurred in CBP or Immigration and Customs Enforcement custody. The College strongly urges the Department of Homeland Security (DHS) to implement specific meaningful steps to ensure that all children and pregnant women in CBP custody receive appropriate medical and mental health screening and necessary follow-up care by trained providers.

Client expense: $92,631 · Firm income: Not reported

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

General Medicare Protection, Prevention of Fraud, Waste, and Abuse: H.R. 2460 and H.R. 4841 and H.R. 4704, Prescription Drug Re-Importation: S. 92 and S. 469 and H.R. 1245, Negotiation of Prescription Drug Prices: H.R. 242 and S. 41, General Prescription Drug Affordability: S. 124 and S. 771 and H.R. 1776 and H.R. 4138 and H.R. 4116 and H.R. 4117 and S. 2011 and S. 974 and H.R. 2212 and S. 2553, Medicare Enrollment Simplification: H.R. 2575 and S. 1909, Expanding Medicare Coverage: H.R. 5083 and H.R. 4957 and S. 2387 and H.R. 807 and H.R. 3098 and H.R. 4701 and H.R. 508 and H.R. 2276 and S. 2575 and H.R. 5083.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Care Reform Legislation HR1628 Access to Affordable Prescription Drugs Medicare Prescription Drug Price Negotiation Act HR 242 Protecting Medicare from executive Action S 251 Medicare Prescription Drug Price Negotiation Act S 41 Race for Children Act HR 1231

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

Government targets: Administration for Children & Families (ACF), HOUSE OF REPRESENTATIVES, SENATE

Discussions involving nominations to federally authorized commissions HR 676 Expanded & Improved Medicare for All Act (all sections of full text) HR 1156 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) S 1133 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) Monitored Protecting Patients from Surprise Medical Bills Act (proposed legislation) Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation H.R. 1316: Prescription Drug Price Transparency Act - Provisions related to transparency of payment methodologies H.R. 3635: Local Coverage Deteremination Clarification Act of 2018 H.R. 4005: Medicaid Reentry Act H.R. 5150: Protecting Medicare from Excessive Price Increases Act of 2018 - To require drug manufacturers to pay a Medicare part B rebate for certain drugs H.R. 5675: To amend title XVIII of the Social Security Act to require prescription drug plan sponsors under the Medicare program to establish drug management programs for at-risk beneficiaries. H.R. 5797: Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Executive Act H.R. 5799: Medicaid Drug Review, Utilization, Good Governance Improvement Act H.R. 5801: Medicaid PARTNERSHIP Act H.R. 5808: Medicaid Pharmaceutical Home Act of 2018 H.R. 6505: Medicare Negotiation and Competitive Licensing Act of 2018 H.R. 6642: To amend title XIX of the Social Security Act to sunset the limit on the maximum rebate amount for single source drugs and innovator multiple source drugs H.R. __: To amend title XIX of the Social Security Act to provide the Medicare Payment Advisory Commission with access to certain drug rebate information S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation S. 348: Prescription Drug and Health Improvement Act of 2017 - Provisions related to Part D S. 637: Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act of 2017 - Provisions related to transparency of prescription drug pricing and pharmacy benefit managers S. 870: CHRONIC Care Act of 2017 - Provisions related to Medicare and chronic care S. 1348: Stopping the Pharmaceutical Industry from Keeping Drugs Expensive (SPIKE) Act of 2017 - Provisions related to increases in the wholesale acquisition costs of prescription drugs S. 1688: Empowering Medicare Seniors to Negotiate Drugs Prices Act of 2017 - Part D and non-interference provisions S. 3000: Patient Advocacy Transparency Act - Social Security Act amendments Department of Health and Human Services (HHS) drug policy issues and regulatory policy issues Part D policy issues including non-interference and rebates policy issues Part B reform including MedPAC recommendations and other policy issues and local coverage decisions Drug cost and pricing policy issues Transparency policy issues Alternative payment models policy issues Value-based purchasing arrangements policy issues Anti-Kickback Statute policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues Medicaid rebates and waiver policy issues Prescription drug abuse policy issues Final Rule; Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC) - Revisions to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018 Proposed Rule; Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P) Request for Information: Medicare and State Health Care Programs: Fraud and Abuse; Request for Information Regarding the Anti-Kickback Statute and Beneficiary Inducements CMP; 83 Fed. Reg. 43607 (Aug. 27, 2018) Removal of Safe Harbor Protection for Rebates to Plans or PBMs Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection (RIN 0936-AA08) Medicare Part D Doughnut Hole Medicare Part D Cliff S 974/HR 2212 - CREATES Act340B Drug Pricing Program Medicare Part D Six Protected Classes

Client expense: $1,130,000 · Firm income: Not reported

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

H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation H.R. 1316: Prescription Drug Price Transparency Act - Provisions related to transparency of payment methodologies H.R. 3192: CHIP Mental Health Parity Act H.R. 3635: Local Coverage Determination Clarification Act of 2018 H.R. 4005: Medicaid Reentry Act H.R. 5150: Protecting Medicare from Excessive Price Increases Act of 2018 - To require drug manufacturers to pay a Medicare part B rebate for certain drugs H.R. 5590: Opioid Addiction Action Plan Act H.R. 5605: Advancing High Quality Treatment for Opioid Use Disorders in Medicare Act H.R. 5675: To amend title XVIII of the Social Security Act to require prescription drug plan sponsors under the Medicare program to establish drug management programs for at-risk beneficiaries. H.R. 5797: Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Executive Act H.R. 5799: Medicaid Drug Review, Utilization, Good Governance Improvement Act H.R. 5801: Medicaid PARTNERSHIP Act H.R. 5808: Medicaid Pharmaceutical Home Act of 2018 H.R. 5810: Medicaid Health Homes for Opioid-Use-Disorder Medicaid Enrollees Encouraged Act H.R. 6505: Medicare Negotiation and Competitive Licensing Act of 2018 H.R. 6642: To amend title XIX of the Social Security Act to sunset the limit on the maximum rebate amount for single source drugs and innovator multiple source drugs H.R. __: To amend title XIX of the Social Security Act to provide the Medicare Payment Advisory Commission with access to certain drug rebate information S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation S. 348: Prescription Drug and Health Improvement Act of 2017 - Provisions related to Part D S. 637: Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act of 2017 - Provisions related to transparency of prescription drug pricing and pharmacy benefit managers S. 870: CHRONIC Care Act of 2017 - Provisions related to Medicare and chronic care S. 1348: Stopping the Pharmaceutical Industry from Keeping Drugs Expensive (SPIKE) Act of 2017 - Provisions related to increases in the wholesale acquisition costs of prescription drugs S. 1688: Empowering Medicare Seniors to Negotiate Drugs Prices Act of 2017 - Part D and non-interference provisions S. 3000: Patient Advocacy Transparency Act - Social Security Act amendments Medicare Access and Childrens Health Insurance Program (CHIP) reauthorization policy issues Department of Health and Human Services (HHS) drug policy issues and regulatory policy issues Part D policy issues including non-interference and rebates policy issues Part B reform including MedPAC recommendations and other policy issues and local coverage decisions Drug cost and pricing policy issues Transparency policy issues Alternative payment models policy issues Value-based purchasing arrangements policy issues Anti-Kickback Statute policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues Medicaid rebates and waiver policy issues Prescription drug abuse policy issues Final Rule; Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC) - Revisions to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018 Proposed Rule; Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P) Request for Information: Medicare and State Health Care Programs: Fraud and Abuse; Request for Information Regarding the Anti-Kickback Statute and Beneficiary Inducements CMP; 83 Fed. Reg. 43607 (Aug. 27, 2018) Removal of Safe Harbor Protection for Rebates to Plans or PBMs Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection (RIN 0936-AA08)

Client expense: $5,990,000 · Firm income: Not reported

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

issues pertaining to Medicare and Medicaid.S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family Based Care Act of 2017; HR 2263 Medicaid and CHIP Territory Transparency and Information Act;HR 3172 Medicare IVIG Demonstration Extension Act of 2017; HR3920 Medicare Demonstration Program to reduce Medicare hospital part A bad debt claims; HR 5685 Medicare Opiod Safety Education Act 2018; HR 5686 Medicare Clear Healthcare Options in Care for Enrollees Act 2018; HR 6341 Protect Seniors Act 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

issues pertaining to Medicare and Medicaid. H.Res.215 Expressing the fact that the House of Representatives supports the system for prescription drug coverage provided under part D of the Medicare program and believes that changes to such system should not be part of the American Health Care Act of 2017;H.R.259 To prevent the territories of the United States from losing current Medicaid funding; S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family-Based Care Services Act of 2017;H.R.2263 - Medicaid and CHIP Territory Transparency and Information Act; HR 5685 Medicare Opiod Safety Ed Act 2018;HR 5686 Medicare Clear Health Options Enrollees Act 2018; HR 6341 Protect Seniors Medicare Act 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Discussions involving nominations to federally authorized commissions HR 676 Expanded & Improved Medicare for All Act (all sections of full text) HR 1156 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) S 1133 Patient Access to Higher Quality Health Care Act of 2017 (all sections of full text) Monitored Protecting Patients from Surprise Medical Bills Act (proposed legislation) Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S 41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

Client expense: Not reported · Firm income: $130,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

HR - 1892 Bipartisan Budget Act of 2018. Larson (D-CT) HR - 849 Protecting Seniors' Access to Medicare Act of 2017: To repeal the provisions of the Patient Protection and Affordable Care Act providing for the Independent Payment Advisory Board. Roe (R-TN). HR - 1148 Furthering Access to Stroke Telemedicine Act of 2017: To amend title XVIII of the Social Security Act to expand access to telehealth-eligible stroke services under the Medicare program. Griffith (R-VA) HR - 3178 Medicare Part B Improvement Act of 2017: To amend title XVIII of the Social Security Act to improve the delivery of home infusion therapy and dialysis and the application of the Stark rule under the Medicare program, and for other purposes. Brady (R-TX) HR - 3727 To amend title XVIII of the Social Security Act to include additional telehealth services for purposes of MA organization bids, and for other purposes. Black (R-TN). HR - 242 and S 41 - Medicare Prescription Drug Price Negotiation Act of 2017: To amend part D of title XVIII of the Social Security Act to require the Secretary of Health and Human Services to negotiate covered part D drug prices on behalf of Medicare beneficiaries. Welch (D-VT) & Klobuchar (D-MN). HR - 908 Medicare Advantage Quality Payment Relief Act of 2017: To amend title XVIII of the Social Security Act to eliminate a provision under the Medicare Advantage program that inadvertently penalizes Medicare Advantage plans for providing high quality care to Medicare beneficiaries. Kelly (R-PA) HR - 1995 To amend title XVIII of the Social Security to provide for national testing of a model of Medicare Advantage value-based insurance design to meet the needs of chronically ill Medicare Advantage enrollees. Black (R-TN) S 870 Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017: A bill to amend title XVIII of the Social Security Act to implement Medicare payment policies designed to improve management of chronic disease, streamline care coordination, and improve quality outcomes without adding to the deficit. No Sponsor Listed HR - 3636 Local Coverage Determination Clarification Act of 2018 S 2553 Know the Lowest Price Act S 3497 Medicare Advantage Quality Payment Relief Act

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

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

S. 870 - Chronic Care S. 251 - Protecting Medicare from Executive Action of 2017 H.R. 849/S. 260 - Protecting Seniors' Access to Medicare Act of 2017 H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017 S. 348 - Prescription Drug and Health Improvement Act of 2017 H.R. 1316 - Prescription Drug Price Transparency Act H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 3921 - Healthy Kids Act S. 1827 - Kids Act of 2017 ***, no specific bill(s), Medicare and Medicaid Drug Reimbursement, Medicaid Rebate, dual eligibles, Sunshine, discount cards, MedPAC, biosimilars, Alternative Payment Models, Value based Purchasing, coding, CMMI, Part B, Part D, non-interference, IPAB, donut hole, Part D cliff, prescription drug access and affordability

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

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

discount programs, hepatitis C, Sunshine, pipeline, biosimilars, Part B demonstration, Part D, Noninterference, donut hole, Part D cliff, Rebates, CMM1 S. 251 - Protecting Medicare from Executive Action of 2017 S. 260/H.R. 849 - Protecting Seniors' Access to Medicare Act of 2017 H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017

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

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

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Medicare Physician Payment Reform: Advocated in support of H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was enacted in April 2015 and repealed Medicares Sustainable Growth Rate (SGR) formula and moved us to a new value-based payment and delivery system under Medicare; Advocated with CMS on numerous aspects of the MACRA proposed and final rules, including: proposing a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments; proposing specific alternatives to CMS Advancing Care Information program that replaced the Meaningful Use program; proposing additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Improvement Activities categories; urging CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available; proposing more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category; Proposing four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk: Advocated with CMS on Patient Relationship Categories and Codes, as required by MACRA, specifically: that CMS work to ensure that patients, families, and the relationship of patients and families with their physicians are at the forefront of the Agencys thinking in the development of both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways; that the implementation of these categories and codes is carried out in a manner that fully considers and minimizes the impact of reporting burden on the participating clinicians and that has appropriate flexibility to allow for learning and improvement in the approach by both the Agency and the clinicians. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Under the Affordable Care Act, advocated to ensure that people residing in states with health insurance marketplaces operated by the federal government do not lose their cost-sharing reduction subsidies (CSRs) and that those CSRs should be continued indefinitely as part of a larger bipartisan effort to stabilize the individual insurance market. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided; Advocated with Congress on the need for adequate funding for the VHA for FY2019 and the long-term. Immigration: Voiced support to Congress on the need to pass the Development, Relief, and Education for Alien Minors (DREAM) Act of 2017, H.R. 3440. This legislation would establish a three-step pathway to U.S. citizenship through college, work, or the armed services for individuals who were born in another country and brought illegally to the U.S. at a young age (DREAMers). Clinical Labs: Commented to the Centers for Medicare and Medicaid Services (CMS) on issues pertaining to the Protecting Access to Medicare Act of 2014 (PAMA), specifically citing concerns about the potential impacts of PAMA on patient access to critical rapid clinical testing services offered to patients while they are receiving medical care in their physicians office; expressed further concerns about impending cuts on Jan. 1, 2018 for physician office-based testing services. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Repeal the Dickey amendment restricting firearms-related research by federal agencies and support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians. Title X Regulations: Commented to HHS in July on the proposed rule to revise Title X regulations (Title X of the Public Health Service Act) to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where pregnancy termination is a method of family planning and related statutory requirements. The College asserts that women should have sufficient access to evidence-based family planning and sexual health information and the full range of medically accepted forms of contraception. The College opposes government restrictions that would erode or abrogate a woman's right to continue or discontinue a pregnancy. The College opposes any legislation or regulations that limit access to comprehensive reproductive health care by putting medically unnecessary restrictions on health care professionals or facilities. Kentucky Health Waiver: The College commented to CMS on Kentuckys Health Waiver expressing concern that: it would impose a substantial monthly premium on Medicaid beneficiaries; would also create a six-month lock-out period for certain enrollees who do not pay their premiums on time, which is unduly harsh; that proposed work requirements will impose an unnecessary and unjustified burden on patients to document that they are eligible for an exemption and an unnecessary and unjustified burden on physicians who may be asked to attest that their patients have an exempted medical condition. 2019 Physician Fee Schedule and Quality Payment Program: Advocated to CMS that: cognitive care of more complex patients must be recognized with higher allowed payment rates than less complex care patients; supports the overall direction of CMS's proposal to reduce the burden of documentation for E/M services, but strongly disagrees that such improvements should be contingent on acceptance of the proposal to pay a single flat fee for levels 2-5; CMS not establish a regulatory deadline (e.g. January 1, 2019 or January 1, 2020) for finalizing and implementing its flat fee E/M proposals or possible alternatives that change how E/M services would be paid; calls on CMS to move forward with implementation of their proposal to simplify E/M documentation requirements effective January 1, 2019, while alternatives to the flat fee structure are being developed and pilot-tested; supports implementation on January 1, 2019 of proposals to pay for virtual check-ins, other telehealth and technology-based services, and prolonged face-to-face visits. Short-Term Health Plans: Urged Congress to support the joint resolutions disapproving of the rule related to short-term, limited-duration insurance, as published in the federal register on August 3, 2018, that such rule shall have no force or effect.

Client expense: $279,872 · Firm income: Not reported

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

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Medicare Physician Payment Reform: Advocated in support of H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was enacted in April 2015 and repealed Medicares Sustainable Growth Rate (SGR) formula and moved us to a new value-based payment and delivery system under Medicare; Advocated with CMS on numerous aspects of the MACRA proposed and final rules, including: proposing a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments; proposing specific alternatives to CMS Advancing Care Information program that replaced the Meaningful Use program; proposing additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Improvement Activities categories; urging CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available; proposing more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category; Proposing four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk: Advocated with CMS on Patient Relationship Categories and Codes, as required by MACRA, specifically: that CMS work to ensure that patients, families, and the relationship of patients and families with their physicians are at the forefront of the Agencys thinking in the development of both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways; that the implementation of these categories and codes is carried out in a manner that fully considers and minimizes the impact of reporting burden on the participating clinicians and that has appropriate flexibility to allow for learning and improvement in the approach by both the Agency and the clinicians. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Under the Affordable Care Act, advocated to ensure that people residing in states with health insurance marketplaces operated by the federal government do not lose their cost-sharing reduction subsidies (CSRs) and that those CSRs should be continued indefinitely as part of a larger bipartisan effort to stabilize the individual insurance market. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided; Advocated with Congress on the need for adequate funding for the VHA for FY2019 and the long-term. Immigration: Voiced support to Congress on the need to pass the Development, Relief, and Education for Alien Minors (DREAM) Act of 2017, H.R. 3440. This legislation would establish a three-step pathway to U.S. citizenship through college, work, or the armed services for individuals who were born in another country and brought illegally to the U.S. at a young age (DREAMers). Clinical Labs: Commented to the Centers for Medicare and Medicaid Services (CMS) on issues pertaining to the Protecting Access to Medicare Act of 2014 (PAMA), specifically citing concerns about the potential impacts of PAMA on patient access to critical rapid clinical testing services offered to patients while they are receiving medical care in their physicians office; expressed further concerns about impending cuts on Jan. 1, 2018 for physician office-based testing services. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Repeal the Dickey amendment restricting firearms-related research by federal agencies and support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians. Title X Regulations: Commented to HHS in July on the proposed rule to revise Title X regulations (Title X of the Public Health Service Act) to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where pregnancy termination is a method of family planning and related statutory requirements. The College asserts that women should have sufficient access to evidence-based family planning and sexual health information and the full range of medically accepted forms of contraception. The College opposes government restrictions that would erode or abrogate a woman's right to continue or discontinue a pregnancy. The College opposes any legislation or regulations that limit access to comprehensive reproductive health care by putting medically unnecessary restrictions on health care professionals or facilities. Kentucky Health Waiver: The College commented to CMS on Kentuckys Health Waiver expressing concern that: it would impose a substantial monthly premium on Medicaid beneficiaries; would also create a six-month lock-out period for certain enrollees who do not pay their premiums on time, which is unduly harsh; that proposed work requirements will impose an unnecessary and unjustified burden on patients to document that they are eligible for an exemption and an unnecessary and unjustified burden on physicians who may be asked to attest that their patients have an exempted medical condition. 2019 Physician Fee Schedule and Quality Payment Program: Advocated to CMS that: cognitive care of more complex patients must be recognized with higher allowed payment rates than less complex care patients; supports the overall direction of CMS's proposal to reduce the burden of documentation for E/M services, but strongly disagrees that such improvements should be contingent on acceptance of the proposal to pay a single flat fee for levels 2-5; CMS not establish a regulatory deadline (e.g. January 1, 2019 or January 1, 2020) for finalizing and implementing its flat fee E/M proposals or possible alternatives that change how E/M services would be paid; calls on CMS to move forward with implementation of their proposal to simplify E/M documentation requirements effective January 1, 2019, while alternatives to the flat fee structure are being developed and pilot-tested; supports implementation on January 1, 2019 of proposals to pay for virtual check-ins, other telehealth and technology-based services, and prolonged face-to-face visits. Short-Term Health Plans: Urged Congress to support the joint resolutions disapproving of the rule related to short-term, limited-duration insurance, as published in the federal register on August 3, 2018, that such rule shall have no force or effect.

Client expense: $97,099 · Firm income: Not reported

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

S. 469, Affordable and Safe Prescription Drug Importation Act; H.R. 1245, Affordable and Safe Prescription Drug Importation Act; H.R. 1776, Improving Access to Affordable Prescription Drugs Act; S. 771, Improving Access to Affordable Prescription Drugs Act; H.R. 242, Medicare Prescription Drug Price Negotiation Act of 2017; S. 41, Medicare Prescription Drug Price Negotiation Act of 2017; Drug Pricing Transparency

Client expense: $290,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Centers For Medicare and Medicaid Services (CMS), Defense, Dept of (DOD), Drug Enforcement Administration (DEA), Environmental Protection Agency (EPA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), Office of Natl Drug Control Policy (NDCP), Office of Personnel Management (OPM), SENATE, Small Business Administration (SBA), Substance Abuse & Mental Health Services Administration (SAMHSA), White House Office

General Medicare Protection, Prevention of Fraud, Waste, and Abuse: H.R. 2460 and H.R. 4841 and H.R. 4704, Prescription Drug Re-Importation: S. 92 and S. 469 and H.R. 1245, Negotiation of Prescription Drug Prices: H.R. 242 and S. 41, General Prescription Drug Affordability: S. 124 and S. 771 and H.R. 1776 and H.R. 4138 and H.R. 4116 and H.R. 4117 and S. 2011 and S. 974 and H.R. 2212 and S. 2553, Medicare Enrollment Simplification: H.R. 2575 and S. 1909, Expanding Medicare Coverage: H.R. 5083 and H.R. 4957 and S. 2387 and H.R. 807 and H.R. 3098 and H.R. 4701 and H.R. 508 and H.R. 2276 and S. 2575 and H.R. 5083.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Care Reform Legislation HR1628 Access to Affordable Prescription Drugs Medicare Prescription Drug Price Negotiation Act HR 242 Protecting Medicare from executive Action S 251 Medicare Prescription Drug Price Negotiation Act S 41 Race for Children Act HR 1231

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

Government targets: Administration for Children & Families (ACF), HOUSE OF REPRESENTATIVES, SENATE

discount programs, hepatitis C, Sunshine, pipeline, biosimilars, Part B demonstration, Part D, Noninterference, donut hole, Part D cliff, Rebates, CMM1 S. 251 - Protecting Medicare from Executive Action of 2017 S. 260/H.R. 849 - Protecting Seniors' Access to Medicare Act of 2017 H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017

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

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

Part D doughnut holeHouse and Senate Labor HHS Subcommittee appropriations House and Senate DoD Subcommittee appropriations H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation Part D policy issues including non-interference and rebates policy issues Drug cost and pricing policy issues Transparency policy issues Value-based purchasing arrangements policy issues Anti-Kickback Statute policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues

Client expense: $1,400,000 · Firm income: Not reported

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

HR 1892 - Bipartisan Budget Act of 2018. Larson (D-CT) HR 849 - Protecting Seniors' Access to Medicare Act of 2017: To repeal the provisions of the Patient Protection and Affordable Care Act providing for the Independent Payment Advisory Board. Roe (R-TN). HR 1148 - Furthering Access to Stroke Telemedicine Act of 2017: To amend title XVIII of the Social Security Act to expand access to telehealth-eligible stroke services under the Medicare program. Griffith (R-VA) H.R.3178 - Medicare Part B Improvement Act of 2017: To amend title XVIII of the Social Security Act to improve the delivery of home infusion therapy and dialysis and the application of the Stark rule under the Medicare program, and for other purposes. Brady (R-TX) HR 3727 - To amend title XVIII of the Social Security Act to include additional telehealth services for purposes of MA organization bids, and for other purposes. Black (R-TN). HR 242 and S 41 - Medicare Prescription Drug Price Negotiation Act of 2017: To amend part D of title XVIII of the Social Security Act to require the Secretary of Health and Human Services to negotiate covered part D drug prices on behalf of Medicare beneficiaries. Welch (D-VT) & Klobuchar (D-MN). HR 908 - Medicare Advantage Quality Payment Relief Act of 2017: To amend title XVIII of the Social Security Act to eliminate a provision under the Medicare Advantage program that inadvertently penalizes Medicare Advantage plans for providing high quality care to Medicare beneficiaries. Kelly (R-PA) HR 1995 - To amend title XVIII of the Social Security to provide for national testing of a model of Medicare Advantage value-based insurance design to meet the needs of chronically ill Medicare Advantage enrollees. Black (R-TN) S 870 - Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2017: A bill to amend title XVIII of the Social Security Act to implement Medicare payment policies designed to improve management of chronic disease, streamline care coordination, and improve quality outcomes without adding to the deficit. No Sponsor Listed

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

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

discount programs, hepatitis C, Sunshine, pipeline, biosimilars, Part B demonstration, Part D, Noninterference, donut hole, Part D cliff, Rebates, CMM1 S. 251 - Protecting Medicare from Executive Action of 2017 S. 260/H.R. 849 - Protecting Seniors' Access to Medicare Act of 2017 H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017 H.R. 3921 - Healthy Kids Act S. 1827 - KIDS Act of 2017 H.R. 3922 - Championing Healthy Kids Act

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

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

Discussions involving nominations to federally authorized commissions Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S. 870 - Chronic Care S. 251 - Protecting Medicare from Executive Action of 2017 H.R. 849/S. 260 - Protecting Seniors' Access to Medicare Act of 2017 H.R. 242/S. 41 - Medicare Prescription Drug Price Negotiation Act of 2017 S. 348 - Prescription Drug and Health Improvement Act of 2017 H.R. 1316 - Prescription Drug Price Transparency Act H.J.Res. 51/S.J.Res. 16 - IPAB discontinuation H.R. 3921 - Healthy Kids Act S. 1827 - Kids Act of 2017 ***, no specific bill(s), Medicare and Medicaid Drug Reimbursement, Medicaid Rebate, dual eligibles, Sunshine, discount cards, MedPAC, biosimilars, Alternative Payment Models, Value based Purchasing, coding, CMMI, Part B, Part D, non-interference, IPAB, donut hole, Part D cliff, prescription drug access and affordability

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

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

H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation H.R. 1316: Prescription Drug Price Transparency Act - Provisions related to transparency of payment methodologies H.R. 3192: CHIP Mental Health Parity Act H.R. 4005: Medicaid Reentry Act H.R. 5590: Opioid Addiction Action Plan Act H.R. 5605: Advancing High Quality Treatment for Opioid Use Disorders in Medicare Act H.R. 5675: To amend title XVIII of the Social Security Act to require prescription drug plan sponsors under the Medicare program to establish drug management programs for at-risk beneficiaries. H.R. 5797: Individuals in Medicaid Deserve Care that is Appropriate and Responsible in its Executive Act H.R. 5799: Medicaid Drug Review, Utilization, Good Governance Improvement Act H.R. 5801: Medicaid PARTNERSHIP Act H.R. 5808: Medicaid Pharmaceutical Home Act of 2018 H.R. 5810: Medicaid Health Homes for Opioid-Use-Disorder Medicaid Enrollees Encouraged Act H. Res. 949: Providing for consideration of the bill (H.R. 6) to provide for opioid use disorder prevention, recovery, and treatment, and for other purposes; providing for consideration of the bill (H.R. 5797) to amend title XIX of the Social Security Act to allow States to provide under Medicaid services for certain individuals with opioid use disorders in institutions for mental diseases; and providing for consideration of the bill (H.R. 6082) to amend the Public Health Service Act to protect the confidentiality of substance use disorder patient records S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation S. 348: Prescription Drug and Health Improvement Act of 2017 - Provisions related to Part D S. 637: Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act of 2017 - Provisions related to transparency of prescription drug pricing and pharmacy benefit managers S. 870: CHRONIC Care Act of 2017 - Provisions related to Medicare and chronic care S. 1348: Stopping the Pharmaceutical Industry from Keeping Drugs Expensive (SPIKE) Act of 2017 - Provisions related to increases in the wholesale acquisition costs of prescription drugs S. 1688: Empowering Medicare Seniors to Negotiate Drugs Prices Act of 2017 - Part D and non-interference provisions Medicare Access and Childrens Health Insurance Program (CHIP) reauthorization policy issues Department of Health and Human Services (HHS) drug policy issues and regulatory policy issues Part D policy issues including non-interference and rebates policy issues Part B reform including MedPAC recommendations and other policy issues Drug cost and pricing policy issues Transparency policy issues Alternative payment models policy issues Value-based purchasing arrangements policy issues Anti-Kickback Statute policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues Medicaid rebates and waiver policy issues Prescription drug abuse policy issues Final Rule; Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC) - Revisions to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018 Proposed Rule: Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P)

Client expense: $5,540,000 · Firm income: Not reported

Government targets: Centers For Medicare and Medicaid Services (CMS), Commerce, Dept of (DOC), Executive Office of the President (EOP), Federal Trade Commission (FTC), Food & Drug Administration (FDA), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Natl Institute of Standards & Technology (NIST), Office of Management & Budget (OMB), Office of the Vice President of the United States, Patent & Trademark Office (PTO), SENATE, U.S. Trade Representative (USTR)

issues pertaining to Medicare and Medicaid.S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family Based Care Act of 2017; HR 2263 Medicaid and CHIP Territory Transparency and Information Act;HR 3172 Medicare IVIG Demonstration Extension Act of 2017; HR3920 Medicare Demonstration Program to reduce Medicare hospital part A bad debt claims; HR 5685 Medicare Opiod Safety Education Act 2018; HR 5686 Medicare Clear Healthcare Options in Care for Enrollees Act 2018; HR 6341 Protect Seniors Act 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

issues pertaining to Medicare and Medicaid. H.Res.215 Expressing the fact that the House of Representatives supports the system for prescription drug coverage provided under part D of the Medicare program and believes that changes to such system should not be part of the American Health Care Act of 2017;H.R.259 To prevent the territories of the United States from losing current Medicaid funding; S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family-Based Care Services Act of 2017;H.R.2263 - Medicaid and CHIP Territory Transparency and Information Act; HR 5685 Medicare Opiod Safety Ed Act 2018;HR 5686 Medicare Clear Health Options Enrollees Act 2018; HR 6341 Protect Seniors Medicare Act 2018.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

S. 469, Affordable and Safe Prescription Drug Importation Act; H.R. 1245, Affordable and Safe Prescription Drug Importation Act; H.R. 1776, Improving Access to Affordable Prescription Drugs Act; S. 771, Improving Access to Affordable Prescription Drugs Act; H.R. 242, Medicare Prescription Drug Price Negotiation Act of 2017; S. 41, Medicare Prescription Drug Price Negotiation Act of 2017; Drug Pricing Transparency

Client expense: $320,000 · Firm income: Not reported

Government targets: Agriculture, Dept of (USDA), Centers For Medicare and Medicaid Services (CMS), Defense, Dept of (DOD), Drug Enforcement Administration (DEA), Food & Drug Administration (FDA), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Office of Management & Budget (OMB), Office of Natl Drug Control Policy (NDCP), Office of Personnel Management (OPM), SENATE, Substance Abuse & Mental Health Services Administration (SAMHSA), White House Office

Discussions involving nominations to federally authorized commissions Monitored HR 1130 Fair Medicare Hospital Payments Act of 2017 Monitored S 397 Fair Medicare Hospital Payments Act of 2017 Monitored S 41 Medicare Prescription Drug Price Negotiation Act of 2017 Monitored HR 242 Medicare Prescription Drug Price Negotiation Act of 2017

Client expense: Not reported · Firm income: $130,000

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Medicare Physician Payment Reform: Advocated in support of H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was enacted in April 2015 and repealed Medicares Sustainable Growth Rate (SGR) formula and moved us to a new value-based payment and delivery system under Medicare; Advocated with CMS on numerous aspects of the MACRA proposed and final rules, including: proposing a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments; proposing specific alternatives to CMS Advancing Care Information program that replaced the Meaningful Use program; proposing additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Improvement Activities categories; urging CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available; proposing more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category; Proposing four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk: Advocated with CMS on Patient Relationship Categories and Codes, as required by MACRA, specifically: that CMS work to ensure that patients, families, and the relationship of patients and families with their physicians are at the forefront of the Agencys thinking in the development of both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways; that the implementation of these categories and codes is carried out in a manner that fully considers and minimizes the impact of reporting burden on the participating clinicians and that has appropriate flexibility to allow for learning and improvement in the approach by both the Agency and the clinicians. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Under the Affordable Care Act, advocated to ensure that people residing in states with health insurance marketplaces operated by the federal government do not lose their cost-sharing reduction subsidies (CSRs) and that those CSRs should be continued indefinitely as part of a larger bipartisan effort to stabilize the individual insurance market. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Maternal Health: Advocated for the Preventing Maternal Deaths Act, H.R. 1318, which supports state Maternal Mortality Review Committees, and promotes national information sharing through the Centers for Disease Control and Prevention (CDC), so that states can continue to learn from best practices and collaborate as needed. This bill will also put data to work through demonstration projects to eliminate disparities in maternal health outcomes. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided. Non-discrimination Protections: Urged the U.S. Department of Health and Human Services not to weaken nondiscrimination protections for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals under Section 1557 of the Affordable Care Act. Immigration: Voiced support to Congress on the need to pass the Development, Relief, and Education for Alien Minors (DREAM) Act of 2017, H.R. 3440. This legislation would establish a three-step pathway to U.S. citizenship through college, work, or the armed services for individuals who were born in another country and brought illegally to the U.S. at a young age (DREAMers). Clinical Labs: Commented to the Centers for Medicare and Medicaid Services (CMS) on issues pertaining to the Protecting Access to Medicare Act of 2014 (PAMA), specifically citing concerns about the potential impacts of PAMA on patient access to critical rapid clinical testing services offered to patients while they are receiving medical care in their physicians office; expressed further concerns about impending cuts on Jan. 1, 2018 for physician office-based testing services. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Repeal the Dickey amendment restricting firearms-related research by federal agencies and support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians.

Client expense: $388,427 · Firm income: Not reported

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

Preserve Access to Primary Care Services: Address the shortage of primary care physicians; provide scholarships and loan forgiveness in exchange for primary care service commitments to practice in critical shortage areas; provide grants for medical school mentorship programs and primary care training in community health centers; increase Title VII funding for primary care health programs; increase funding for the National Health Service Corps, provide regulatory relief for primary care physicians; H.R. 7192/S. 1174, the Preserving Patient Access to Primary Care Act (as first introduced in the 111th Congress). Support the Affordable Care Act (P.L. 111-148, P.L. 111-152) by: Expanding coverage and improving Medicare benefits; Providing needed protections to guard against insurance practices that unfairly limit, deny or rescind coverage based on health status; public and private health insurers should encourage preventive health care by providing full coverage, with no cost-sharing, for preventive services recommended by an expert advisory group, such as the U.S. Preventive Services Task Force; Ensuring access to primary care physicians; and beginning to bend the cost curve; Prohibiting insurers from excluding or charging excessive rates to children based on pre-existing conditions, which later will be expanded to all persons; Covering young adults on their parents' plans; Eliminating lifetime and annual limits on health insurance coverage; Requiring that health insurers spend more on patient care and less on administration; support enactment of S. 248, the Empowering States to Innovate Act, which amends the Patient Protection and Affordable Care Act (ACA) to: (1) allow states to apply for waivers of certain health insurance coverage requirements in such Act (including requirements for the establishment of qualified health plans and health insurance exchanges) for plan years beginning on or after January 1, 2014 (currently, January 1, 2017), and (2) require the waiver application process to begin not later than 180 days after the enactment of this Act; Phasing out the Medicare Part D doughnut hole; Eliminating patient cost-sharing for preventive services offered by Medicare or private insurers; Increasing Medicare and Medicaid payments to primary care physicians; Supporting the Patient-Centered Outcomes Research Institute to help physicians and patients make care decisions based on the best available evidence; Supporting the Center on Medicare and Medicaid Innovation to fund pilots of delivery models to improve outcomes and reduce costs, including patient-centered medical homes. Medicare Physician Payment Reform: Advocated in support of H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), which was enacted in April 2015 and repealed Medicares Sustainable Growth Rate (SGR) formula and moved us to a new value-based payment and delivery system under Medicare; Advocated with CMS on numerous aspects of the MACRA proposed and final rules, including: proposing a distinctive alternative scoring methodology, developed by ACP, which combines, simplifies, aligns and reduces the complexity of the four reporting categories that will qualify physicians for FFS payment adjustments; proposing specific alternatives to CMS Advancing Care Information program that replaced the Meaningful Use program; proposing additional improvements to simplify the reporting requirements for the Quality, Advancing Care Information and Improvement Activities categories; urging CMS to immediately create virtual reporting options and to create safe harbors for smaller practices until such options are available; proposing more options and flexibility, instead of a one-size fits all approach, for practices to be certified as Patient-Centered Medical Homes or Patient-Centered Medical Home specialty practices, qualifying them for the highest possible score for the Clinical Practice Improvement Activity reporting category; Proposing four different options for Medical Home practices to qualify as advanced Alternative Payment Models, instead of the single option proposed by CMS, including options to allow PCMHs to qualify without taking financial risk: Advocated with CMS on Patient Relationship Categories and Codes, as required by MACRA, specifically: that CMS work to ensure that patients, families, and the relationship of patients and families with their physicians are at the forefront of the Agencys thinking in the development of both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways; that the implementation of these categories and codes is carried out in a manner that fully considers and minimizes the impact of reporting burden on the participating clinicians and that has appropriate flexibility to allow for learning and improvement in the approach by both the Agency and the clinicians. Improve Access to Primary Care in the Context of Comprehensive Healthcare Reform Legislation (H.R. 3962/H.R. 3590/H.R. 4872): Provide sliding scale subsidies based on income to buy coverage from qualified plans; Qualified plans should: provide evidence-based benefits, including preventive services; and be prohibited from excluding persons with pre-existing conditions, charging them more, cherry-picking enrollees, or cancelling or failing to renew coverage; Expand Medicaid to cover all persons below the Federal Poverty Level and ensure fair payments to participating physicians; As coverage becomes affordable, all persons should participate and coverage should be guaranteed; Responsibility for financing should be shared by individuals, employers and government. The College believes that strong oversight is needed when determining the initial benchmark plan (and whether it reflects the coverage requirements of the Affordable Care Act) and how the package will be updated, particularly if insurers are given the ability to substitute benefits within and across categories. State and the federal government must work in concert with physicians, health care providers and payers to determine and promote use of clinically effective and cost-effective services that result in improved patient health while bending the cost curve. Under the Affordable Care Act, advocated to ensure that people residing in states with health insurance marketplaces operated by the federal government do not lose their cost-sharing reduction subsidies (CSRs) and that those CSRs should be continued indefinitely as part of a larger bipartisan effort to stabilize the individual insurance market. Pilot test Medicare payment models that re-align incentives to support effective, efficient, patient-centered, coordinated care. Priority should be given to models designed to support the value of services provided by primary care physicians as well as to models that would create incentives, across physician specialties and sites of services, to improve the quality, effectiveness, and efficiency of care provided. Policy criteria for selecting the most promising models for pilot testing should be developed, in consultation with outside experts; The Patient-Centered Medical Home (PCMH), which has shown great promise in meeting the policy objectives suggested above, should be among the models selected for broader testing on a national pilot basis; the use of the medical home model for treatment or services under private health plans, the requirement of health plans to provide incentives to promote and report on medical home services provided, the establishment of community health teams and a primary care extension program to educate and support primary care practices in the delivery of medical home services, and the establishment of a demonstration project to educate physicians and other clinicians in training in the competencies required to deliver care consistent with the medical home care model. Maternal Health: Advocated for the Preventing Maternal Deaths Act, H.R. 1318, which supports state Maternal Mortality Review Committees, and promotes national information sharing through the Centers for Disease Control and Prevention (CDC), so that states can continue to learn from best practices and collaborate as needed. This bill will also put data to work through demonstration projects to eliminate disparities in maternal health outcomes. Veterans Care: Regarding the VA Mission Act of 2018 (H.R. 5674), the College urged Congress to ensure that veterans have access to timely, contiguous care across the spectrum of health care services, with coordination and management of that care in the hands of a primary clinician or clinical care team; that the expansion of care to non-VHA facilities does not come at the cost of maintaining or improving existing VHA services or infrastructure; and that recruitment and retention of clinicians to the VHA is valued appropriately, including reimbursement for services provided. Non-discrimination Protections: Urged the U.S. Department of Health and Human Services not to weaken nondiscrimination protections for lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals under Section 1557 of the Affordable Care Act. Immigration: Voiced support to Congress on the need to pass the Development, Relief, and Education for Alien Minors (DREAM) Act of 2017, H.R. 3440. This legislation would establish a three-step pathway to U.S. citizenship through college, work, or the armed services for individuals who were born in another country and brought illegally to the U.S. at a young age (DREAMers). Clinical Labs: Commented to the Centers for Medicare and Medicaid Services (CMS) on issues pertaining to the Protecting Access to Medicare Act of 2014 (PAMA), specifically citing concerns about the potential impacts of PAMA on patient access to critical rapid clinical testing services offered to patients while they are receiving medical care in their physicians office; expressed further concerns about impending cuts on Jan. 1, 2018 for physician office-based testing services. Expand Coverage and Stabilizing the Insurance Market: Congress should work to help stabilize the individual health insurance market and expand coverage. Specifically by develop and introduce comprehensive market stabilization legislation that includes reinsurance options to help stabilize the markets; Expanding cost-sharing assistance eligibility to purchase insurance in the exchanges as well as increase the level of premium tax credits and cost sharing subsidies offered to purchase a qualified health plan; Introducing legislation that would block the expansion of access to short-term health plans or Association Health Plans that allow insurers to charge more to individuals with pre-existing conditions and permit them to exclude from coverage essential medical care; Supporting $690 million in discretionary funding for federal exchanges within CMS Program Operations as part of the FY2019 Labor, Health and Human Services, and Education Appropriations bill. Reduce Unnecessary Administrative Tasks on Physicians and Patients: Congress should accelerate its efforts to reduce administrative burdens on clinicians and patients, including: Passing the Standardizing Electronic Prior Authorization for Safe Prescribing Act (H.R. 4841), which standardizes electronic prior authorization for prescription drugs under Medicare Part D. Adopt even greater harmonization of such standards across the health care industry; Passing the CONNECTIONS Act (H.R. 5812) by Reps. Griffith (R-VA) and Pallone (D-NJ) that would authorize CDC grants to state-run PDMPs to improve data collection and integration into physician clinical workflow specifically, of controlled substances overdose prevention and surveillance activities; Urging health care committees in Congress with jurisdiction over Medicare to exercise their oversight authority of CMS effort to overhaul clinical documentation guidelines with input from practicing clinicians; Passing the Improving Access to Medicare Coverage Act of 2017 (S. 568/H.R. 1421), which deems patients under observation as inpatients for the purposes of satisfying the Medicare 3-day inpatient stay requirement. Reduce Prescription Drug Costs: Congress should increase transparency and accountability in prescription drug pricing and improve access to lower-cost generic medications by passing the Drug Price Transparency in Communications Act (S. 2157), which would require drug companies to disclose the Wholesale Acquisition Cost of an Rx in Direct-to-Consumer Advertising. Representatives should introduce the companion bill; Passing the Creating and Restoring Equal Access to Equivalent Samples (CREATES) Act of 2017 (S. 974/H.R. 2212), which would improve patient access to alternative low-cost prescription drugs and biological products by preventing prescription drug manufacturers from misusing the FDAs Risk Evaluation and Mitigation Strategies (REMS) process to make it difficult for competing generics to be brought to the market; Passing the Medicare Prescription Drug Price Negotiation Act of 2017 (S. 41/H.R. 242), which would grant authority to the Secretary of HHS to negotiate prescription drug prices with manufacturers for high�cost drugs and biologics covered under Part D; Passing the Fair Accountability and Innovative Research (FAIR) Pricing Act (S. 1131/H.R. 2439), which would require drug manufacturers to disclose and provide more information about planned drug price increases, including R&D costs. Fund Workforce, Medical and Health Services Research, Public Health Initiatives: Congress should ensure funding in FY 2019 for federal programs/initiatives designed to support primary care and reject funding rescissions that would harm childrens health coverage or CMS Innovation Center. This includes funding the Primary Care and Training Enhancement (PCTE) at $71 million in order to maintain and expand the pipeline for individuals training in primary care; Funding the National Health Service Corps (NHSC) at least at $415 million in total program funding to fund scholarships and loan repayment to health care professionals to help expand the countrys primary care workforce and meet the health care needs of underserved communities; Funding the Centers for Disease Control and Prevention (CDC) and Prevention and Public Health Fund (PPHF) at $8.45 billion; including PPHF funding at $805 million; Funding the Agency for Healthcare Research and Quality (AHRQ) at $454 million, restoring the agency to its FY2010 enacted level adjusting for inflation after cuts in FY2016 and FY2017 and a small increase in FY2018 so it can help clinicians help patients by making evidence-informed decisions, fund research that serves as the evidence engine for much of the private sectors work to keep patients safe; Funding the National Institutes of Health (NIH) at $39 billion so that this nations biomedical research can continue to fund cures for disease and maintain the U.S. standing as the world leader in medical and biomedical research. Promote Continued Action to Address the Epidemic of Opioid Use: Congress should pass a comprehensive legislative package to improve prevention, education, treatment and recovery for those suffering from opioid-related addictions, including: Providing for sufficient and increased funding to address the opioid epidemic, building and expanding upon the $4.65 billion in the omnibus bill approved by Congress, with at least $1 billion for programs as authorized by CARA 2.0; Expanding access and coverage for medication assisted treatment (methadone, buprenorphine, and naltrexone to prevent opioid and substance use disorders; Rejecting any proposal to impose a three day prescribing limit for initial opioid prescriptions to ensure that doctors have appropriate flexibility to determine the proper duration of each opioid prescription; Passing the Comprehensive Addiction and Recovery Act 2.0 of 2018 (S. 2456/H.R. 5311) as a step toward a more comprehensive opioids-related package. Reduce Firearms-Related Injury and Death: Congress should pass the Assault Weapons Ban of 2018 (S. 2095/H.R. 5077), which would ban the sale of high velocity, rapid file assault rifles and large capacity ammunition magazines and bump stocks; Pass the Brady Background Expansion Act (S. 2009), to expand background checks to virtually all firearm sales in the United States; Pass the Stop Illegal Trafficking in Firearms Act of 2017 (S. 1185), and the Stop Straw Purchases Act (H.R. 5134). Both would increase penalties for individuals who unlawfully purchase firearms for other persons who are prohibited from possessing firearms (known as straw purchasers); Repeal the Dickey amendment restricting firearms-related research by federal agencies and support $50 million in funding for the CDC to conduct such research; Pass S. 834/H.R. 1832 that authorizes funding for the CDC to conduct such research. Make Graduate Medical Education (GME) Funding More Effective: Congress should develop and pass legislation to reform GME to prioritize funding toward physician specialties where millions of patients lack access, including internal medicine specialists trained in comprehensive primary care, to: Increase the number of GME slots by at least 3,000 per year over five years for specialties facing shortages, including internal medicine, as contained in the Resident Physician Shortage Reduction Act of 2017 (S. 1301/H.R. 2267); Combine DGME/IME into a single, more functional program; broaden the GME financing structure to include all payers; Allocate GME funds transparently and to activities that further the educational mission of teaching and training residents/fellows with input from practicing clinicians and in collaboration with their professional organizations; Support continued adequate funding for the VHA and its substantial contributions to the ongoing training of the next generation of physicians.

Client expense: $89,568 · Firm income: Not reported

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

General Medicare Protection, Prevention of Fraud, Waste, and Abuse: H.R. 2460 and H.R. 4841 and H.R. 4704, Prescription Drug Re-Importation: S. 92 and S. 469 and H.R. 1245, Negotiation of Prescription Drug Prices: H.R. 242 and S. 41, General Prescription Drug Affordability: S. 124 and S. 771 and H.R. 1776 and H.R. 4138 and H.R. 4116 and H.R. 4117 and S. 2011 and S. 974 and H.R. 2212 and S. 2553, Medicare Enrollment Simplification: H.R. 2575 and S. 1909, Expanding Medicare Coverage: H.R. 5083 and H.R. 4957 and S. 2387 and H.R. 807 and H.R. 3098 and H.R. 4701 and H.R. 508 and H.R. 2276 and S. 2575 and H.R. 5083.

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Health Care Reform Legislation HR1628 Access to Affordable Prescription Drugs Medicare Prescription Drug Price Negotiation Act HR 242 Protecting Medicare from executive Action S 251 Medicare Prescription Drug Price Negotiation Act S 41 Race for Children Act HR 1231

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

Government targets: Administration for Children & Families (ACF), HOUSE OF REPRESENTATIVES, SENATE

S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 S. 251: Protecting Medicare from Executive Action Act of 2017 S. 260: Protecting Seniors' Access to Medicare Act of 2017 H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 H.R. 849: Protecting Seniors' Access to Medicare Act of 2017 H.J.Res. 51: Approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act S.J.Res. 16: A joint resolution approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act S.J.Res. 17: A joint resolution approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899A of the Social Security Act Part D policy issues including non-interference and rebates policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues H.R. 3921: HEALTHY KIDS Act - Funding for the Childrens Health Insurance Program S. 1827: KIDS Act of 2017 - Funding for the Childrens Health Insurance Program H.R. 3922: Championing Healthy Kids Act - CHIP and CHC reauthorization

Client expense: $2,890,000 · Firm income: Not reported

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

H.R. 242: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation H.R. 849: Protecting Seniors Access to Medicare Act - Provisions related to repeal of the IPAB H.R. 1316: Prescription Drug Price Transparency Act - Provisions related to transparency of payment methodologies H.R. 3921: HEALTHY KIDS Act - Funding for the Childrens Health Insurance Program H.R. 3922: CHAMPIONING HEALTHY KIDS Act - CHIP and CHC reauthorization H.J.Res. 51: Approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899a of the Social Security Act - Provisions related to IPAB repeal S. 41: Medicare Prescription Drug Price Negotiation Act of 2017 - Provisions related to Part D and drug pricing negotiation S. 251: Protecting Medicare from Executive Action Act of 2017 - Provisions related to repeal of the Independent Patient Advisory Board (IPAB) S. 260: Protecting Seniors Access to Medicare Act of 2017 - Provisions related to repeal of the IPAB S. 348: Prescription Drug and Health Improvement Act of 2017 - Provisions related to Part D S. 637: Creating Transparency to Have Drug Rebates Unlocked (C-THRU) Act of 2017 - Provisions related to transparency of prescription drug pricing and pharmacy benefit managers S. 870: CHRONIC Care Act of 2017 - Provisions related to Medicare and chronic care S. 1348: Stopping the Pharmaceutical Industry from Keeping Drugs Expensive (SPIKE) Act of 2017 - Provisions related to increases in the wholesale acquisition costs of prescription drugs S. 1688: Empowering Medicare Seniors to Negotiate Drugs Prices Act of 2017 - Part D and non-interference provisions S. 1827: KIDS Act of 2017 - Funding for the Childrens Health Insurance Program S.J.Res. 16: A joint resolution approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899a of the Social Security Act - Provisions related to IPAB repeal S.J.Res. 17: A joint resolution approving the discontinuation of the process for consideration and automatic implementation of the annual proposal of the Independent Medicare Advisory Board under section 1899a of the Social Security Act - Provisions related to IPAB repeal Medicare Access and Childrens Health Insurance Program (CHIP) reauthorization policy issues Department of Health and Human Services (HHS) drug policy issues and regulatory policy issues Part D policy issues including non-interference and rebates policy issues Part B reform including MedPAC recommendations and other policy issues Drug cost and pricing policy issues Transparency policy issues Alternative payment models policy issues Value-based purchasing arrangements policy issues Anti-Kickback Statute policy issues Center for Medicare and Medicaid Innovation (CMMI) policy issues Medicaid rebates and waiver policy issues Prescription drug abuse policy issues Final Rule; Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC) - Revisions to the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2018 Proposed Rule: Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P)

Client expense: $1,110,000 · Firm income: Not reported

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

issues pertaining to Medicare and Medicaid. H.Res.215 Expressing the fact that the House of Representatives supports the system for prescription drug coverage provided under part D of the Medicare program and believes that changes to such system should not be part of the American Health Care Act of 2017;H.R.259 To prevent the territories of the United States from losing current Medicaid funding; S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family-Based Care Services Act of 2017;H.R.2263 - Medicaid and CHIP Territory Transparency and Information Act.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

issues pertaining to Medicare and Medicaid.S 520 Medicaid Accountability and Care Act of 2017. H.R.542 Better Accounting for Medicaid Costs Act of 2017; H.R.242 Medicare Prescription Drug Price Negotiation Act of 2017;S.41 Medicare Prescription Drug Price Negotiation Act of 2017;S.252 Medicare Drug Savings Act of 2017;S.568 Improving Access to Medicare Coverage Act of 2017; HR 2290 Family Based Care Act of 2017; HR 2263 Medicaid and CHIP Territory Transparency and Information Act;HR 3172 Medicare IVIG Demonstration Extension Act of 2017; HR3920 Medicare Demonstration Program to reduce Medicare hospital part A bad debt claims.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE