Improving Access to Medicare Coverage Act of 2017

Legislative proposals affecting Medicare and Medicaid hospital reimbursement policies Health Information Technology Health Care Reform Implementation Medicare Graduate Medical Education Payments H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 1130/S. 397, Fair Medicare Hospital Payments Act of 2017 H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts and codifying the definition of patient Additional legislative proposals modifying the 340B program

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Observation Stays Issue Outreach to HHS/CMS Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994) Therapy caps exception process Group and Concurrent Therapy CR: Public Law No: 115-123 Omni: Public Law No: 115-141 The Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (S. 1028 and H.R. 3759). Congress passed the legislation, and became Public Law No: 115-119 on 1/22/2018. Outreach to HHS/ACL on Implementation of the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (Public Law No: 115-119). Allow Secretarial discretion of CNA Training termination pertaining to Sec. 1819 (f)(2)(B)(iii)(l)(c). HR 6502, the RUSH Act VA Provider Agreement related language and the VA MISSION Act of 2018 HR 6986, Nursing Home Workforce Act. (CNA bill) AHCA/NCAL supported the Building Our Largest Dementia Infrastructure for Alzheimers Act, or BOLD Infrastructure for Alzheimers Act (S. 2076/H.R. 4256), which became Public Law No. 115-406 on December 31, 2018

Client expense: $970,000 · Firm income: Not reported

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

Proposed changes to Medicare hospital reimbursement policy Issues related to the Hospital Compare Star Ratings S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts, codify the definition of patient Additional legislative proposals modifying the 340B program

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

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

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

Advocate for reform of the CMS two-midnight rule, communicated with Congressional offices in support of HR 1421/S. 568 the Improving Access to Medicare Coverage Act.Observation statues under Medicare.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

American Healthcare Act (H.R. 1628) The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Physician payment policy including implementation of H.R.2, the Medicare Access and CHIP Reauthorization Act of 2015; H.R. 1421/S. 568 related to observation status; H.R.6, SUPPORT for Patients and Communities Act.

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

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

1. Patient Protection and Affordable Health Care Act, implementation of provisions regarding Medicare Part D coverage gap assistance, preventive care services, and dual eligible Medicare and Medicare beneficiaries 2. Proposals to create a premium support or voucher program under Medicare 3. Proposals to "means test" Medicare premiums and benefits 4. Proposals to change federal and state Medicaid cost sharing 5. Proposals to raise the Medicare eligibility age 6. Proposals regarding prescription drug costs for low income Medicare beneficiaries 7. Expansion of Medicare benefits to include hearing, vision, and dental benefits 8. Administration of the Medicare State Health Insurance Assistance Programs 9. H.R.1421, Improving Access to Medicare Coverage Act of 2017, entire bill 10. S. 568, Improving Access to Medicare Coverage Act of 2017, entire bill 11. H.R. 1776, Improving Access To Affordable Prescription Drugs Act, entire bill 12. S. 2704, Medicare Beneficiary Opioid Addiction Treatment Act, entire bill 13. Medicare Observation Status Regulations 14. Nursing Home Arbitration Regulations 15. CMS Medicare Handbook and Open Season Materials 16. H.R. 5757, Fighting Medicare Fraud Act of 2018, entire bill 17. Medicare 340(B) drug reimbursement policy 18. H.R. 6505, Medicare Negotiation and Competitive Licensing Act of 2018, entire bill 19. Home care workers and Medicare Reassignment Policy 20. Medicare equitable relief policy 21. Medicare Special Enrollment Period

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), Pension Benefit Guaranty Corporation (PBGC), SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA)

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

Hearing Aids. H.R. 3426, Medicare Hearing Aid Coverage Act: Proposal to provide Medicare coverage of hearing aids. Medicare Dental, Vision, and Hearing Coverage. H.R. 508, Seniors Have Eyes, Ears and Teeth Act and H.R. 3111, Medicare Dental, Vision, and Hearing Benefit Act of 2017: Proposals to expand Medicare coverage to include comprehensive coverage of dental, vision, and hearing care. Medicare Observation Status. S. 568/H.R. 1421, Improving Access to Medicare Coverage Act of 2017: Proposal to count days in the hospital in observation status toward meeting the three-day prior hospitalization requirement for skilled nursing facility care eligibility. Dementia and Alzheimers Disease. S. 2076/H.R. 4256, Building Our Largest Dementia Infrastructure for Alzheimers Act (BOLD Act): Proposal to apply a public health approach to combat Alzheimers disease and related dementias. Generic Drug Introduction. S. 974/H.R. 2212, CREATES Act: Proposal to speed the introduction of generic competition by curbing brand drug maker abuses of safety procedures as a means to limit generic manufacturer access to the drug samples needed to obtain Food and Drug Administration approval. Opioid Treatment. H.R. 6, SUPPORT for Patients and Communities Act: Section 2005 proposals related to Medicare coverage of certain services furnished by opioid treatment programs. Medicare Beneficiary Equitable Relief. (No bill): Efforts to extend and make permanent the Centers for Medicare and Medicaid Services policy for equitable relief for select individuals currently or previously enrolled in Affordable Care Act Marketplace plans who delayed Medicare enrollment during their Initial Enrollment Period or during a qualifying Special Enrollment Period. Medicare Physician Payment. (No bill): Proposal to collapse the current five levels of payments for office visits into two levels. Medicare and Medicaid Protection. S. 3330, Medicare and Medicaid Protection Act: Proposed changes to budget reconciliation legislation affecting Medicare and Medicaid program protections. Medicaid Home and Community Based Services. H.R. 7217, IMPROVE Act/H.R. 695, Department of Defense Appropriations Act, 2018: Provisions to extend spousal impoverishment protections to Medicaid home and community based services, and to extend the demonstration program, Money Follows the Person, which provides funding to states to assist people requiring long term care services to stay in their homes. Medicare Prescription Drug Costs. (No bill): Proposals to reduce amount drug manufacturers must contribute to closing the donut hole in 2019. Medicare Prescription Drug Costs. H.R. 6505, Medicare Negotiation and Competitive Licensing Act of 2018: Proposal to allow the Secretary of Health and Human Services to pay another manufacturer to produce a drug in instances where a drug manufacturer fails to provide Medicare a reasonable price for the drug. Medicare Prescription Drug Costs. (No bill): Provisions of the United States-Mexico-Canada Agreement (formerly the North American Free Trade Agreement) addressing countries having expansive regulatory approval monopolies for biologic drugs and restrict the ability of Congress to reform patent laws that drive up drug costs for Medicare. Medicare Part B Drug Costs. (No bill): Proposals to reduce Medicare Part B drug costs by limiting Medicare payment when a drug price increase exceeds an inflation limit. Medicare Open Enrollment. (No bill): Proposals to ensure the Centers for Medicare and Medicaid Services conducts open enrollment in a way that is unbiased toward the traditional program. Medigap reform. (No bill): Proposals to extend Medigap guaranteed issue protections -requiring plans to extend coverage without regard to health status - to all beneficiaires with Medicare Advantage, to disabled beneficiaries under the age of 65 and to beneficiaries with Medigap plans C and F, which will stop taking new enrollees in 2020.

Client expense: $210,000 · Firm income: Not reported

Government targets: Administration on Aging, Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Natl Economic Council (NEC), Office of Management & Budget (OMB), SENATE, Social Security Administration (SSA), Treasury, Dept of

S. 568/H.R. 1421, Improving Access to Medicare Coverage Act of 2017; changes to the Medicare advancing care information program for purposes of a long-term care setting; geriatrics workforce enhancement program funding; issues surrounding opioids; H.R. 6502, Reducing Unnecessary Senior Hospitalization Act (RUSH) Act of 2018

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Changes to Medicare Observation Stay requirements (HR 1421 & S 568). Changes to 340B drug program (HR 4392).

Client expense: Not reported · Firm income: $6,000

Government targets: Federal Communications Commission (FCC), HOUSE OF REPRESENTATIVES, SENATE

Support H.R. 1421/S. 568, providing for all time a Medicare beneficiary spends in the hospital to count toward the 3-day stay requirement for coverage of post-acute care. Support H.R. 6986, the Nursing Home Workforce Quality Act, to modify the nurse aide training lock-out provisions of the Omnibus Budget Reconciliation Act of 1987. Support S. 1334/HR 2797, the Patient Choice and Quality Care Act, to allow for better service coordination for Medicare beneficiaries with advanced illnesses. Support S. 445/H.R. 1825, the Home Health Planning Improvement Act, to allow non-physician health professionals to approve Medicare coverage of home health care. Support S. 309, Community-Based Independence for Seniors Act, establishing a demonstration of Medicare coverage of non-medical supportive services Support H.R. 2797/S. 1334, the Patient Choice and Quality Care Act, to create a new Medicare model for advanced illness care. Support H.R. 2663, Home Health Documentation and Program Improvement Act, to address the current backlog of appeals on claims for Medicare reimbursement. Support H.R. 3098, Medicare Adult Day Services Act Advocating for modification of the "settings rule" for Medicaid coverage of home care services provided to beneficiaries living on the campus of a nursing home or assisted living facility. Oppose revisions to Medicaid to set lifetime limits on coverage.

Client expense: $91,901 · Firm income: Not reported

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

The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Observation Stays Issue Outreach to HHS/CMS Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994) Therapy caps exception process Group and Concurrent Therapy CR: Public Law No: 115-123 Omni: Public Law No: 115-141 The Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (S. 1028 and H.R. 3759). Congress passed the legislation, and became Public Law No: 115-119 on 1/22/2018. Outreach to HHS on Implementation of the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (Public Law No: 115-119). Allow Secretarial discretion of CNA Training termination pertaining to Sec. 1819 (f)(2)(B)(iii)(l)(c). HR 6502, the RUSH Act VA Provider Agreement related language and the VA MISSION Act of 2018 HR 6986, Nursing Home Workforce Act. (CAN bill)

Client expense: $980,000 · Firm income: Not reported

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

Advocate for reform of the CMS two-midnight rule, communicated with Congressional offices in support of HR 1421/S. 568 the Improving Access to Medicare Coverage Act.Observation statues under Medicare.

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.

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

Medicare reform Medicaid expansion and reform Medicare and Medicaid Disproportionate Share (DSH) funding Wage index Medicare inpatient and outpatient payment system Integrated health care delivery Medical education for teaching hospitals Health information technology (HIT) and telehealth Behavioral health Off-campus hospital outpatient department (HOPD) funding 340B program Post acute care programs/funding including H.R.2663 (the Home Health Documentation and Program Improvement Act of 2017) H.R. 1421/S.568: The Improving Access to Medicare Coverage Act of 2017.(allowing observation days to count towards 3-day stay requirement of Medicare) CAR-T funding support

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

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

1. Patient Protection and Affordable Health Care Act, implementation of provisions regarding Medicare Part D coverage gap assistance, preventive care services, and dual eligible Medicare and Medicare beneficiaries 2. Proposals to create a premium support or voucher program under Medicare 3. Proposals to "means test" Medicare premiums and benefits 4. Proposals to change federal and state Medicaid cost sharing 5. Proposals to raise the Medicare eligibility age 6. Proposals regarding prescription drug costs for low income Medicare beneficiaries 7. Expansion of Medicare benefits to include hearing, vision, and dental benefits 8. Administration of the Medicare State Health Insurance Assistance Programs 9. H.R.1421, Improving Access to Medicare Coverage Act of 2017, entire bill 10. S. 568, Improving Access to Medicare Coverage Act of 2017, entire bill 11. H.R. 1776, Improving Access To Affordable Prescription Drugs Act, entire bill 12. S. 2704, Medicare Beneficiary Opioid Addiction Treatment Act, entire bill 13. Medicare Observation Status Regulations 14. Nursing Home Arbitration Regulations 15. CMS Medicare Handbook and Open Season Materials 16. H.R. 5757, Fighting Medicare Fraud Act of 2018, entire bill 17. Medicare 340(B) drug reimbursement policy 18. H.R. 6505, Medicare Negotiation and Competitive Licensing Act of 2018, entire bill 19. Home care workers and Medicare Reassignment Policy 20. Kentucky Medicaid waiver application 21. Medicare equitable relief policy

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), Pension Benefit Guaranty Corporation (PBGC), President of the U.S., SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA)

American Healthcare Act (H.R. 1628) The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Legislative proposals affecting Medicare and Medicaid hospital reimbursement policies Health Information Technology Health Care Reform Implementation Medicare Graduate Medical Education Payments H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 1130/S. 397, Fair Medicare Hospital Payments Act of 2017 H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts and codifying the definition of patient Additional legislative proposals modifying the 340B program H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act - provisions related to Medicare and Medicaid policy and reimbursement

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Proposed changes to Medicare hospital reimbursement policy Issues related to the Hospital Compare Star Ratings S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts, codify the definition of patient Additional legislative proposals modifying the 340B program H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act - provisions related to Medicare and Medicaid policy and reimbursement

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

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. 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

Physician payment policy including implementation of H.R.2, the Medicare Access and CHIP Reauthorization Act of 2015; H.R. 1421/S. 568 related to observation status; H.R.6, SUPPORT for Patients and Communities Act.

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

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

Hearing Health Care Services. S. 2575/H.R. 2276, Audiology Patient Choice Act of 2018: Proposal to expand access to hearing health care services for Medicare beneficiaries. Hearing Aids. H.R. 3426, Medicare Hearing Aid Coverage Act: Proposal to provide Medicare coverage of hearing aids. Medicare Dental, Vision, and Hearing Coverage. H.R. 508, Seniors Have Eyes, Ears and Teeth Act and H.R. 3111, Medicare Dental, Vision, and Hearing Benefit Act of 2017: Proposals to expand Medicare coverage to include comprehensive coverage of dental, vision, and hearing care. Medicare Observation Status. S. 568/H.R. 1421, Improving Access to Medicare Coverage Act of 2017: Proposal to count days in the hospital in observation status toward meeting the three-day prior hospitalization requirement for skilled nursing facility care eligibility. Dementia and Alzheimers. S. 2076/H.R. 4256, Building Our Largest Dementia Infrastructure for Alzheimers Act (BOLD Act): Proposal to apply a public health approach to combat Alzheimers disease and related dementias. Alzheimers Disease. S. 2387/H.R. 4957, Concentrating on High-Value Alzheimers Needs to Get to an End (CHANGE) Act of 2018: Proposal to aid Alzheimers disease suffers, their families and caregivers, including authorization of a cognitive impairment detection benefit in the Medicare annual wellness visit and initial preventive physical examination. Drug Price Negotiation. S. 2011/H.R. 4138, Medicare Drug Price Negotiation Act: Proposals to lower prescription drug prices in the Medicare Part D program, including allowing Medicare to negotiate directly with prescription drug manufacturers and requiring drug manufacturers to rebate to the federal government for drugs covered under Medicare Part D for low-income Medicare beneficiaries. Generic Drug Introduction. S. 974/H.R. 2212, CREATES Act: Proposal to speed the introduction of generic competition by curbing brand drug maker abuses of safety procedures as a means to limit generic manufacturer access to the drug samples needed to obtain Food and Drug Administration approval. Opioid Treatment. H.R. 6, SUPPORT for Patients and Communities Act: Section 2005 proposals related to Medicare coverage of certain services furnished by opioid treatment programs. Medicare Beneficiary Equitable Relief. (No bill): Efforts to extend and make permanent the Centers for Medicare and Medicaid Services policy for equitable relief for select individuals currently or previously enrolled in Marketplace plans who delayed Medicare enrollment during their Initial Enrollment Period or during a qualifying Special Enrollment Period. Medicare Physician Payment. (No bill): Proposal to collapse the current five levels of payments for office visits (Evaluation and Management) into two levels. Medicare and Medicaid Protection. S. 3330, Medicare and Medicaid Protection Act: Proposed changes to budget reconciliation legislation affecting Medicare and Medicaid program protections. Medicaid Protection. (No bill): Proposals requiring Medicaid recipients to work and ending homecare workers rights to make deductions from their pay for health care and union dues. Medicare Prescription Drug Costs. (May be attached to several legislative vehicles.) Proposals to reduce amount drug manufacturers must contribute to closing the donut hole. Medicare Prescription Drug Costs. S. 2553, Know the Lowest Price Act of 2018: Proposal to prohibit Medicare Advantage plans from putting clauses in contracts with pharmacists prohibiting them from disclosing to beneficiaries when a drug is less expensive if the beneficiary doesnt use his or her insurance. Medicare Part B Drug Costs. H.R. 5150, Protecting Medicare from Excessive Price Increases Act of 2018: Proposal to reduce Medicare Part B drug costs by requiring Medicare to rebate to the government the amount by which a drug price increase exceeds an inflation limit. Medicare Open Enrollment. (No bill). Efforts to ensure the Centers for Medicare and Medicaid Services conducts open enrollment in a way that is unbiased toward the traditional program.

Client expense: $210,000 · Firm income: Not reported

Government targets: Administration on Aging, Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Justice, Dept of (DOJ), Labor, Dept of (DOL), Natl Economic Council (NEC), Office of Management & Budget (OMB), SENATE, Social Security Administration (SSA), Treasury, Dept of

S. 568/H.R. 1421, Improving Access to Medicare Coverage Act of 2017; changes to the Medicare advancing care information program for purposes of a long-term care setting; geriatrics workforce enhancement program funding; issues surrounding opioids; H.R. 6502, Reducing Unnecessary Senior Hospitalization Act (RUSH) Act of 2018

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Changes to Medicare Observation Stay requirements (HR 1421 & S 568). Changes to 340B drug program (HR 4392).

Client expense: Not reported · Firm income: $6,000

Government targets: Federal Communications Commission (FCC), HOUSE OF REPRESENTATIVES, SENATE

H.R.817-End Surprise Billing Act of 2017 H.R.1323-Reducing Unnecessary Emergency Room Visits under Medicaid Act H.R.2957-Save Rural Hospitals Act H.R.3181-Medicare Choices Empowerment and Protection Act H.R.5678-Rural Emergency Medical Center Act of 2018 S.260-Protecting Seniors' Access to Medicare Act of 2017 S.284-End Surprise Billing Act of 2017 S.568-Improving Access to Medicare Coverage Act of 2017 S.1130-Rural Emergency Acute Care Hospital (REACH) Act S.1530- Medicare Choices Empowerment and Protection Act

Client expense: $702,392 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)

Essential emergency medication shortages Mental health services for emergency psychiatric patients Price transparency of emergency medical services Due process rights for physicians furnishing emergency medical services H.Res.906-Congratulating the American College of Emergency Physicians on its 50th anniversary H.R.6-Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act H.R.372-Competetive Health Insurance Reform Act of 2017 H.R.548-Health Care Safety Net Enhancement Act of 2017 H.R.767-Stop, Observe, Ask, and Respond (SOAR) to Health and Wellness Act of 2017 H.R.817-End Surprise Billing Act of 2017 H.R.880-Military Injury Surgical Systems Integrated Operationally Nationwide to Achieve ZERO Preventable Deaths Act H.R.1057-Synthetics Trafficking and Overdose Prevention Act of 2017 H.R.1215-Protecting Access to Care Act of 2017 H.R.1323-Reducing Unnecessary Emergency Room Visits under Medicaid Act H.R.1492-Medical Controlled Substances Transportation Act of 2017 H.R.1565-Saving Lives, Saving Costs Act H.R.1822-Good Samaritan Health Professionals Act of 2017 H.R.1876-Good Samaritan Health Professionals Act of 2017 H.R.2200-Frederick Douglass Trafficking Victims Prevention and Protection Reauthorization Act of 2017 H.R.2851-Stop the Importation and Trafficking of Synthetic Analogues (SITSA) Act of 2017 H.R.2957-Save Rural Hospitals Act H.R.3181-Medicare Choices Empowerment and Protection Act H.R.3258-Marketplace Certainty Act H.R.3545-Overdose Prevention and Patient Safety (OPPS) Act H.R.4922-Stopping Overdoses of Fentanyl Analogues Act H.R.5176-Preventing Overdoses While in Emergency Rooms Act of 2018 H.R.5197-Alternatives to Opioids (ALTO) in the Emergency Department Act H.R.5531-Opioid Emergency Response Act H.R.5558-Alternatives to Opioids Prescribing Act H.R.5678-Rural Emergency Medical Center Act of 2018 H.R.6082-Overdose Prevention and Patient Safety (OPPS) Act S.191-Patient Freedom Act of 2017 S.256-SOAR to Health and Wellness Act of 2017 S.284-End Surprise Billing Act of 2017 S.372- Synthetics Trafficking and Overdose Prevention Act of 2017 S.527-Health Care Safety Net Enhancement Act of 2017 S.568-Improving Access to Medicare Coverage Act of 2017 S.781-Good Samaritan Health Professionals Act of 2017 S.1016-Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2017 S.1022-Military Injury Surgical Systems Integrated Operationally Nationwide to Achieve ZERO Preventable Deaths Act S.1130-Rural Emergency Acute Care Hospital (REACH) Act S.1462-Marketplace Certainty Act S.1530- Medicare Choices Empowerment and Protection Act S.1553-Stopping Overdoses of Fentanyl Analogues Act S.1835-Lower Premiums Through Reinsurance Act of 2017 S.2516-Alternatives to Opioids (ALTO) in the Emergency Department Act S.2609-Recovery Coaches Offer Addiction Counseling and Healing (COACH) Act S.2610-Preventing Overdoses While in Emergency Departments Act of 2018

Client expense: $702,392 · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE, Veterans Affairs, Dept of (VA)

Support H.R. 1421/S. 568, providing for all time a Medicare beneficiary spends in the hospital to count toward the 3-day stay requirement for coverage of post-acute care. Advocating for modification of the nurse aide training lock-out provisions of the Omnibus Budget Reconciliation Act of 1987. Support S. 1334/HR 2797, the Patient Choice and Quality Care Act, to allow for better service coordination for Medicare beneficiaries with advanced illnesses. Support S. 445/H.R. 1825, the Home Health Planning Improvement Act, to allow non-physician health professionals to approve Medicare coverage of home health care. Support S. 309, Community-Based Independence for Seniors Act, establishing a demonstration of Medicare coverage of non-medical supportive services Support H.R. 2797/S. 1334, the Patient Choice and Quality Care Act, to create a new Medicare model for advanced illness care. Support H.R. 2663, Home Health Documentation and Program Improvement Act, to address the current backlog of appeals on claims for Medicare reimbursement. Support H.R. 3098, Medicare Adult Day Services Act Advocating for modification of the "settings rule" for Medicaid coverage of home care services provided to beneficiaries living on the campus of a nursing home or assisted living facility. Oppose revisions to Medicaid to set lifetime limits on coverage.

Client expense: $32,306 · Firm income: Not reported

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

The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Observation Stays Issue Outreach to HHS/CMS Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994) Therapy caps exception process Group and Concurrent Therapy CR: Public Law No: 115-123 Omni: Public Law No: 115-141 The Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (S. 1028 and H.R. 3759). Congress passed the legislation, and became Public Law No: 115-119 on 1/22/2018. Outreach to HHS on Implementation of the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (Public Law No: 115-119). Allow Secretarial discretion of CNA Training termination pertaining to Sec. 1819 (f)(2)(B)(iii)(l)(c).

Client expense: $920,000 · Firm income: Not reported

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

Legislative proposals affecting Medicare and Medicaid hospital reimbursement policies Health Information Technology Health Care Reform Implementation Medicare Graduate Medical Education Payments H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 1130/S. 397, Fair Medicare Hospital Payments Act of 2017 H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts, codify the definition of patient Additional legislative proposals modifying the 340B program H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act - provisions related to Medicare policy and reimbursement

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Legislative proposals affecting Medicare and Medicaid hospital reimbursement policies Health Information Technology Health Care Reform Implementation Medicare Graduate Medical Education Payments H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-supported residency positions Proposed changes to Medicare hospital reimbursement policy S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 1130/S. 397, Fair Medicare Hospital Payments Act of 2017 H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants

Client expense: Not reported · Firm income: Not reported

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Proposed changes to Medicare hospital reimbursement policy Issues related to the Hospital Compare Star Ratings S. 568/H.R.1421, "Improving Access to Medicare Coverage Act" - provisions related to counting outpatient observation services toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare H.R. 2267/S. 1301, "Resident Physician Shortage Reduction Act" - provisions related to increasing the number of Medicare-funded residency positions H.R. 4392, a bill to prevent cuts to the 340B drug savings program, which would provide relief from deep cuts to payments to hospitals participating in the 340B program Opposed H.R. 4710, a bill to implement reporting requirement for certain 340B participants and to establish a 2-year moratorium on new 340B program participants H.R. 6071, Stretching Entity Resources for Vulnerable Communities Act - provisions related to rescinding Medicare reimbursements cuts, codify the definition of patient Additional legislative proposals modifying the 340B program H.R. 6, Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act - provisions related to Medicare and Medicaid policy and reimbursement

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

American Healthcare Act (H.R. 1628) The Improving Access to Medicare Coverage Act of 2017 (S.568/H.R. 1421) Medicare Post-Acute Care Value-Based Purchasing Act of 2015 H.R. 3298 Skilled Nursing Facility Payment Reform Skilled Nursing Facility Requirements of Participation, RIN 0938-AR61 Survey Relief/Civil Monetary Penalties Medicare Access to Rehabilitation Services Act of 2017 (S. 253/H.R. 807) Payroll Based Journal - Section 6106 of the Affordable Care Act The Improving Medicare Post-Acute Care Transformation Act of 2014 (H.R. 4994)

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

Advocate for reform of the CMS two-midnight rule, communicated with Congressional offices in support of HR 1421/S. 568 the Improving Access to Medicare Coverage Act.Observation statues under Medicare.

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

Government targets: HOUSE OF REPRESENTATIVES, SENATE

1. Patient Protection and Affordable Health Care Act, implementation of provisions regarding Medicare Part D coverage gap assistance, preventive care services, and dual eligible Medicare and Medicare beneficiaries 2. Proposals to create a premium support or voucher program under Medicare 3. Proposals to "means test" Medicare premiums and benefits 4. Proposals to change federal and state Medicaid cost sharing 5. Proposals to raise the Medicare eligibility age 6. Proposals regarding prescription drug costs for low income Medicare beneficiaries 7. Expansion of Medicare benefits to include hearing, vision, and dental benefits 8. Administration of the Medicare State Health Insurance Assistance Programs 9. H.R.1421, Improving Access to Medicare Coverage Act of 2017, entire bill 10. S. 568, Improving Access to Medicare Coverage Act of 2017, entire bill 11. H.R. 1776, Improving Access To Affordable Prescription Drugs Act, entire bill 12. H.R. 1628, American Health Care Act of 2017, entire bill 13. Medicare Observation Status Regulations 14. Nursing Home Arbitration Regulations 15. CMS Medicare Handbook and Open Season Materials 16. H.R. 5757, Fighting Medicare Fraud Act of 2018, entire bill 17. Medicare 340(B) drug reimbursement policy

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

Government targets: Centers For Medicare and Medicaid Services (CMS), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Labor, Dept of (DOL), Pension Benefit Guaranty Corporation (PBGC), President of the U.S., SENATE, Social Security Administration (SSA)

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. 3158, Labor-HHS Appropriations bill for FY 2019 - Lobbied in support of increased funding for CMS' state survey and certification program and in opposition to hostile policy riders regarding Patient Protection and Affordable Care Act, and various related medical care research and Older Americans Act programs. Submitted comments on Medicare Direct Provider Contracting request for information to the Center for Medicare and Medicaid Innovation (CMMI). Submitted comments on alternative payment models to the Physician-focused Payment Model Technical Advisory Committee (PTAC). Submitted comments on the Hospital Inpatient Prospective Payment System to the Centers for Medicare and Medicaid Services (CMS). Family Caregiving: Medicare and Medicaid Hill briefing - Discussed family caregiving, Medicare and Medicaid including RAISE Family Caregivers Act (P.L. 115-119). Discussed access to Medicare home health with ACL. Sent letter to CMS on federal nursing home regulation, oversight, and enforcement. Discussed nursing homes, quality, and enforcement, nursing home abuses with Senate staff. Discussed RAISE Family Caregivers Act implementation (P.L. 115-119). Discussed ways to support family caregivers caring for Medicare beneficiaries, prescription drugs, Medicare, and fraud and abuse. S. 1091, Supporting Grandparents Raising Grandchildren Act - Discussed bill. Discussed rural health care and certified nurse aide training programs in nursing homes. S. 445/H.R. 1825, Home Health Planning Improvement Act - Discussed support for the bill. H.R. 1421/S. 568, Improving Access to Medicare Coverage Act - Discussed the legislation and possible next steps. Discussed supporting family caregivers in Medicare and Medicaid. Submitted comment letters to CMS on proposed Medicare payment rules regarding skilled nursing facilities, hospice, and inpatient rehabilitation facilities. Responded to inquiry regarding Medicare funding being used for various purposes and noted relevant legislation and regulatory action including the Bipartisan Budget Act (P.L. 115-123), Independence at Home Act (S. 464), Independence at Home Demonstration Improvement and Extension Act (H.R. 3263), CHRONIC Care Act (S. 870), and Medicare Advantage supplemental benefits. H.R. 5306/S. 2227, EMPOWER Care Act - Discussed support for bill. Submitted federal comments to CMS on New Jersey 1115 waiver amendment regarding a caregiving program. Discussed Medicare post-acute care, family caregivers and ways to support them. Discussed Medicare and Diabetes Prevention Program with CMS and CDC staff. Provided feedback on Medicare Long-Term Care Services and Supports Act. Discussed Medicare Advantage (MA) benchmark caps and the impact on certain states. Filed comments on 1115 waiver applications or 1115 waiver amendment applications for Arizona, and Florida. Filed a comment letter in response to an RFI on D-SNP appeals and grievance processes. Filed a comment letter on a proposed Medicaid Access Rule.

Client expense: $2,220,000 · Firm income: Not reported

Government targets: Centers For Disease Control & Prevention (CDC), Centers For Medicare and Medicaid Services (CMS), Consumer Financial Protection Bureau (CFPB), Federal Communications Commission (FCC), Government Accountability Office (GAO), HOUSE OF REPRESENTATIVES, Health & Human Services, Dept of (HHS), Housing & Urban Development, Dept of (HUD), Natl Highway Traffic Safety Administration (NHTSA), Office of Management & Budget (OMB), SENATE, Securities & Exchange Commission (SEC), Social Security Administration (SSA), U.S. Trade Representative (USTR), Veterans Affairs, Dept of (VA), White House Office

Physician payment policy including implementation of H.R.2, the Medicare Access and CHIP Reauthorization Act of 2015; H.R. 1421/S. 568 related to observation status; H.R.6, SUPPORT for Patients and Communities Act.

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

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

Imputed Floor (FY 19 IPPS rule) 340B Drug Pricing Program Opioids SUD patient record sharing (H.R. 3545/S. 1850) 190-day limit on inpatient psychiatric care under Medicare (HR 2509) IMD exclusion (H.R. 2938/S. 1169) Veterans mental health and SUD at non-VA facilities (no specific bill) Observation status (H.R. 1421/S. 568) MISSION ZERO (H.R. 880/S. 1022) ALTO (H.R. 5197/S. 2516)

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

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