MARSHFIELD CLINIC HEALTH SYSTEM

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: H.R.3682

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: H.R.3765

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: HR 3258

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: HR 3590

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: HR 3962

The following bullet points summarize the objectives of the Marshfield Clinic's Health Policy Agenda: "value-based purchasing of health services including bonus payments for high value Medicare Advantage programs; "establishment and funding of comparative effectiveness research; "promoting payment fairness in Medicare physician and practice expense payments; promoting payment fairness in Medicare physician and practice expense payments; new formulas for aligning Medicare reimbursement with value; bonus payments for efficient providers; bonus payments for primary care providers; financing for the adoption and utilization of health information technology; repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments; improved reimbursement for the CMS Physician Group Practice (PGP) demonstration; expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration; Adequate funding for CMS; Adequate funding for community health centers; Funding for after-school programs Integration of Medical and dental care and records Meaningful use of HIT; Funding for medical simulation training Personalized medicine Healthy lifestyles programs Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. H.R.3682 : Patient Centered Healthcare Savings Act of 2011 Sponsor: Rep Duffy, Sean P. - Marshfield Clinic, the corporate sponsor of Security Health Plan, a five star Medicare Advantage program, opposes provisions which promote the sale of insurance across state lines but do not address the disparities in existing state law which would allow other insurance entities to circumvent Wisconsin law. HR 3630 the House Payroll Tax holiday bill H.R.3630 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave. The bill also included a "doc fix" - a 1% increase in Medicare physician payment for 2012 and 2013; The bill also extends through 2012 the floor at 1.0 on the work geographic index in the formula for determining relative values for physicians' services for the Medicare physician payment; and directed MEDPAC to assess whether any geographic adjustment is needed under Medicare to distinguish the difference in work effort by geographic area, and if so, what that level should be and were it should be applied. The bill also revises Medicare hospital outpatient department (OPD) payment amounts for evaluation and management services, bringing them into parity with physician E&M payments. H.R.3765 Temporary Payroll Tax Cut Continuation Act of 2011 Sponsor: Rep Camp, Dave two month extension Medicare physician payment increase. HR 3258 - Medicare Equity Extension Act of 2011 Sponsor Rep. Bruce Braley- Amends Medicare formulae for determining payments for physician services under part B to extend through calendar 2013: (1) a specified formula element for the employee wage and rent portions of the Medicare practice expense geographic adjustment, and (2) the Medicare work geographic adjustment floor at 1.0 under the Medicare and Medicaid Extenders Act of 2010. Value Based Purchasing The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. Medicare Payment Dilemma The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. Current Medicare payment policy values service delivery without regard to quality or need. The Medicare system rewards physicians for providing care even when it is not needed. We recognize the importance of primary care and care coordinated through the use of unitary electronic medical records, but these expectations and values are at odds with the current reimbursement system and the distribution of payments throughout the country. Sustainable Growth Rate Medicares SGR mechanism unfairly links physician payment updates to factors unrelated to patients needs and the cost of providing patient care. For years the Marshfield Clinic has watched Medicare physician payments atrophy in proportion to the cost of providing Medicare Services. In 2010 the Clinic recovered only 52.45% of the Medicare Allowable Costs of serving Medicare patients. In 2009 the Clinic lost 49.6 cents on each dollar of care provided. As payments have deteriorated in both the Medicare and Medicaid sector, the Clinic has documented increasing patient counts as other physicians and providers in the communities that we serve turn patients away. The difficulty of correctly updating physician fees is complicated by problems with the fee schedule regarding resource use, compensation for care coordination, and volume growth that point to Mispricing related to the value of physician services; inaccuracy of practice expense (overhead) calculations; and increasing variation in the volumes of services provided in different regions of the country. Uncertainty about the Medicare/Medicaid revenue stream complicates Clinic efforts to provide services where they are needed. Stability, adequacy, and predictability in payment should be the highest priority for Congress to assure high quality efficient care for all patients, but especially for the 20% of the population that is chronically ill and responsible for 75% of Medicare spending. Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities? Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis. Payment Fairness for Practice Costs The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs. Currently, CMS uses the median hourly earnings of four occupational classes -- Clerical Workers, Registered Nurses, Licensed Practical Nurses, and Medical Technicians -- found in physician offices as proxy non-physician wage input cost measures. These proxy occupational classes, which were the most common employees in physician practices in the 1980s, are now only a subset of non-physician employees in physician practices. The practice of medicine has changed substantially since the proxy measurement formulae were established. Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments. Medicare Advantage The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. Medical Simulation Training The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. The need for medical simulation is great; medical errors continue to kill approximately 98,000 people annually. Over the past decade, this amounts to almost a staggering one million accidental patient deaths. These errors cost the US approximately $17-$29 billion annually. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience. New measures may be necessary for ACOs because the current measures reflect the limitations and incentives of the current FFS payment system. A focused set of measures would help assure Medicare that the ACO is doing its job and help assure beneficiaries that they are receiving high quality care. The ACO metrics could include population-based outcomes measures such as: Emergency room use, Potentially preventable admission rates, In-hospital mortality rates, and possibly patient safety measures, and Readmission rates. In addition to outcomes measures, CMS could also consider measuring patient experience with health care provided under the ACO and health status. There should be a focused set of measures tracking how well care is provided, rather than how many services are provided. Community Health Centers Under Health Reform The Affordable Care Act included provisions relating to community health centers, including $11 billion in new funding for the community health center program. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. It is possible that these payment reforms may open up new avenues for enhanced Medicare reimbursement for Family Health Center/Marshfield Clinic patients. Finally, the Act acknowledges the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center -based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records. Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act.

Client expense: $55,000 · Firm income: —

Matched citations: S. 365

Budget Control Act (S. 365, PL 112-25) provisions requiring mandatory sequestration of federal funding if Congress does not act to implement deficit reduction. Medicare Payment Advisory Commission recommendations regarding reform of the Sustainable Growth Rate (SGR) formula of the Medicare physician fee schedule, and offsets to fund the reforms. Afterschool Health Services Program The primary focus is an Afterschool Health Services Program, which provides the infrastructure for communities to work collaboratively to improve health of youth in afterschool settings. This approach recognizes afterschool programs as a credible venue for health improvement as our nation moves forward with health care reform. This approach also takes into account the research base that demonstrates that a quality education is a number one determinant to good health. Afterschool programs have an opportunity to facilitate the transformation of existing programs to add value in both the health and education sectors. Marshfield Clinic will support legislation to implement quality services in afterschool settings that include case management of individual youth to promote academic success, personal/social development and health/wellness. This will include access to clinical services designed to meet the identified needs of enrolled youth i.e. early and periodic screening, well-child visits, immunizations, behavioral health appointments/treatment plan compliance, dental screening and sealants, asthma case management; Evidence-based programs, practices and policies targeting identified health priorities i.e. alcohol and other substance use and addiction, high-risk sexual behavior, intentional and unintentional injuries and violence, overweight, obesity and lack of physical activity, tobacco use and exposure; Release of information forms and written consents signed by parents prior to services. Healthy Lifestyles Program There is a need for strategic action at the federal level to counter the obesity epidemic in our nation. Chronic diseases related to obesity such as diabetes, heart disease, high blood pressure and certain cancers are the leading causes of premature death and disability. Unless the obesity epidemic can be curbed, the life expectancy of future generations will be compromised. Programs, practices and policy approaches that have been effective in the adult population such as employee wellness and policies promoting physical activity must be implemented early in life to redirect obesity inducing habits and behaviors in children. Evidence shows that physical activity and nutrition policies and programs can decrease obesity levels and promote life-long healthy habits in children. Marshfield Clinic will support legislation to implement policies that take a comprehensive approach to obesity prevention, addressing nutrition and physical activity in a broad variety of environments including communities, businesses and schools. Medicaid Block Grants On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2013, the federal share of all Medicaid payments would be paid to the states as a block grant (indexed to CPI-U and population growth). Federal requirements would be reduced and states would have flexibility in designing their programs. Starting in 2022, the block grant would be reduced to exclude projected spending for acute care services or Medicare premiums and cost-sharing paid by Medicaid. Ryans projected savings to federal government are $750 billion over 10 years. Federal spending in 2022 would be 35% lower than it is now. Premium support On April 15, the House approved Rep. Paul Ryans budget proposal for FY 2012, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For people now 55 or younger, the traditional Medicare program a defined benefit plan would cease to exist and, starting in 2022, would be converted to a defined contribution program which has been described as a premium support program.

Client expense: $55,000 · Firm income: —

Matched citations: S. 365

INS (Insurance) Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs.

Client expense: $90,000 · Firm income: —

Matched citations: HR 1628

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Calls for Value Based Purchasing for all providers The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare physician payments will transition to an incentive-based system based on value and accountability. Starting in 2019, Medicare physician payment will be based on the Merit-Based Incentive Payment System (MIPS). Physicians who perform well on quality, value and IT metrics will be rewarded with higher pay rates and those who perform poorly will face penalties. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) is developing metrics that will be used to determine the bonus payments and penalties that will start in 2019. The proposed metrics simplify and consolidate the existing measurements employed under the Meaningful Use Incentive Program, the Physician Reporting System (PQRS), and the Value-Based Modifier (VBM) to streamline the reporting burden for physician practices. MIPS will then pay physicians based on four weighted performance categories: Quality, Advancing Care Information; Clinical Practice Improvement Activities; and Resource Use. Having a source of credible data as the foundation of CMS metrics is critical both to fair payment and maintaining access to medical services in rural areas. We expressed concerns about the dilution of incentives payments for good performance, due to the increased number of exceptions from MACRA requirements. Federal funding for children with complex medical needs We asked for assistance in funding care coordination for children with complex medical needs. Medicare Advantage The Medicare Advantage program provides a full-risk, capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) By authorizing Quality Incentive Payments for MA plans with star ratings of 4 stars and above, Congress made a significant policy change towards value-based purchasing in the MA program. If a plan is eligible for a Quality Incentive Payment, it receives it in the form of a 5 percent increase to its benchmark. However, Congress also authorized a new methodology for calculating benchmarks, and mandated that benchmarks under the new methodology cannot be greater than what they would have been under the old benchmark methodology. This is the benchmark cap. The benchmark cap reduces or even eliminates Quality Incentive Payments. The policy issue is that the cap weakens the incentive for plans to attain higher star ratings and undermines the shift towards paying for performance in the MA program. We do not think that Congress intended to take away with one provision (the cap) the significant policy change towards paying for value that it enacted in the ACA. This change will have a significant negative impact on Medicare Advantage beneficiaries. CMS has indicated that it wants to remove the cap administratively, and we believe that HHS and CMS have the discretionary authority under law to make the necessary changes. If HHS and CMS do not make the change, then a statutory change will be necessary in the 115th Congress. The benchmark cap costs Medicare Advantage enrollees in Security Health Plans population more than $25 more in their monthly premium. We supported HR 4952 introduced by Rep Ron Kind that calls for an HHS study and report of the effects of the inclusion of quality increases in the determination of blended benchmark amounts under part C of the Medicare Program. Graduate Medical Education MCHS is concerned about having a sufficient supply of primary care physicians to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in rural settings. Currently only about 10% of physicians practice in rural areas while 25% of the population resides there. While 36% allopathic residents and 50% osteopathic residents who are trained in a rural residency end up practicing in a rural area, only 4% of the residency training actually occurs in rural areas. Currently there are more US medical students graduating from medical school than there are GME slots. An increase in GME primary care training positions is essential to maintaining high-quality, accessible, and cost efficient care. Teaching hospitals in rural locations provide an environment for residents to learn and faculty to serve as educators, providers and researchers. These roles advance the broad mission of preparing each generation of physicians, provide critical patient care and specialized services, often to the disadvantaged, facilitate the discovery of new therapies and treatments, and enable residents to acclimate to the rural setting. As new payment and delivery models emphasize primary care to improve patient outcomes and reduce costs, and as more care shifts to outpatient settings, teaching faculty and residency programs must increase access to ambulatory residency rotations to serve Americans who live in areas with an under-supply of primary care physicians including Geriatrics and Psychiatry. The purpose and value of residency training in clinical settings and the financial support needed to sustain physician education will only increase as the U.S. population lives longer with more complex health conditions. To ensure GME can meet the future needs of the newly insured and aging population, Congress must commit to the consistent GME funding and lift Medicares limit on funded residency positions. We support the Teaching Health Center funding in the Medicare Access and CHIP Reauthorization ACT (MACRA) for Community Health Centers but request you extend funding beyond 2017. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine (IOM) and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. These corrections are necessary to assure the credibility of the changes enacted in MACRA. We supported congressional requests for additional research by the GAO to understand the discrepancies in rural costs and reimbursement. Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. We recommend that the Medicare requirement for non-MSA geographic location of the patient be expanded to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. In addition, MCHS supports the CONNECT for Health Act that contains a provision which would permit Medicare Advantage plans to use telehealth or remote patient monitoring technologies to provide basic Medicare benefits, without the restrictions that limit originating sites, geographic locations, store-and-forward technologies, and types of health care provider. We believe that telehealth is a different way of delivering an already covered service, and that Medicare should treat remote access technologies as an alternative modality or complementary means of providing clinical services, and not a service itself. In other words, telehealth should not be seen as simply a supplement or complement to face-to-face encounters. Patients increasingly expect their health plans to provide the access to services and convenience that remote technologies facilitate. These technologies can increase communication between providers and patients, enhance care coordination, and help physicians and patients work together to treat illness and maintaining health.

Client expense: $90,000 · Firm income: —

Matched citations: HR 4952

HCR (Health Issues) National Farm Safety Support for occupational safety and health funding for Fiscal Year 2015. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program. Accountability in Drug Pricing MCHS and Security health Plan have supported the FAIR Drug Pricing Act Introduced by U.S. Senators Tammy Baldwin (D-WI) and John McCain (R-AZ) and U.S. Representative Jan Schakowsky (D-IL). The legislation takes the first step in addressing skyrocketing prescription drug prices by requiring transparency for pharmaceutical corporations that plan to increase drug prices. Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082 This bill amends the Public Health Service Act to align federal privacy standards for substance use disorder (SUD) patient records more closely with standards under the Health Insurance Portability and Accountability Act (HIPAA). Specifically, the bill authorizes the disclosure of SUD patient records without a patient's written consent to: (1) a covered entity for the purposes of treatment, payment, and health care operations, as long as the disclosure is made in accordance with HIPAA; and (2) a public health authority, as long as the content of the disclosure meets HIPAA standards regarding de-identified information. Current law authorizes disclosure of SUD patient records without a patient's written consent only to medical personnel in a medical emergency, to specified personnel for research or program evaluations, or pursuant to a court order. The House bill, the SUPPORT for Patients and Communities Act, H.R. 6, and the Senate bill, the Opioid Crisis Response Act represent critical steps in addressing the nations opioid epidemic. We strongly urge you to include the Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082, in the final opioid agreement. This language will bolster the effectiveness of other key provisions in the package that promote coordinated care and expand access to treatment. Part 2, federal regulations that govern confidentiality of drug and alcohol treatment and prevention records, sets requirements limiting the use and disclosure of patients substance use records from certain substance use programs. Patients are required to give multiple consents, creating a barrier for integration and coordination of health care. A lack of access to the full scope of medical information for each patient can result in the inability of providers and organizations to deliver safe, high-quality treatment and care coordination. The barriers presented by Part 2 can result in the failure to integrate services and can lead to potentially dangerous medical situations for patients. As Congress works to reconcile both chambers opioid bills, the inclusion of provisions to align Part 2 with HIPAA for TPO is critical. Modifying Part 2 to ensure that HIPAA-covered entities have access to a patients entire medical record will improve patient safety, treatment, and outcomes across the care delivery spectrum, enhancing the entire opioid package. MCHS believes that the modernization of privacy regulations and medical records for persons with substance use disorders is a critical component for tackling the opioid crisis and will improve the overall coordination of care in the United States. We urge you to include H.R. 6082 in the final opioids agreement sent to the President.

Client expense: $90,000 · Firm income: —

Matched citations: H.R. 6

HCR (Health Issues) National Farm Safety Support for occupational safety and health funding for Fiscal Year 2015. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program. Accountability in Drug Pricing MCHS and Security health Plan have supported the FAIR Drug Pricing Act Introduced by U.S. Senators Tammy Baldwin (D-WI) and John McCain (R-AZ) and U.S. Representative Jan Schakowsky (D-IL). The legislation takes the first step in addressing skyrocketing prescription drug prices by requiring transparency for pharmaceutical corporations that plan to increase drug prices. Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082 This bill amends the Public Health Service Act to align federal privacy standards for substance use disorder (SUD) patient records more closely with standards under the Health Insurance Portability and Accountability Act (HIPAA). Specifically, the bill authorizes the disclosure of SUD patient records without a patient's written consent to: (1) a covered entity for the purposes of treatment, payment, and health care operations, as long as the disclosure is made in accordance with HIPAA; and (2) a public health authority, as long as the content of the disclosure meets HIPAA standards regarding de-identified information. Current law authorizes disclosure of SUD patient records without a patient's written consent only to medical personnel in a medical emergency, to specified personnel for research or program evaluations, or pursuant to a court order. The House bill, the SUPPORT for Patients and Communities Act, H.R. 6, and the Senate bill, the Opioid Crisis Response Act represent critical steps in addressing the nations opioid epidemic. We strongly urge you to include the Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082, in the final opioid agreement. This language will bolster the effectiveness of other key provisions in the package that promote coordinated care and expand access to treatment. Part 2, federal regulations that govern confidentiality of drug and alcohol treatment and prevention records, sets requirements limiting the use and disclosure of patients substance use records from certain substance use programs. Patients are required to give multiple consents, creating a barrier for integration and coordination of health care. A lack of access to the full scope of medical information for each patient can result in the inability of providers and organizations to deliver safe, high-quality treatment and care coordination. The barriers presented by Part 2 can result in the failure to integrate services and can lead to potentially dangerous medical situations for patients. As Congress works to reconcile both chambers opioid bills, the inclusion of provisions to align Part 2 with HIPAA for TPO is critical. Modifying Part 2 to ensure that HIPAA-covered entities have access to a patients entire medical record will improve patient safety, treatment, and outcomes across the care delivery spectrum, enhancing the entire opioid package. MCHS believes that the modernization of privacy regulations and medical records for persons with substance use disorders is a critical component for tackling the opioid crisis and will improve the overall coordination of care in the United States. We urge you to include H.R. 6082 in the final opioids agreement sent to the President.

Client expense: $90,000 · Firm income: —

Matched citations: H.R. 6082

INS (Insurance) Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs.

Client expense: $110,000 · Firm income: —

Matched citations: HR 1628

MMM (Medicare and Medicaid) Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Calls for Value Based Purchasing for all providers The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare physician payments will transition to an incentive-based system based on value and accountability. Starting in 2019, Medicare physician payment will be based on the Merit-Based Incentive Payment System (MIPS). Physicians who perform well on quality, value and IT metrics will be rewarded with higher pay rates and those who perform poorly will face penalties. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) is developing metrics that will be used to determine the bonus payments and penalties that will start in 2019. The proposed metrics simplify and consolidate the existing measurements employed under the Meaningful Use Incentive Program, the Physician Reporting System (PQRS), and the Value-Based Modifier (VBM) to streamline the reporting burden for physician practices. MIPS will then pay physicians based on four weighted performance categories: Quality, Advancing Care Information; Clinical Practice Improvement Activities; and Resource Use. Having a source of credible data as the foundation of CMS metrics is critical both to fair payment and maintaining access to medical services in rural areas. We expressed concerns about the dilution of incentives payments for good performance, due to the increased number of exceptions from MACRA requirements. Medicare Advantage The Medicare Advantage program provides a full-risk, capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) By authorizing Quality Incentive Payments for MA plans with star ratings of 4 stars and above, Congress made a significant policy change towards value-based purchasing in the MA program. If a plan is eligible for a Quality Incentive Payment, it receives it in the form of a 5 percent increase to its benchmark. However, Congress also authorized a new methodology for calculating benchmarks, and mandated that benchmarks under the new methodology cannot be greater than what they would have been under the old benchmark methodology. This is the benchmark cap. The benchmark cap reduces or even eliminates Quality Incentive Payments. The policy issue is that the cap weakens the incentive for plans to attain higher star ratings and undermines the shift towards paying for performance in the MA program. We do not think that Congress intended to take away with one provision (the cap) the significant policy change towards paying for value that it enacted in the ACA. This change will have a significant negative impact on Medicare Advantage beneficiaries. CMS has indicated that it wants to remove the cap administratively, and we believe that HHS and CMS have the discretionary authority under law to make the necessary changes. If HHS and CMS do not make the change, then a statutory change will be necessary in the 115th Congress. The benchmark cap costs Medicare Advantage enrollees in Security Health Plans population more than $25 more in their monthly premium. We supported HR 4952 introduced by Rep Ron Kind that calls for an HHS study and report of the effects of the inclusion of quality increases in the determination of blended benchmark amounts under part C of the Medicare Program. Graduate Medical Education MCHS is concerned about having a sufficient supply of primary care physicians to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in rural settings. Currently only about 10% of physicians practice in rural areas while 25% of the population resides there. While 36% allopathic residents and 50% osteopathic residents who are trained in a rural residency end up practicing in a rural area, only 4% of the residency training actually occurs in rural areas. Currently there are more US medical students graduating from medical school than there are GME slots. An increase in GME primary care training positions is essential to maintaining high-quality, accessible, and cost efficient care. Teaching hospitals in rural locations provide an environment for residents to learn and faculty to serve as educators, providers and researchers. These roles advance the broad mission of preparing each generation of physicians, provide critical patient care and specialized services, often to the disadvantaged, facilitate the discovery of new therapies and treatments, and enable residents to acclimate to the rural setting. As new payment and delivery models emphasize primary care to improve patient outcomes and reduce costs, and as more care shifts to outpatient settings, teaching faculty and residency programs must increase access to ambulatory residency rotations to serve Americans who live in areas with an under-supply of primary care physicians including Geriatrics and Psychiatry. The purpose and value of residency training in clinical settings and the financial support needed to sustain physician education will only increase as the U.S. population lives longer with more complex health conditions. To ensure GME can meet the future needs of the newly insured and aging population, Congress must commit to the consistent GME funding and lift Medicares limit on funded residency positions. We support the Teaching Health Center funding in the Medicare Access and CHIP Reauthorization ACT (MACRA) for Community Health Centers but request you extend funding beyond 2017. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine (IOM) and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. These corrections are necessary to assure the credibility of the changes enacted in MACRA. Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. We recommend that the Medicare requirement for non-MSA geographic location of the patient be expanded to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. In addition, MCHS supports the CONNECT for Health Act that contains a provision which would permit Medicare Advantage plans to use telehealth or remote patient monitoring technologies to provide basic Medicare benefits, without the restrictions that limit originating sites, geographic locations, store-and-forward technologies, and types of health care provider. We believe that telehealth is a different way of delivering an already covered service, and that Medicare should treat remote access technologies as an alternative modality or complementary means of providing clinical services, and not a service itself. In other words, telehealth should not be seen as simply a supplement or complement to face-to-face encounters. Patients increasingly expect their health plans to provide the access to services and convenience that remote technologies facilitate. These technologies can increase communication between providers and patients, enhance care coordination, and help physicians and patients work together to treat illness and maintaining health. General Issue Area Code

Client expense: $110,000 · Firm income: —

Matched citations: HR 4952

HCR (Health Issues) National Farm Safety Support for occupational safety and health funding for Fiscal Year 2015. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program. Accountability in Drug Pricing MCHS and Security health Plan have supported the FAIR Drug Pricing Act Introduced by U.S. Senators Tammy Baldwin (D-WI) and John McCain (R-AZ) and U.S. Representative Jan Schakowsky (D-IL). The legislation takes the first step in addressing skyrocketing prescription drug prices by requiring transparency for pharmaceutical corporations that plan to increase drug prices. Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082 This bill amends the Public Health Service Act to align federal privacy standards for substance use disorder (SUD) patient records more closely with standards under the Health Insurance Portability and Accountability Act (HIPAA). Specifically, the bill authorizes the disclosure of SUD patient records without a patient's written consent to: (1) a covered entity for the purposes of treatment, payment, and health care operations, as long as the disclosure is made in accordance with HIPAA; and (2) a public health authority, as long as the content of the disclosure meets HIPAA standards regarding de-identified information. Current law authorizes disclosure of SUD patient records without a patient's written consent only to medical personnel in a medical emergency, to specified personnel for research or program evaluations, or pursuant to a court order. The House bill, the SUPPORT for Patients and Communities Act, H.R. 6, and the Senate bill, the Opioid Crisis Response Act represent critical steps in addressing the nations opioid epidemic. We strongly urge you to include the Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082, in the final opioid agreement. This language will bolster the effectiveness of other key provisions in the package that promote coordinated care and expand access to treatment. Part 2, federal regulations that govern confidentiality of drug and alcohol treatment and prevention records, sets requirements limiting the use and disclosure of patients substance use records from certain substance use programs. Patients are required to give multiple consents, creating a barrier for integration and coordination of health care. A lack of access to the full scope of medical information for each patient can result in the inability of providers and organizations to deliver safe, high-quality treatment and care coordination. The barriers presented by Part 2 can result in the failure to integrate services and can lead to potentially dangerous medical situations for patients. As Congress works to reconcile both chambers opioid bills, the inclusion of provisions to align Part 2 with HIPAA for TPO is critical. Modifying Part 2 to ensure that HIPAA-covered entities have access to a patients entire medical record will improve patient safety, treatment, and outcomes across the care delivery spectrum, enhancing the entire opioid package. MCHS believes that the modernization of privacy regulations and medical records for persons with substance use disorders is a critical component for tackling the opioid crisis and will improve the overall coordination of care in the United States. We urge you to include H.R. 6082 in the final opioids agreement sent to the President.

Client expense: $110,000 · Firm income: —

Matched citations: H.R. 6

HCR (Health Issues) National Farm Safety Support for occupational safety and health funding for Fiscal Year 2015. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program. Accountability in Drug Pricing MCHS and Security health Plan have supported the FAIR Drug Pricing Act Introduced by U.S. Senators Tammy Baldwin (D-WI) and John McCain (R-AZ) and U.S. Representative Jan Schakowsky (D-IL). The legislation takes the first step in addressing skyrocketing prescription drug prices by requiring transparency for pharmaceutical corporations that plan to increase drug prices. Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082 This bill amends the Public Health Service Act to align federal privacy standards for substance use disorder (SUD) patient records more closely with standards under the Health Insurance Portability and Accountability Act (HIPAA). Specifically, the bill authorizes the disclosure of SUD patient records without a patient's written consent to: (1) a covered entity for the purposes of treatment, payment, and health care operations, as long as the disclosure is made in accordance with HIPAA; and (2) a public health authority, as long as the content of the disclosure meets HIPAA standards regarding de-identified information. Current law authorizes disclosure of SUD patient records without a patient's written consent only to medical personnel in a medical emergency, to specified personnel for research or program evaluations, or pursuant to a court order. The House bill, the SUPPORT for Patients and Communities Act, H.R. 6, and the Senate bill, the Opioid Crisis Response Act represent critical steps in addressing the nations opioid epidemic. We strongly urge you to include the Overdose Prevention and Patient Safety (OPPS) Act, H.R. 6082, in the final opioid agreement. This language will bolster the effectiveness of other key provisions in the package that promote coordinated care and expand access to treatment. Part 2, federal regulations that govern confidentiality of drug and alcohol treatment and prevention records, sets requirements limiting the use and disclosure of patients substance use records from certain substance use programs. Patients are required to give multiple consents, creating a barrier for integration and coordination of health care. A lack of access to the full scope of medical information for each patient can result in the inability of providers and organizations to deliver safe, high-quality treatment and care coordination. The barriers presented by Part 2 can result in the failure to integrate services and can lead to potentially dangerous medical situations for patients. As Congress works to reconcile both chambers opioid bills, the inclusion of provisions to align Part 2 with HIPAA for TPO is critical. Modifying Part 2 to ensure that HIPAA-covered entities have access to a patients entire medical record will improve patient safety, treatment, and outcomes across the care delivery spectrum, enhancing the entire opioid package. MCHS believes that the modernization of privacy regulations and medical records for persons with substance use disorders is a critical component for tackling the opioid crisis and will improve the overall coordination of care in the United States. We urge you to include H.R. 6082 in the final opioids agreement sent to the President.

Client expense: $110,000 · Firm income: —

Matched citations: H.R. 6082

INS (Insurance) Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs.

Client expense: $100,000 · Firm income: —

Matched citations: HR 1628

MMM (Medicare and Medicaid) Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: Extends health insurance to the uninsured Calls for Value Based Purchasing for all providers The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare physician payments will transition to an incentive-based system based on value and accountability. Starting in 2019, Medicare physician payment will be based on the Merit-Based Incentive Payment System (MIPS). Physicians who perform well on quality, value and IT metrics will be rewarded with higher pay rates and those who perform poorly will face penalties. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) is developing metrics that will be used to determine the bonus payments and penalties that will start in 2019. The proposed metrics simplify and consolidate the existing measurements employed under the Meaningful Use Incentive Program, the Physician Reporting System (PQRS), and the Value-Based Modifier (VBM) to streamline the reporting burden for physician practices. MIPS will then pay physicians based on four weighted performance categories: Quality, Advancing Care Information; Clinical Practice Improvement Activities; and Resource Use. Having a source of credible data as the foundation of CMS metrics is critical both to fair payment and maintaining access to medical services in rural areas. We expressed concerns about the dilution of incentives payments for good performance, due to the increased number of exceptions from MACRA requirements. Medicare Advantage The Medicare Advantage program provides a full-risk, capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) By authorizing Quality Incentive Payments for MA plans with star ratings of 4 stars and above, Congress made a significant policy change towards value-based purchasing in the MA program. If a plan is eligible for a Quality Incentive Payment, it receives it in the form of a 5 percent increase to its benchmark. However, Congress also authorized a new methodology for calculating benchmarks, and mandated that benchmarks under the new methodology cannot be greater than what they would have been under the old benchmark methodology. This is the benchmark cap. The benchmark cap reduces or even eliminates Quality Incentive Payments. The policy issue is that the cap weakens the incentive for plans to attain higher star ratings and undermines the shift towards paying for performance in the MA program. We do not think that Congress intended to take away with one provision (the cap) the significant policy change towards paying for value that it enacted in the ACA. This change will have a significant negative impact on Medicare Advantage beneficiaries. CMS has indicated that it wants to remove the cap administratively, and we believe that HHS and CMS have the discretionary authority under law to make the necessary changes. If HHS and CMS do not make the change, then a statutory change will be necessary in the 115th Congress. The benchmark cap costs Medicare Advantage enrollees in Security Health Plans population more than $25 more in their monthly premium. We supported HR 4952 introduced by Rep Ron Kind that calls for an HHS study and report of the effects of the inclusion of quality increases in the determination of blended benchmark amounts under part C of the Medicare Program. Graduate Medical Education MCHS is concerned about having a sufficient supply of primary care physicians to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in rural settings. Currently only about 10% of physicians practice in rural areas while 25% of the population resides there. While 36% allopathic residents and 50% osteopathic residents who are trained in a rural residency end up practicing in a rural area, only 4% of the residency training actually occurs in rural areas. Currently there are more US medical students graduating from medical school than there are GME slots. An increase in GME primary care training positions is essential to maintaining high-quality, accessible, and cost efficient care. Teaching hospitals in rural locations provide an environment for residents to learn and faculty to serve as educators, providers and researchers. These roles advance the broad mission of preparing each generation of physicians, provide critical patient care and specialized services, often to the disadvantaged, facilitate the discovery of new therapies and treatments, and enable residents to acclimate to the rural setting. As new payment and delivery models emphasize primary care to improve patient outcomes and reduce costs, and as more care shifts to outpatient settings, teaching faculty and residency programs must increase access to ambulatory residency rotations to serve Americans who live in areas with an under-supply of primary care physicians including Geriatrics and Psychiatry. The purpose and value of residency training in clinical settings and the financial support needed to sustain physician education will only increase as the U.S. population lives longer with more complex health conditions. To ensure GME can meet the future needs of the newly insured and aging population, Congress must commit to the consistent GME funding and lift Medicares limit on funded residency positions. We support the Teaching Health Center funding in the Medicare Access and CHIP Reauthorization ACT (MACRA) for Community Health Centers but request you extend funding beyond 2017. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine (IOM) and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. These corrections are necessary to assure the credibility of the changes enacted in MACRA. Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine. We recommend that the Medicare requirement for non-MSA geographic location of the patient be expanded to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. In addition, MCHS supports the CONNECT for Health Act that contains a provision which would permit Medicare Advantage plans to use telehealth or remote patient monitoring technologies to provide basic Medicare benefits, without the restrictions that limit originating sites, geographic locations, store-and-forward technologies, and types of health care provider. We believe that telehealth is a different way of delivering an already covered service, and that Medicare should treat remote access technologies as an alternative modality or complementary means of providing clinical services, and not a service itself. In other words, telehealth should not be seen as simply a supplement or complement to face-to-face encounters. Patients increasingly expect their health plans to provide the access to services and convenience that remote technologies facilitate. These technologies can increase communication between providers and patients, enhance care coordination, and help physicians and patients work together to treat illness and maintaining health. Oral Health Coverage for the Medically Compromised and at Risk Populations There is sufficient data that demonstrates oral health impacts the systemic health of the patient and in doing can reduce the cost of care. Linkages that encourage patient compliance, patient education, provider education, and bi-directional referral and surveillance should be incented and compensated. Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care. Protecting Access to Medicare Act of 2014 (PAMA) PAMA includes reforms to the Clinical Lab Fee Schedule (CLFS). This rule for PAMA requires reporting of Clinical lab prices and volumes. MCHS requested a delay in the reporting, and changes to expand the definition of applicable lab to represent the true market of all laboratories; requested greater transparency of calculations; more time to allow for gathering data and implementation.

Client expense: $100,000 · Firm income: —

Matched citations: HR 4952

INS (Insurance) Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. HR 1628 the Better Care Reconciliation Act -- MCHS expressed reservations about the Better Care Reconciliation Act (BCRA) as currently written. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs.

Client expense: $120,000 · Firm income: —

Matched citations: HR 1628

TAX Private Activity Bonds We opposed the elimination of private activity bonds and advance refunding bonds contained in H.R. 1, the Tax Cuts and Jobs Act. Health Provisions Individual Mandate Penalties We opposed to the repeal of the individual mandate. The Senate bill effectively repeals the Affordable Care Act individual mandate by eliminating the tax penalty in 2019. Eliminating the mandate without implementing an alternative means to drive enrollment among healthy individuals will likely result in a deterioration of the risk pool due to lower coverage rates among healthier individuals. Refunding Cost Sharing Reductions is needed but must also be coupled with other mechanisms such as a federally funded reinsurance program, to assure stability of the exchanges. If the individual mandate is repealed, these alternative stabilization programs could mitigate some of the resulting premium increases, leading to a stable market. Deduction of Medical Expenses We opposed the repeal of the itemized deduction for Medical Expenses included in the House Bill. This provision would adversely affect those individuals who experience a high-cost medical event. While this is a small percentage of the population every year, these individuals are the most vulnerable to medical bankruptcies, which are difficult both for the individual and the community that must absorb the costs.

Client expense: $80,000 · Firm income: —

Matched citations: H.R. 1

INS (Insurance) Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. HR 1628 the Better Care Reconciliation Act -- MCHS expressed reservations about the Better Care Reconciliation Act (BCRA) as currently written. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs. Impact of the Better Care Reconciliation Act -Tax credits are income based, but only up to 350% of the FPL versus 400% as in the ACA. The impact of this is significant to the population we serve. -Cost sharing subsides are eliminated as of 2020. This will mean increases in out-of-pocket expenses for those under 250% of FPL of thousands of dollars. -The benchmark plan will be lowered to 58% actuarial value (currently at 70%). That reduction will substantially lower the amount of tax credit people will be eligible for and will likely make most plans unaffordable for those under 250% FPL. While the House of Representatives did acknowledge the divide between expansion and non-expansion states, the House-passed bill came up far short of providing true equity and fairness in the system. The Senate BCRA has not improved on the equity of the formula, and in the most basic analysis, taxes paid in Wisconsin will go to fund expansion in other States. We asked for fairness for Medicaid payments throughout the States, including Wisconsin.

Client expense: $80,000 · Firm income: —

Matched citations: HR 1628

BUD (Budget and Appropriations) We requested inclusion of Community Health Center funding, Childrens Health Insurance Program funding, and Medicare extenders with the Continuing resolutions filed as a stopgap for federal funding. National Farm Safety Support for occupational safety and health funding for Fiscal Year 2017 and 2018. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program. AmeriCorps Funding We supported continued Funding of the AmeriCorps program in fiscal year 2017 and 2018. Market Stability in budget reconciliation legislation and in tax bill HR 1628, the American Health Care Act (AHCA) and the Better Care Reconciliation Act (BRCA) will result in a large number of individuals covered under the Affordable Care Act (ACA) with preexisting conditions to lose the necessary coverage to maintain their health. MCHS recommended opposition to the AHCA, BRCA, and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA and BRCA will undermine what works in the ACA without improving on the circumstances, coverage and care of Wisconsin residents in the individual and small group market. We urged Congress to take steps to improve and repair health coverage in the areas where the ACA was falling short, and to also maintain the gains that the ACA has provided to assure that no one, especially those near poverty, fall through the cracks: Stabilizing the market - Regulatory relief offered earlier this year by Secretary Tom Price at HHS gave health insurers tools to better manage their ACA individual population, but those reforms didnt go far enough to fully stabilize the market. We believe that the suggestions below will improve the ACA and ensure coverage for vulnerable populations. a. Cost sharing reduction payments - SHPs ACA individual population is heavily reliant on the cost sharing reduction (CSR) subsides paid monthly to help our members lower their out-of-pocket costs. Nearly half of the total enrollment in SHPs ACA products is eligible and enrolled in this important program. We recommend that Congress should fully fund CSR payments to health insurance carriers for 2018 and beyond and allow states that have already reached their filing deadline to reopen carriers bids to allow for an adjustment to rates. b. Extension of the reinsurance program - The transitional reinsurance program established by the ACA helped to hold down premiums in 2014, 2015 and 2016. Our Plans experience shows that premiums would have been nearly 20 percent higher in 2014 and 6 percent higher in 2015, had this program not been in effect. We recommend that Congress create a reinsurance program similar to the program that expired in 2017 to stabilize premiums in the ACA individual market for the long term. c. Continuous coverage provision - The ACA provisions that provide for a three-month grace period and avoid tax penalties has created a perverse incentive for enrollees to stay insured for just enough time to avoid the penalty. We recommend that Congress should create a continuous enrollment provision or late enrollment penalty similar to Medicares Part B and Part D to incentivize 12 month enrollment in the ACA individual market. d. Risk adjustment program enhancements - We recommend that HHS risk adjustment program should pay carriers a capitation for members whose risk scores exceed a certain predefined value. Lower-than-current future rate increases would reduce expenditures for the advanced premium tax credits. e. Federal funding for enrollee outreach - Health insurance and the subsidies available to help area residents afford coverage is a complex and confusing topic. We recommend that navigator services should be re-instated and funds prioritized to rural areas for community outreach. HR 1628 the Better Care Reconciliation Act -- MCHS expressed reservations about the Better Care Reconciliation Act (BCRA) as currently written. Challenges of serving rural Wisconsin . We serve about 1 million residents in our rural area Subsidization of health coverage for low income Wisconsinites has helped mainstream tens of thousands into traditional commercial coverage through the Health Insurance Marketplace. This has been vital to the health of our patients enabling us to educate patients and include them in prevention programs. Impact of the Better Care Reconciliation Act -Tax credits are income based, but only up to 350% of the FPL versus 400% as in the ACA. The impact of this is significant to the population we serve. -Cost sharing subsides are eliminated as of 2020. This will mean increases in out-of-pocket expenses for those under 250% of FPL of thousands of dollars. -The benchmark plan will be lowered to 58% actuarial value (currently at 70%). That reduction will substantially lower the amount of tax credit people will be eligible for and will likely make most plans unaffordable for those under 250% FPL. While the House of Representatives did acknowledge the divide between expansion and non-expansion states, the House-passed bill came up far short of providing true equity and fairness in the system. The Senate BCRA has not improved on the equity of the formula, and in the most basic analysis, taxes paid in Wisconsin will go to fund expansion in other States. We requested fairness for Medicaid payments throughout the States, including Wisconsin.

Client expense: $80,000 · Firm income: —

Matched citations: HR 1628