mr BRENT MILLER

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.

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

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.

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.

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.

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.

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.

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.

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.

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. Market Stability in budget reconciliation legislation HR 1628, the American Health Care Act (AHCA) 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 and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA 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: Near term stability of the individual market: In the short term, it is imperative the individual market remain a stable, viable option for people to get and maintain coverage. Through Security Health Plan, Marshfield Clinic Health System has seen many people who previously did not have coverage secure coverage, sometimes for the first time. Ensuring that this market is stable through 2018 will give enrollees and health insurers time to enact new reforms aimed at making care more affordable in the long term. Maintaining coverage for the near poverty population: Replacement plans should consider the low income population under 250 percent of the Federal Poverty Line. Half of Security Health Plans membership purchasing a plan on the individual market falls into this category. The AHCAs elimination of cost sharing subsides would have a significant impact on the affordability of care and will increase bad debt to providers which ultimately increases costs for everyone. Stability and continuity of coverage for this population is critical to the health of rural Wisconsin. Reduction in uncollected medical debt: Hand in hand with coverage of the near poverty population is the reduction in uncollected medical debt care providers have experienced. This reduction has allowed integrated delivery systems, like Marshfield Clinic Health System, to keep overall commercial rates down. If uncollected medical debt were to again increase due to an increase in the uninsured rate, the commercial market pricing (i.e. employer group market) will bear the brunt of price increases. Flexibility in coverage of care that saves long term costs: Marshfield Clinic Health System has been a leader in providing care in alternative settings that saves cost, maintains quality and improves patient experience. Programs such as our comfort and recovery suites save our patients considerably more than the cost of the same procedure done in an inpatient setting. Marshfield Clinic Health System would advocate for the opportunity to use these programs for any patient, but due to regulatory barriers cannot (e.g. Medicaid beneficiaries). Flexibility in benefits offered: Today, due to Federal regulation, health insurers are mandated to cover a set of essential health benefits with little flexibility in altering coverage. This approach leaves minimal opportunity to design benefit plans that meet the needs of particular populations (i.e. the very young or near Medicare populations). A more flexible, state-based approach to regulating the benefits that can be offered in health insurance product is preferable. Regionalized high risk pools: Wisconsin has significant experience with high risk pools, like the Health Insurance Risk Sharing Pool. If risk pools are enacted in a thoughtful manner, they can reduce the cost to consumers across the commercially insured population. Marshfield Clinic Health System would advocate for the establishment of high risk pools managed by the private market and infused with federal dollars. Integrated care delivery systems are uniquely positioned to manage the risk of these high care need populations. 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 urge you to demand fairness for Medicaid payments throughout the States, including Wisconsin.

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.

HR 1628, the American Health Care Act (AHCA) 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 and any changes to the coverage afforded by the ACA. The changes proposed under the AHCA 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: Near term stability of the individual market: In the short term, it is imperative the individual market remain a stable, viable option for people to get and maintain coverage. Through Security Health Plan, Marshfield Clinic Health System has seen many people who previously did not have coverage secure coverage, sometimes for the first time. Ensuring that this market is stable through 2018 will give enrollees and health insurers time to enact new reforms aimed at making care more affordable in the long term. Maintaining coverage for the near poverty population: Replacement plans should consider the low income population under 250 percent of the Federal Poverty Line. Half of Security Health Plans membership purchasing a plan on the individual market falls into this category. The AHCAs elimination of cost sharing subsides would have a significant impact on the affordability of care and will increase bad debt to providers which ultimately increases costs for everyone. Stability and continuity of coverage for this population is critical to the health of rural Wisconsin. Reduction in uncollected medical debt: Hand in hand with coverage of the near poverty population is the reduction in uncollected medical debt care providers have experienced. This reduction has allowed integrated delivery systems, like Marshfield Clinic Health System, to keep overall commercial rates down. If uncollected medical debt were to again increase due to an increase in the uninsured rate, the commercial market pricing (i.e. employer group market) will bear the brunt of price increases. Flexibility in coverage of care that saves long term costs: Marshfield Clinic Health System has been a leader in providing care in alternative settings that saves cost, maintains quality and improves patient experience. Programs such as our comfort and recovery suites save our patients considerably more than the cost of the same procedure done in an inpatient setting. Marshfield Clinic Health System would advocate for the opportunity to use these programs for any patient, but due to regulatory barriers cannot (e.g. Medicaid beneficiaries). Flexibility in benefits offered: Today, due to Federal regulation, health insurers are mandated to cover a set of essential health benefits with little flexibility in altering coverage. This approach leaves minimal opportunity to design benefit plans that meet the needs of particular populations (i.e. the very young or near Medicare populations). A more flexible, state-based approach to regulating the benefits that can be offered in health insurance product is preferable. Regionalized high risk pools: Wisconsin has significant experience with high risk pools, like the Health Insurance Risk Sharing Pool. If risk pools are enacted in a thoughtful manner, they can reduce the cost to consumers across the commercially insured population. Marshfield Clinic Health System would advocate for the establishment of high risk pools managed by the private market and infused with federal dollars. Integrated care delivery systems are uniquely positioned to manage the risk of these high care need populations. 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 urge you to demand fairness for Medicaid payments throughout the States, including Wisconsin.

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.

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 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 urge you to demand fairness for Medicaid payments throughout the States, including Wisconsin.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. 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. Flexibility in coverage of care that saves long term costs: Marshfield Clinic Health System has been a leader in providing care in alternative settings that saves cost, maintains quality and improves patient experience. Programs such as our comfort and recovery suites cut approximately a third of the costs vs hospitalization. Marshfield Clinic Health System would advocate for the opportunity to use these programs for any patient, but due to regulatory barriers cannot (e.g. Medicaid beneficiaries).

Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. Unfortunately, CMS has not allowed for a pathway for Track 1 ACOs in their second three year term to transition to a full risk Track until 2019, which forecloses our opportunities to become an APM. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 Secretary Burwell and CMS have the authority under law to make the necessary changes. If HHS and CMS do not make the change, then a statutory change will be necessary. Medicare Advantage benchmark cap legislation was introduced in December. We urge you to cosponsor H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress eliminated the constant threat of inappropriate cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2025. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) must develop specific metrics that will be used to determine the bonus payments and penalties that will start in 2019 in public rulemaking well before 2019. We have concerns about the regulatory process that will be used to determine which alternative delivery systems warrant bonus payments, as well as the metrics that will determine bonuses and penalties for those remaining in a fee-for-service payment system. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Graduate Medical Education - 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. 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 MACRA for Community Health Centers but request you extend funds beyond 2017. 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. Medicare Advantage benchmark cap legislation was introduced in December. H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, would remove the quality incentive payments from the calculation of the benchmark cap. Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) are the initial co-sponsors. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. Unfortunately, CMS has not allowed for a pathway for Track 1 ACOs in their second three year term to transition to a full risk Track until 2019, which forecloses our opportunities to become an APM. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 Secretary Burwell and CMS have the authority under law to make the necessary changes. If HHS and CMS do not make the change, then a statutory change will be necessary. Medicare Advantage benchmark cap legislation was introduced in December. We urge you to cosponsor H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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 Calls for the establishment of Accountable Care Organizations 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), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. 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 in a public rulemaking currently underway. 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 (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). 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. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable Care Act and MACRA. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Accountable Care Organizations Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition. 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 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 MACRA for Community Health Centers but request you extend funding beyond 2017. The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) 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. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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 (S. 2484) and (H.R. 4442) 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. Part B Drug Payment Model CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care. MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients. MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. Advance Care Planning MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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. Personalized (Precision) Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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 population-based 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

Federally Facilitated Exchange Policy Issues Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013. Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience. Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies. Privacy and Security provisions of ARRA The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about: Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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 population-based 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress eliminated the constant threat of inappropriate cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2025. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) must develop specific metrics that will be used to determine the bonus payments and penalties that will start in 2019 in public rulemaking well before 2019. We have concerns about the regulatory process that will be used to determine which alternative delivery systems warrant bonus payments, as well as the metrics that will determine bonuses and penalties for those remaining in a fee-for-service payment system. The GAO has recently posted notice seeking nomination for a Technical Advisory Committee to assist CMS in the development of metrics. We urged Congress support the nomination of individuals that represent the interests of health systems that will be participating in the Alternative Payment Systems. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Graduate Medical Education -- 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; and facilitate the discovery of new therapies and treatments. 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. 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 and current level of GME funding and lift Medicares limit on funded residency positions. 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. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Improvements Marshfield Clinic supports legislation expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Calls for the establishment of Accountable Care Organizations The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress eliminated the constant threat of inappropriate cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2025. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) must develop specific metrics that will be used to determine the bonus payments and penalties that will start in 2019 in public rulemaking well before 2019. We have concerns about the regulatory process that will be used to determine which alternative delivery systems warrant bonus payments, as well as the metrics that will determine bonuses and penalties for those remaining in a fee-for-service payment system. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Graduate Medical Education - 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. 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 MACRA for Community Health Centers but request you extend funds beyond 2017. 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. Medicare Advantage benchmark cap legislation was introduced in December. H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, would remove the quality incentive payments from the calculation of the benchmark cap. Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) are the initial co-sponsors. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Calls for the establishment of Accountable Care Organizations The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress eliminated the constant threat of inappropriate cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2025. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) must develop specific metrics that will be used to determine the bonus payments and penalties that will start in 2019 in public rulemaking well before 2019. We have concerns about the regulatory process that will be used to determine which alternative delivery systems warrant bonus payments, as well as the metrics that will determine bonuses and penalties for those remaining in a fee-for-service payment system. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Graduate Medical Education - 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. 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 MACRA for Community Health Centers but request you extend funds beyond 2017. 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. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Calls for the establishment of Accountable Care Organizations The following are key elements of the health policy agenda of the Marshfield Clinic Health System: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Access and CHIP Reauthorization Act With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress eliminated the constant threat of inappropriate cuts to Medicare physician fees. Going forward 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. Participants in Alternative Payment Systems such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2025. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) must develop specific metrics that will be used to determine the bonus payments and penalties that will start in 2019 in public rulemaking well before 2019. We have concerns about the regulatory process that will be used to determine which alternative delivery systems warrant bonus payments, as well as the metrics that will determine bonuses and penalties for those remaining in a fee-for-service payment system. MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals. Graduate Medical Education - 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. 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 MACRA for Community Health Centers but request you extend funds beyond 2017. 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. Medicare Advantage benchmark cap legislation was introduced in December. H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, would remove the quality incentive payments from the calculation of the benchmark cap. Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) are the initial co-sponsors. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Transparency Marshfield Clinic supported provisions included in MACRA that would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

Opposition to Innovation Act/H.R. 9. As written, HR 9 could deter investment in research, and reduce protections for patent holders. Marshfield Clinic Health System MCHS is concerned that H.R.9 will hinder legitimate patent holders ability to quickly resolve patent disputes.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

Federally Facilitated Exchange Policy Issues Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013. Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience. Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies. Privacy and Security provisions of ARRA The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about: Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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 population-based 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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. Personalized (Precision) Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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 population-based 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Reform of Medicares Sustainable Growth Rate (HR 2). We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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. We supported repeal of the Medical Device tax in HR 160 and S 149. We supported funding for farm safety in appropriations. We lobbied against further cuts to Medicare Advantage organizations, and requested assistance with CMS to improve the administration of the laboratory fee schedule, and to remove the cuts to high value 4 and 5 star Medicare Advantage plans included in the Medicare Advantage benchmark cap.

Opposition to the Budget Control Act of 2011(PL 112-25), which required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting spending cuts, including the healthcare cuts. HR 2775, the Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014. The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 24% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package. H Con Res 25 - A concurrent resolution establishing the budget for the United States government for fiscal year 2014 and setting forth appropriate budgetary levels for fiscal years 2015 through 2023. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access - Wisconsin's current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinic's proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsin's future rural dental workforce.

Federally Facilitated Exchange Policy Issues Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013.Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience. Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies. We opposed the absence of a complete regular order consideration of the Equitable Access to Care and Health Act, HR 1814, by Rep Aaron Schock, which would create a new religious exemption to the individual mandate. This bill was approved by the House under suspension of the Rules on Community Engagement for Healthy Lifestyles Coalitions, Afterschool, AmeriCorps and Community Organizations Improving the health of an entire community goes beyond doctor-patient visits, to population health efforts directed at vulnerable populations. Recognizing the complexity of health challenges facing young people and the strong intersection between community coalition efforts, afterschool approaches and improved health, Marshfield Clinic has developed a sustainable infrastructure to unite the efforts of its clinics with grassroots coalitions, afterschool programs, tribal communities and other community stakeholders. Marshfield clinic believes that high quality afterschool programs are a credible venue to improve the health and education of children and communities. Afterschool programs are poised to assist children to develop and reinforce lifelong healthy habits to stem the tide of chronic disease and to reduce the incidence of lifestyle related disease related to alcohol, tobacco and other substance abuse; high risk sexual behavior; intentional and unintentional injuries and violence; overweight, obesity and lack of physical activity; and, tobacco use and exposure. There is a critical 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. 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, schools and afterschool programs. To this end, Marshfield Clinic supports federal funding designed to improve the health and education outcomes of youth, children and families. Examples of funding streams that are of particular importance include: Corporation for National Service AmeriCorps Program; Department of Education 21st Century funding; and, the Department of Health and Human Services Child Care Development Block Grant; Center for Disease Control Childhood Obesity Prevention and Community Transformation grants; etc. Privacy and Security provisions of ARRA The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about: Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities. Meaningful Use of health information technology On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. Rules issued by CMS outline provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. Final regulations issued by ONC set initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. 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.

Federally Facilitated Exchange Policy Issues Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013.Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience. Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies. We opposed the absence of a complete regular order consideration of the Equitable Access to Care and Health Act, HR 1814, by Rep Aaron Schock, which would create a new religious exemption to the individual mandate. This bill was approved by the House under suspension of the Rules on Community Engagement for Healthy Lifestyles Coalitions, Afterschool, AmeriCorps and Community Organizations Improving the health of an entire community goes beyond doctor-patient visits, to population health efforts directed at vulnerable populations. Recognizing the complexity of health challenges facing young people and the strong intersection between community coalition efforts, afterschool approaches and improved health, Marshfield Clinic has developed a sustainable infrastructure to unite the efforts of its clinics with grassroots coalitions, afterschool programs, tribal communities and other community stakeholders. Marshfield clinic believes that high quality afterschool programs are a credible venue to improve the health and education of children and communities. Afterschool programs are poised to assist children to develop and reinforce lifelong healthy habits to stem the tide of chronic disease and to reduce the incidence of lifestyle related disease related to alcohol, tobacco and other substance abuse; high risk sexual behavior; intentional and unintentional injuries and violence; overweight, obesity and lack of physical activity; and, tobacco use and exposure. There is a critical 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. 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, schools and afterschool programs. To this end, Marshfield Clinic supports federal funding designed to improve the health and education outcomes of youth, children and families. Examples of funding streams that are of particular importance include: Corporation for National Service AmeriCorps Program; Department of Education 21st Century funding; and, the Department of Health and Human Services Child Care Development Block Grant; Center for Disease Control Childhood Obesity Prevention and Community Transformation grants; etc. Privacy and Security provisions of ARRA The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about: Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities.Meaningful Use of health information technology On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. Rules issued by CMS outline provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. Final regulations issued by ONC set initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. 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.

Federally Facilitated Exchange Policy Issues Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013. Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience. Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies. We opposed the absence of a complete regular order consideration of the Equitable Access to Care and Health Act, HR 1814, by Rep Aaron Schock, which would create a new religious exemption to the individual mandate. This bill was approved by the House under suspension of the Rules on Community Engagement for Healthy Lifestyles Coalitions, Afterschool, AmeriCorps and Community Organizations Improving the health of an entire community goes beyond doctor-patient visits, to population health efforts directed at vulnerable populations. Recognizing the complexity of health challenges facing young people and the strong intersection between community coalition efforts, afterschool approaches and improved health, Marshfield Clinic has developed a sustainable infrastructure to unite the efforts of its clinics with grassroots coalitions, afterschool programs, tribal communities and other community stakeholders. Marshfield clinic believes that high quality afterschool programs are a credible venue to improve the health and education of children and communities. Afterschool programs are poised to assist children to develop and reinforce lifelong healthy habits to stem the tide of chronic disease and to reduce the incidence of lifestyle related disease related to alcohol, tobacco and other substance abuse; high risk sexual behavior; intentional and unintentional injuries and violence; overweight, obesity and lack of physical activity; and, tobacco use and exposure. There is a critical 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. 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, schools and afterschool programs. To this end, Marshfield Clinic supports federal funding designed to improve the health and education outcomes of youth, children and families. Examples of funding streams that are of particular importance include: Corporation for National Service AmeriCorps Program; Department of Education 21st Century funding; and, the Department of Health and Human Services Child Care Development Block Grant; Center for Disease Control Childhood Obesity Prevention and Community Transformation grants; etc. Privacy and Security provisions of ARRA The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about: Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision. Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities. Meaningful Use of health information technology On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. Rules issued by CMS outline provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. Final regulations issued by ONC set initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy which will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. Meaningful Use of Health Information Technology The 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. 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, the tailoring of medical treatments to patient characteristics, allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. This should be supported.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: oExtends health insurance to the uninsured oEstablishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research oImposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limitsExpands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) without any of the extenders. Another version of doc fix legislation, H.R.4302 - Protecting Access to Medicare Act of 2014, was approved by the House and Senate on March 28 and March 31. This bill prevents the 24% cut in reimbursement to doctors, extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year; Delays the transition to ICD-10 under the Medicare program for 1 year. Transitional Fund for SGR Reform: Uses the $2.3 billion set aside for SGR in the Bipartisan Budget Act of 2013. Ensuring Accurate Values for Physician Fee Schedule Services: Allows the Secretary of Health and Human Services to use information received from medical providers and other sources to adjust code pricing to address mis-valued codes used under the Medicare Physician Fee Schedule. Medicare Pay for Value --Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments-- Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.Dental Access -Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics with another under construction. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions. Advance Care Planning - Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. There may or may not cost savings achieved depending on an individual patients wishes. More importantly, the discussions are necessary to assure that an individual patients desires for care at the end of life are being met and respected. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Call Letter On Feb 7, 2014, CMS released the "Call letter"- its annual advance notice regarding 2015 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 6-710%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Medicaid Block Grants On March 21, 2013 the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. The Clinic does not support this proposal in its present form. Loan Forgiveness Congress must continue to fund loan forgiveness for health profession shortage areas. The program funding should be regardless of HPSA ranking to ensure rural areas as well as urban areas can attract and staff an adequate workforce. S.T.E.M. Programming in High Schools and CollegesThe Department of Education should work in partnership with HRSA to promote change within accrediting bodies and states to create such programming. Distance learning technology should be seen as an alternative to cost prohibitive face to face curriculum. Incentives should for incorporating such technology should be considered.Premium support On March 21, 2013, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost. Accountable Care Organizations The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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]. Adequate Funding for CMS -- The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. GME Residency Expansion ---Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism --- As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs. This could include a shift from hospital based payment mechanisms for GME to ambulatory and community health center training locations. This would particularly help rural and underserved areas establish GME training programs. Additionally, given that teaming in healthcare is an essential element of achieving cost and quality opportunities, incentives should be developed for programs that incorporate inter-professional, team based training programs, and iEHR training. 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. Simulation Program Development 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness researchImposes necessary regulations on Insurers banning rescissions and exclusions for pre-existing medical conditions limits Expands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate -- We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value -- Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health -The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Transparency -- Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement - The Medicare Advantage program provides a 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. Medicare Advantage Improvements -H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Accountable Care Organizations - The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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. We recommend that CMS relax restrictions on the provision of services using telemedicine technologies to allow ACOs to increase the efficiency of services provided. Adequate Funding for CMS -The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform -- The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. 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. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: oExtends health insurance to the uninsured oEstablishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research oImposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limitsExpands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) without any of the extenders. Another version of doc fix legislation, H.R.4302 - Protecting Access to Medicare Act of 2014, was approved by the House and Senate on March 28 and March 31. This bill prevents the 24% cut in reimbursement to doctors, extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year; Delays the transition to ICD-10 under the Medicare program for 1 year. Transitional Fund for SGR Reform: Uses the $2.3 billion set aside for SGR in the Bipartisan Budget Act of 2013. Ensuring Accurate Values for Physician Fee Schedule Services: Allows the Secretary of Health and Human Services to use information received from medical providers and other sources to adjust code pricing to address mis-valued codes used under the Medicare Physician Fee Schedule. Medicare Pay for Value --Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments-- Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.Dental Access -Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics with another under construction. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions. Advance Care Planning - Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. There may or may not cost savings achieved depending on an individual patients wishes. More importantly, the discussions are necessary to assure that an individual patients desires for care at the end of life are being met and respected. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Call Letter On Feb 7, 2014, CMS released the "Call letter"- its annual advance notice regarding 2015 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 6-710%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Medicaid Block Grants On March 21, 2013 the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. The Clinic does not support this proposal in its present form. Loan Forgiveness Congress must continue to fund loan forgiveness for health profession shortage areas. The program funding should be regardless of HPSA ranking to ensure rural areas as well as urban areas can attract and staff an adequate workforce. S.T.E.M. Programming in High Schools and CollegesThe Department of Education should work in partnership with HRSA to promote change within accrediting bodies and states to create such programming. Distance learning technology should be seen as an alternative to cost prohibitive face to face curriculum. Incentives should for incorporating such technology should be considered.Premium support On March 21, 2013, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost. Accountable Care Organizations The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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]. Adequate Funding for CMS -- The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. GME Residency Expansion ---Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism --- As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs. This could include a shift from hospital based payment mechanisms for GME to ambulatory and community health center training locations. This would particularly help rural and underserved areas establish GME training programs. Additionally, given that teaming in healthcare is an essential element of achieving cost and quality opportunities, incentives should be developed for programs that incorporate inter-professional, team based training programs, and iEHR training. 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. Simulation Program Development 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. 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.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: oExtends health insurance to the uninsured oEstablishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research oImposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limitsExpands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) without any of the extenders. Another version of doc fix legislation, H.R.4302 - Protecting Access to Medicare Act of 2014, was approved by the House and Senate on March 28 and March 31. This bill prevents the 24% cut in reimbursement to doctors, extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year; Delays the transition to ICD-10 under the Medicare program for 1 year. Transitional Fund for SGR Reform: Uses the $2.3 billion set aside for SGR in the Bipartisan Budget Act of 2013. Ensuring Accurate Values for Physician Fee Schedule Services: Allows the Secretary of Health and Human Services to use information received from medical providers and other sources to adjust code pricing to address mis-valued codes used under the Medicare Physician Fee Schedule. Medicare Pay for Value --Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments-- Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.Dental Access -Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics with another under construction. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions. Advance Care Planning - Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. There may or may not cost savings achieved depending on an individual patients wishes. More importantly, the discussions are necessary to assure that an individual patients desires for care at the end of life are being met and respected. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Call Letter On Feb 7, 2014, CMS released the "Call letter"- its annual advance notice regarding 2015 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 6-710%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Medicaid Block Grants On March 21, 2013 the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. The Clinic does not support this proposal in its present form. Loan Forgiveness Congress must continue to fund loan forgiveness for health profession shortage areas. The program funding should be regardless of HPSA ranking to ensure rural areas as well as urban areas can attract and staff an adequate workforce. S.T.E.M. Programming in High Schools and CollegesThe Department of Education should work in partnership with HRSA to promote change within accrediting bodies and states to create such programming. Distance learning technology should be seen as an alternative to cost prohibitive face to face curriculum. Incentives should for incorporating such technology should be considered.Premium support On March 21, 2013, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost. Accountable Care Organizations The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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]. Adequate Funding for CMS -- The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. GME Residency Expansion ---Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism --- As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs. This could include a shift from hospital based payment mechanisms for GME to ambulatory and community health center training locations. This would particularly help rural and underserved areas establish GME training programs. Additionally, given that teaming in healthcare is an essential element of achieving cost and quality opportunities, incentives should be developed for programs that incorporate inter-professional, team based training programs, and iEHR training. 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. Simulation Program Development 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness researchImposes necessary regulations on Insurers banning rescissions and exclusions for pre-existing medical conditions limits Expands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate -- We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value -- Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health -The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Transparency -- Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement - The Medicare Advantage program provides a 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. Medicare Advantage Improvements -H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Accountable Care Organizations - The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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. We recommend that CMS relax restrictions on the provision of services using telemedicine technologies to allow ACOs to increase the efficiency of services provided. Adequate Funding for CMS -The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform -- The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. 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. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy which will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. Meaningful Use of Health Information Technology The 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. 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, the tailoring of medical treatments to patient characteristics, allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. This should be supported.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness researchImposes necessary regulations on Insurers banning rescissions and exclusions for pre-existing medical conditions limits Expands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate -- We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value -- Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health -The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Transparency -- Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement - The Medicare Advantage program provides a 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. Medicare Advantage Improvements -H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Accountable Care Organizations - The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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. We recommend that CMS relax restrictions on the provision of services using telemedicine technologies to allow ACOs to increase the efficiency of services provided. Adequate Funding for CMS -The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform -- The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. 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. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: oExtends health insurance to the uninsured oEstablishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research oImposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limitsExpands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) without any of the extenders. Another version of doc fix legislation, H.R.4302 - Protecting Access to Medicare Act of 2014, was approved by the House and Senate on March 28 and March 31. This bill prevents the 24% cut in reimbursement to doctors, extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year; Delays the transition to ICD-10 under the Medicare program for 1 year. Transitional Fund for SGR Reform: Uses the $2.3 billion set aside for SGR in the Bipartisan Budget Act of 2013. Ensuring Accurate Values for Physician Fee Schedule Services: Allows the Secretary of Health and Human Services to use information received from medical providers and other sources to adjust code pricing to address mis-valued codes used under the Medicare Physician Fee Schedule. Medicare Pay for Value --Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments-- Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.Dental Access -Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics with another under construction. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions. Advance Care Planning - Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. There may or may not cost savings achieved depending on an individual patients wishes. More importantly, the discussions are necessary to assure that an individual patients desires for care at the end of life are being met and respected. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Call Letter On Feb 7, 2014, CMS released the "Call letter"- its annual advance notice regarding 2015 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 6-710%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Medicaid Block Grants On March 21, 2013 the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. The Clinic does not support this proposal in its present form. Loan Forgiveness Congress must continue to fund loan forgiveness for health profession shortage areas. The program funding should be regardless of HPSA ranking to ensure rural areas as well as urban areas can attract and staff an adequate workforce. S.T.E.M. Programming in High Schools and CollegesThe Department of Education should work in partnership with HRSA to promote change within accrediting bodies and states to create such programming. Distance learning technology should be seen as an alternative to cost prohibitive face to face curriculum. Incentives should for incorporating such technology should be considered.Premium support On March 21, 2013, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost. Accountable Care Organizations The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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]. Adequate Funding for CMS -- The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. GME Residency Expansion ---Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism --- As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs. This could include a shift from hospital based payment mechanisms for GME to ambulatory and community health center training locations. This would particularly help rural and underserved areas establish GME training programs. Additionally, given that teaming in healthcare is an essential element of achieving cost and quality opportunities, incentives should be developed for programs that incorporate inter-professional, team based training programs, and iEHR training. 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. Simulation Program Development 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. 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.

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 Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research Imposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limits Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy which will further public health. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative - amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. 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. Meaningful Use of Health Information Technology The 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. 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, the tailoring of medical treatments to patient characteristics, allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. This should be supported.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic: oExtends health insurance to the uninsured oEstablishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research oImposes necessary regulations on Insurers - banning rescissions and exclusions for pre-existing medical conditions limitsExpands Medicaid Eligibility to 133% of FPL Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL) Increases practice expense payments, Calls for IOM study to Correct Geographic payment disparities Calls for CMS to establish a Value Index to align payment with quality Establishes Bonus payments for primary care, efficiency, quality Calls for Value Based Purchasing for all providers Calls for the establishment of Accountable Care Organizations Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models The following are key elements of the health policy agenda of the Marshfield Clinic: Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) without any of the extenders. Another version of doc fix legislation, H.R.4302 - Protecting Access to Medicare Act of 2014, was approved by the House and Senate on March 28 and March 31. This bill prevents the 24% cut in reimbursement to doctors, extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year; Delays the transition to ICD-10 under the Medicare program for 1 year. Transitional Fund for SGR Reform: Uses the $2.3 billion set aside for SGR in the Bipartisan Budget Act of 2013. Ensuring Accurate Values for Physician Fee Schedule Services: Allows the Secretary of Health and Human Services to use information received from medical providers and other sources to adjust code pricing to address mis-valued codes used under the Medicare Physician Fee Schedule. Medicare Pay for Value --Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices. Geographic Adjustment of Physician Payments-- Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.Dental Access -Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics with another under construction. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions. Advance Care Planning - Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. There may or may not cost savings achieved depending on an individual patients wishes. More importantly, the discussions are necessary to assure that an individual patients desires for care at the end of life are being met and respected. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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.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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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. Transparency Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Medicare Advantage Call Letter On Feb 7, 2014, CMS released the "Call letter"- its annual advance notice regarding 2015 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 6-710%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill. Medicaid Block Grants On March 21, 2013 the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. The Clinic does not support this proposal in its present form. Loan Forgiveness Congress must continue to fund loan forgiveness for health profession shortage areas. The program funding should be regardless of HPSA ranking to ensure rural areas as well as urban areas can attract and staff an adequate workforce. S.T.E.M. Programming in High Schools and CollegesThe Department of Education should work in partnership with HRSA to promote change within accrediting bodies and states to create such programming. Distance learning technology should be seen as an alternative to cost prohibitive face to face curriculum. Incentives should for incorporating such technology should be considered.Premium support On March 21, 2013, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost. Accountable Care Organizations The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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]. Adequate Funding for CMS -- The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. Recommendations: 1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation. 2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement. Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services. 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. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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. GME Residency Expansion ---Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism --- As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs. This could include a shift from hospital based payment mechanisms for GME to ambulatory and community health center training locations. This would particularly help rural and underserved areas establish GME training programs. Additionally, given that teaming in healthcare is an essential element of achieving cost and quality opportunities, incentives should be developed for programs that incorporate inter-professional, team based training programs, and iEHR training. 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. Simulation Program Development 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. 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.

Opposition to the Budget Control Act of 2011(PL 112-25), which required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting spending cuts, including the healthcare cuts. HR 2775, the Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014. The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 24% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package. H Con Res 25 - A concurrent resolution establishing the budget for the United States government for fiscal year 2014 and setting forth appropriate budgetary levels for fiscal years 2015 through 2023. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access - Wisconsin's current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinic's proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsin's future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsin's current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinic's proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsin's future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months,but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. HR 2775 The Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014. The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 21% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed,President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed,President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic. The following are key elements of the health policy agenda of the Marshfield Clinic:Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. The Clinic is in CMS's shared savings program as an Accountable Care Organization effective January 1, 2013. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions.Advance Care Planning Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. Advance care plans are not necessarily a one-time conversation, but an ongoing dialogue between a patient and health provider. Honoring patient desires and wishes at the end-of-life reduces the burden on family members that would otherwise have to make those difficult decisions. An advance care plan must be easily accessible in their medical record. Research indicates that engaging patients on their end-of-life care and following their wishes and desires may reduce healthcare costs. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Physician payment reform On Feb 7, the House Energy and Commerce & Ways and Means Committees released an outline of a collaborative Medicare Physician Payment Reform Effort. Their leaders are united in a collaborative efforts to repeal the Sustainable Growth Rate (SGR) formula and advance a permanent solution for Medicare physician payment. Their proposal seeks to: Repeal the SGR and provide a period of predictable, statutorily-defined physician payment rates; Reform Medicares fee for service (FFS) physician payment system to reward physicians who provide high quality care; and Build upon the improvements made in Phase 2 by also rewarding physicians who deliver efficient care. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) SGR Repeal and Medicare Beneficiary Access Act of 2013 introduced by Senator Max Baucus would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) Medicare Patient Access and Quality Improvement Act of 2013 introduced by Rep. Michael Burgess. 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.Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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 ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. We fully support the continuation of this program, and the financial rewards provided to health plans that perform at the highest level. Medicare Advantage Call Letter On Feb 15 2013, CMS released the "Call letter"- its annual advance notice regarding 2014 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 8-10%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. The Clinic recommended: that CMS delay implementing any change to the county FFS rebasing methodology; override the SGR formula, consistent with the emerging consensus regarding a shift to payment for value; recommended a delay in implementing a new HCC risk adjustment model; recommended postponement of changes to the star ratings calculations. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System Medicaid Block Grants On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. Total annual spending on dual eligibles is estimated to be $300 billion annually. The Patient Protection and Affordable Care Act (PPACA) presents an array of new and enhanced options to improve care for these beneficiaries through better care integration, improved quality measures, and increased access to home and community-based long-term services and support. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost.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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs Oral Health Coverage for the Medically Compromised and at Risk Populations 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. Simulation Program Development 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. 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. 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. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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.Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including funding for the community health center program and funding to expand the National Health Service Corp. Congress has cut the base funding levels for community health centers and it is possible that they may do so again effectively further 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, under network adequacy rules, contract with a sufficient number of essential community providers, the definition of which includes health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminate the outdated Medicare payment cap on FQHC payments. This will modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. ACA recognizes 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. It directly appropriates $230 million over five years for the new Title III payment program. Marshfield Clinic supports the continuation of this funding. 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. FHC has been providing on-site dental services since the fall of 2002 and operates eight dental sites with two additional sites scheduled to open in the summer of 2011. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. The latest version of the CattailsDental includes: a dental dashboard, workflow management tools including tooth charting, periodontal charting and treatment planning; access to centralized medications, allergies, special conditions, problems list, demographics and HIPAA forms; access to medical appointments to support better coordination of care; and highly secure remote access supporting alternate devices (laptops and tablets). 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. GME Residency Expansion Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic. The following are key elements of the health policy agenda of the Marshfield Clinic:Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. The Clinic is in CMS's shared savings program as an Accountable Care Organization effective January 1, 2013. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions.Advance Care Planning Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. Advance care plans are not necessarily a one-time conversation, but an ongoing dialogue between a patient and health provider. Honoring patient desires and wishes at the end-of-life reduces the burden on family members that would otherwise have to make those difficult decisions. An advance care plan must be easily accessible in their medical record. Research indicates that engaging patients on their end-of-life care and following their wishes and desires may reduce healthcare costs. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Physician payment reform On Feb 7, the House Energy and Commerce & Ways and Means Committees released an outline of a collaborative Medicare Physician Payment Reform Effort. Their leaders are united in a collaborative efforts to repeal the Sustainable Growth Rate (SGR) formula and advance a permanent solution for Medicare physician payment. Their proposal seeks to: Repeal the SGR and provide a period of predictable, statutorily-defined physician payment rates; Reform Medicares fee for service (FFS) physician payment system to reward physicians who provide high quality care; and Build upon the improvements made in Phase 2 by also rewarding physicians who deliver efficient care. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) SGR Repeal and Medicare Beneficiary Access Act of 2013 introduced by Senator Max Baucus would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) Medicare Patient Access and Quality Improvement Act of 2013 introduced by Rep. Michael Burgess. 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.Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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 ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. We fully support the continuation of this program, and the financial rewards provided to health plans that perform at the highest level. Medicare Advantage Call Letter On Feb 15 2013, CMS released the "Call letter"- its annual advance notice regarding 2014 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 8-10%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. The Clinic recommended: that CMS delay implementing any change to the county FFS rebasing methodology; override the SGR formula, consistent with the emerging consensus regarding a shift to payment for value; recommended a delay in implementing a new HCC risk adjustment model; recommended postponement of changes to the star ratings calculations. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System Medicaid Block Grants On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. Total annual spending on dual eligibles is estimated to be $300 billion annually. The Patient Protection and Affordable Care Act (PPACA) presents an array of new and enhanced options to improve care for these beneficiaries through better care integration, improved quality measures, and increased access to home and community-based long-term services and support. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost.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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs Oral Health Coverage for the Medically Compromised and at Risk Populations 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. Simulation Program Development 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. 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. 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. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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.Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including funding for the community health center program and funding to expand the National Health Service Corp. Congress has cut the base funding levels for community health centers and it is possible that they may do so again effectively further 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, under network adequacy rules, contract with a sufficient number of essential community providers, the definition of which includes health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminate the outdated Medicare payment cap on FQHC payments. This will modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. ACA recognizes 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. It directly appropriates $230 million over five years for the new Title III payment program. Marshfield Clinic supports the continuation of this funding. 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. FHC has been providing on-site dental services since the fall of 2002 and operates eight dental sites with two additional sites scheduled to open in the summer of 2011. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. The latest version of the CattailsDental includes: a dental dashboard, workflow management tools including tooth charting, periodontal charting and treatment planning; access to centralized medications, allergies, special conditions, problems list, demographics and HIPAA forms; access to medical appointments to support better coordination of care; and highly secure remote access supporting alternate devices (laptops and tablets). 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. GME Residency Expansion Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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.

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic. The following are key elements of the health policy agenda of the Marshfield Clinic:Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use. Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. The Clinic is in CMS's shared savings program as an Accountable Care Organization effective January 1, 2013. Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine 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. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas. Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year. CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions.Advance Care Planning Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. Advance care plans are not necessarily a one-time conversation, but an ongoing dialogue between a patient and health provider. Honoring patient desires and wishes at the end-of-life reduces the burden on family members that would otherwise have to make those difficult decisions. An advance care plan must be easily accessible in their medical record. Research indicates that engaging patients on their end-of-life care and following their wishes and desires may reduce healthcare costs. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Physician payment reform On Feb 7, the House Energy and Commerce & Ways and Means Committees released an outline of a collaborative Medicare Physician Payment Reform Effort. Their leaders are united in a collaborative efforts to repeal the Sustainable Growth Rate (SGR) formula and advance a permanent solution for Medicare physician payment. Their proposal seeks to: Repeal the SGR and provide a period of predictable, statutorily-defined physician payment rates; Reform Medicares fee for service (FFS) physician payment system to reward physicians who provide high quality care; and Build upon the improvements made in Phase 2 by also rewarding physicians who deliver efficient care. The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) SGR Repeal and Medicare Beneficiary Access Act of 2013 introduced by Senator Max Baucus would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) Medicare Patient Access and Quality Improvement Act of 2013 introduced by Rep. Michael Burgess. 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.Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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 ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. We fully support the continuation of this program, and the financial rewards provided to health plans that perform at the highest level. Medicare Advantage Call Letter On Feb 15 2013, CMS released the "Call letter"- its annual advance notice regarding 2014 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 8-10%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. The Clinic recommended: that CMS delay implementing any change to the county FFS rebasing methodology; override the SGR formula, consistent with the emerging consensus regarding a shift to payment for value; recommended a delay in implementing a new HCC risk adjustment model; recommended postponement of changes to the star ratings calculations. Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System Medicaid Block Grants On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, 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 those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program. Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. Total annual spending on dual eligibles is estimated to be $300 billion annually. The Patient Protection and Affordable Care Act (PPACA) presents an array of new and enhanced options to improve care for these beneficiaries through better care integration, improved quality measures, and increased access to home and community-based long-term services and support. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost.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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act. 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. GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs Oral Health Coverage for the Medically Compromised and at Risk Populations 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. Simulation Program Development 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. 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. 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. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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.Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including funding for the community health center program and funding to expand the National Health Service Corp. Congress has cut the base funding levels for community health centers and it is possible that they may do so again effectively further 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, under network adequacy rules, contract with a sufficient number of essential community providers, the definition of which includes health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminate the outdated Medicare payment cap on FQHC payments. This will modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. ACA recognizes 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. It directly appropriates $230 million over five years for the new Title III payment program. Marshfield Clinic supports the continuation of this funding. 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. FHC has been providing on-site dental services since the fall of 2002 and operates eight dental sites with two additional sites scheduled to open in the summer of 2011. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. The latest version of the CattailsDental includes: a dental dashboard, workflow management tools including tooth charting, periodontal charting and treatment planning; access to centralized medications, allergies, special conditions, problems list, demographics and HIPAA forms; access to medical appointments to support better coordination of care; and highly secure remote access supporting alternate devices (laptops and tablets). 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. GME Residency Expansion Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. 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. As of 2012, 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.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsin's current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinic's proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsin's future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months,but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. HR 2775 The Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014. The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 21% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsin's current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinic's proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsin's future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed,President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. HR 2775 The Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014. The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 21% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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.Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months,but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending. The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains. The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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 March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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. 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 Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 into an accountable care organization program; 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 Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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 March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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. 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 Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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 March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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 March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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. 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 Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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. 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 Medicaid Block Grants On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. CMS is presently developing rules to implement a budget neutral value modifier for physician reimbursement modeled after pay for performance concepts. Quality measures for physicians and other providers are being refined and converging with the quality measures identified for the HIT meaningful use incentive program. The proposed rule for the physician value modifier is expected July 1. Marshfield Clinic has utilized its proprietary medical record to implement population health protocols which have successfully improved performance on CMS's Physician Group Practice Demonstration quality metrics while reducing costs for the care of a risk adjusted population. The Clinic intends to continue its participation in CMS's shared savings program as an Accountable Care Organization. Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. Medicare Advantage Performance Measurement The Medicare Advantage program provides a 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. Security Health Plan of Wisconsin, Inc., was one of only two health plans in the nation to be recognized for the second year in a row with the highest rating of 5 stars from the Centers for Medicare and Medicaid Services (CMS) for its Advocare Medicare Advantage plans for 2012. Only eight other plans across the nation this year received a 5-star rating from CMS. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. Affordable Care Act If the Supreme Court repeals all or part of the Affordable Care Act, Marshfield Clinic will continue on its current trajectory and mission serving patients though accessible, high quality, health care, research and education. If any portion of the law is repealed we would urge Congress to work swiftly to shore up the gaps in coverage to preserve universal access to health care services. 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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? 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. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. Further development of this public health infrastructure is in the national interest. 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 March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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. Chairman Ryan has projected savings to federal government that would result from reduced funding to states. Premium support On March 29, the House approved Rep. Paul Ryans budget proposal for FY 2013, 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 2023, would be converted to a defined contribution program which has been described as a premium support program. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas Statutory provisions to extend these additional payments lapse in 2012 and must be extended for 2013. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services initially 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 was selected by CMS to participate in the demonstration program, effective April 1, 2005 and has been involved as a participant working with CMS ever since. Marshfield Clinic supports CMS determination to extend this program, 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.

Budget Control Act (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 expiration of the Medicare Physician Work Floor and offsets to fund the reforms. The House Republican fiscal 2013 budget blueprint, (H. Con. Res. 112), called "the Path To Prosperity" written by Rep. Paul Ryan HR 8, The American Taxpayer Relief Act of 2012 Medicare Physician Payment Update. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013. Medicare physician payment rates are scheduled to be reduced by 26.5 percent on December 31, 2012. This provision would avoid that reduction and extend current Medicare payment rates through December 31, 2013. Work Geographic Adjustment. Under current law, the Medicare fee schedule is adjusted geographically for three factors to reflect differences in the cost of resources needed to produce physician services: physician work, practice expense, and medical malpractice insurance. This provision extends the existing 1.0 floor on the physician work index through December 31, 2013. Sequestration. This proposal would delay by two months automatic across-the-board cuts set to take effect January 2. AmeriCorps Funding: 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. 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. AmeriCorps Funding: 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. 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. Community Health Center Funding Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Payment Dilemma Currently the prevailing methods of paying for health care in the US neither encourage nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. 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. The skill sets that are now necessary to provide efficient, clinically appropriate care are different from those needed 30 years ago. 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 2008 the Clinic recovered only 51.8% 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? Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. 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, this geographic practice expense adjustment has weight of 43% in physician payments, making it a critical component of the physician fee schedule. To place this in perspective, the Congressional Research Service has reported that Medicare paid physicians $59.5 billion in 2007, implying that about $25.6 billion in payments were potentially affected by practice expense adjustments. The sheer magnitude of these potential affects is strong reason to develop and maintain finely tuned data for use in geographic adjustment of payments. 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 1980's, 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. Consequently, the relevance of the proxy occupational classes as a reasonable basis for making non-physician labor-related practice expense adjustments to payments has substantially declined. 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. Accountable Care Organizations The current Medicare payment system is not a forward looking system. It reflects our past medical practices more that it reflects our future medical practices. However, since it is likely that the current system will be in place for the foreseeable future, there are strong reasons to correct its many deficiencies. We fully support those efforts. In the longer term we believe that it will be important to develop alternative payment systems that properly reflect the emerging realities of delivering health care in the US. Some of the emerging ideas in this regard, including the concepts for Accountable Care Organizations and Medical Home as examples, would seem to require fundamentally different payment arrangements and therefore fundamentally different data collection systems to ensure equity in payments for Medicare services and yet maintain some control over global Medicare expenditures. The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. It directly appropriates $230 million over five years for the new Title III payment program. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. 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. 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. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Payment Dilemma Currently the prevailing methods of paying for health care in the US neither encourage nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. 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. The skill sets that are now necessary to provide efficient, clinically appropriate care are different from those needed 30 years ago. 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 2008 the Clinic recovered only 51.8% 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? Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. 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, this geographic practice expense adjustment has weight of 43% in physician payments, making it a critical component of the physician fee schedule. To place this in perspective, the Congressional Research Service has reported that Medicare paid physicians $59.5 billion in 2007, implying that about $25.6 billion in payments were potentially affected by practice expense adjustments. The sheer magnitude of these potential affects is strong reason to develop and maintain finely tuned data for use in geographic adjustment of payments. 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. Consequently, the relevance of the proxy occupational classes as a reasonable basis for making non-physician labor-related practice expense adjustments to payments has substantially declined. 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. Accountable Care Organizations The current Medicare payment system is not a forward looking system. It reflects our past medical practices more that it reflects our future medical practices. However, since it is likely that the current system will be in place for the foreseeable future, there are strong reasons to correct its many deficiencies. We fully support those efforts. In the longer term we believe that it will be important to develop alternative payment systems that properly reflect the emerging realities of delivering health care in the US. Some of the emerging ideas in this regard, including the concepts for Accountable Care Organizations and Medical Home as examples, would seem to require fundamentally different payment arrangements and therefore fundamentally different data collection systems to ensure equity in payments for Medicare services and yet maintain some control over global Medicare expenditures. The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. It directly appropriates $230 million over five years for the new Title III payment program. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

The 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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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 2008 the Clinic recovered only 51.8% 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? Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. 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. 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. Accountable care organizations: The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. It directly appropriates $230 million over five years for the new Title III payment program. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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. 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. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). Statutory provisions to extend these additional payments lapse in 2011 and must be extended for 2012. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

The 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.

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.

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.

The following bullet points summarize the objectives of the Marshfield Clinics 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; 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 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. Medicare Payment Dilemma Currently the prevailing methods of paying for health care in the US neither encourage nor reward providing high quality care. The rising costs of care coupled with the increasing awareness of poor quality care have made clear the need for a transformation in the way health care is financed. 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. The skill sets that are now necessary to provide efficient, clinically appropriate care are different from those needed 30 years ago. 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 2008 the Clinic recovered only 51.8% 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? Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. 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, this geographic practice expense adjustment has weight of 43% in physician payments, making it a critical component of the physician fee schedule. To place this in perspective, the Congressional Research Service has reported that Medicare paid physicians $59.5 billion in 2007, implying that about $25.6 billion in payments were potentially affected by practice expense adjustments. The sheer magnitude of these potential affects is strong reason to develop and maintain finely tuned data for use in geographic adjustment of payments. 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. Consequently, the relevance of the proxy occupational classes as a reasonable basis for making non-physician labor-related practice expense adjustments to payments has substantially declined. 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. Accountable Care Organizations The current Medicare payment system is not a forward looking system. It reflects our past medical practices more that it reflects our future medical practices. However, since it is likely that the current system will be in place for the foreseeable future, there are strong reasons to correct its many deficiencies. We fully support those efforts. In the longer term we believe that it will be important to develop alternative payment systems that properly reflect the emerging realities of delivering health care in the US. Some of the emerging ideas in this regard, including the concepts for Accountable Care Organizations and Medical Home as examples, would seem to require fundamentally different payment arrangements and therefore fundamentally different data collection systems to ensure equity in payments for Medicare services and yet maintain some control over global Medicare expenditures. The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. It directly appropriates $230 million over five years for the new Title III payment program. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. Personalized Medicine Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a person's 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 population-based cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

The 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.

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; 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. 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. Recommendations: Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement. Implement quality/efficiency based payments for physician services as soon as possible. Implement bundled payments for episodes of care. Implement FFS reimbursement for the value added through care management and coordination of services. Improve reimbursement for primary care services. Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions. 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. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. 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. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually. 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 2008 the Clinic recovered only 51.8% 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? Payment Equity for Physician Work Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. 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. 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. Accountable care organizations: The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. 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. Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs. 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 over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. 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. Historically, Family Health Center and Marshfield Clinic have not attempted to access cost-based reimbursement under Medicare because of these payment caps. 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. It directly appropriates $230 million over five years for the new Title III payment program. 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. Health IT on a broad basis is still in its infancy. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement. 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. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. 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. 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. On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also announced that she plans to convene a National Summit on Geographic Variation, cost, Access, and Value in Health Care later this year. Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation). Statutory provisions to extend these additional payments lapse in 2011 and must be extended for 2012. CMS Physician Group Practice Demonstration On September 27, 2002 the Centers for Medicare and Medicaid Services published a notice in the Federal Register informing interested parties of an opportunity to submit proposals for participation in the Medicare Physician Group Practice Demonstration (PGP) project to test a hybrid payment methodology that combines Medicare fee-for-service payments with a bonus pool derived from savings achieved by improvements in patient care management. Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.