[background noises] quick to subcommittee will come to order the chair will recognize for five minutes for opening statement. also a lot of things happening in the whole house today between both sides. and so we are going to have to try to manage this hearing and thank you everyone who is testifying first and second for your patience and willingness to work with everyone. we appreciate that. we are going to have to try to manage this hearing as we move forward and you eccould to everyone who is testifying first and second for your patience and your willingness to work with everyone. we appreciate that. i will recognize myself for an opening statement. we are considering legislation aimed at greater access to care for seniors including low-cost prescription drugs as well as reducing unnecessary redtape for providers. we also want to make updates to the physician reimbursement model that strike a critical balance between well medical care remains solvent for future generations. the centers for medicare and medicaid services, and is expected to grow faster over the next decade and this is simply unsustainable for our medicare program. there is josh almost 2.5 times more than the average person spends. their support underscores -- to sustain and strengthen the program. this is the first time in several years that we have thoughtfully re-examined the reimbursement plan for physicians. near providing specialized care for senior citizens with chronic conditions. they require every targeted reimbursement to meet a higher quality services for these patients. it they are complex problems that require complicated solutions. we want to provide access in a sustainable and responsible manner and this will require work between regulators in the subcommittee. any challenges will be offset and offset quality care for seniors. our first panel, i welcome you. and i will yield my time to the vice chair of the committee. >> this hearing means a lot to me. a making sure that patients have access to healthcare is one of the most fundamental reasons i came to congress in the first place. i want to talk about why this hearing is so important. providers choose to work in healthcare because they care about people. they have dedicated years of their lives to training and then they work grueling hours. they sacrifice time for their in families to provide services. we owe it to the providers and the patience to focus on patient care and not worry about the paperwork waiting for them at the end of the day or the long-term ability to operate their practice. we know that healthcare shapes how private plans approach coverage and it is critical that medicare operates the way it supports providers, thereby that the millions of ereby seniors who rely on medicare continue to have access to their doctors. my passion for this issue is why i have worked for many years to get access across the line to move josh and bipartisan efforts to make sure that physicians are reimbursed appropriately, including hr 2474 to provide them with inflationary updates to inflationary levels. that is why i believe we must pass legislation to promote value-based care as was intended when the medicare chip reauthorization program was authorized. i hope my -- and commit to working with me and others to ensure that provider access for medicare patients. i yelled back. spoke the chair will now recognize representative --. >> i think i speak for all of it to say it is good to be back in the hearing room doing our work. last year my constituent and the president of the california medical association wrote a letter saying that within our harris healthcare system a crisis of grave proportions is taking shape. it was november 2022 when covid- 19 cases had eased. healthcare workers were struggling to keep up. for us in the patient's we serve the crisis was far from over. the california medical association surveyed members about how medicare payments are impacting access to care and the responses were really striking and i think highly instructive. 87% of physicians said low medicare reimbursement rates negatively impact their ability to recruit and retain physicians and 76% of physicians said medicare payments do not cover the cost of providing care. a few bills we are considering will attempt to stabilize medicare reimbursement but they are notably not considering hr 2474 to provide a medicare physician payment update tied to inflation. i think that is really a must on a bipartisan basis. i often hear from physicians in my district about administrative burdens for medicare and commercial health insurers. seven years ago congress passed the medicare access and chip reauthorization act to finally and the need to pass the doc fix that led to the -- that found e more administrative burden while doing little to improve quality of care. i think the subcommittee -- are subcommittee should seriously consider the medpac recommendation to eliminate the merit-based incentive payment system while traditional medicare increased its paperwork through macra advantage plans also started burdening doctors by overusing prior authorization. or prior authorization has morphed into a costly and efficient mechanism that prevents patients from receiving care and it adds unnecessary burdens on to providers. it is why i support the care act to reduce the overuse of prior authorization in medicare advantage plans. while this hearing is focused on patient access to care and ce reducing burdens on physicians i am concerned that my republican colleagues, once again, are not considering legislation to fund state health insurance programs and the area agency on aging. these are critical programs. not that you would remember it but, california state health insurance program is called high camp and this is a program that works. it works very well and to provide stellar services every day for seniors in my district that have medicare problems. we should not allow this to expire. i am also concerned that the subcommittee is once again considering o a huge slate of bills, 23 in total with nearly half in a discussion draft forme or only formally introduced a week ago. i look forward to hearing from witnesses today on how we can enhance a fishery access to care and reduce burdens on physicians. without jeopardizing the financial sustainability of the medicare program. 10,000 americans age into medicare every single day. if that is not reason enough to find a solution, to these issues, i don't know what is. you, mr. chairman and i yield back. >> i will now recognize the chair of the committee, chair rogers. >> good morning everyone. st our focus today is to explore solutions to improve medicare payments to providers and ultimately help patients. everyone has been hurt by inflation driven by the democrat record spending spree. we just got two more bad pieces of news on inflation. first of all medical art medicaid part b is increasing by 6% next year. since president biden took over, medicare premiums are up. we found that inflation metrics show prices continuing to increase by 4% over last year. everyone from patients to providers is feeling the pain of higher prices and higher interest rates. patients have less money to spend on basic needs. and the cost of running an independent practice is growing as well. the whole healthcare system becomes more expensive one providers cannot afford to stay independent. today we focus on how we can and on eliminate unnecessary tape and sustain access to care and lower cost for medicare beneficiaries regardless of where they live. as many of my colleagues have said nit is important to let doctors do what they do best. spend time seeing patients and less time filling out paperwork. the challenge before us is how to balance the need to make sure that passion patients on medicare are paying for that while recognizing that paperwork, even well- intentioned, can limit time spent on healthcare and it increases cost. as we look to modernize the medicare payment system we must be thoughtful in striking the best and thoughtful balance. we are going to consider a wide range of drafts aimed at supporting medicare providers as they deal with rising paperwork, rising inflation, and rising labor costs. a few drops explore payment initiatives. doctors could see a pay cut starting january 1. in the short term, congress should act to avert these cuts. we should consider why we are having the conversation every single year. if we need further evidence that the government should not intervene in the economy, congress has increased medicare payments to doctors seemingly every single year since 2003. i'm not saying these are worthy endeavors. i believe in supporting our doctors. in 2015 we passed macra to get us out of the stream of the annual fixes yet here we are with the system that has yet again under performed. some of my colleagues across the aisle would expand such a system to cover every patient in the country but the fact is, politicians and bureaucrats will always do a worse job than the market in determining the most efficient prices for an item or service. we should spend our efforts on the programs that we have now so that we are not back at this every few years. it is important that we recognize the greater context of this discussion. parts of medicare are on pace to be insolvent by 2031. solutions like the bipartisan low-cost more transparency act will save money in the long run but resources are finite and we must examine every dollar that medicare spends to make sure it is going to the right places before assuming additional resources are necessary. if they are we should work together to find ways to save medicare money in other areas. r our goal today is to strengthen the medicare program and increasing your access to care by improving the way we reimburse providers. thank you to the witnesses for being here. i yield back, mr. chairman. >> i now recognize mr. paloma. >> we are 29 days away from another government shutdown and this hearing comes at a time when house republicans dysfunction is hurting the american people and weakening the economy and undermining national security. house republicans have caved and there is no interest in governing. despite a funding agreement between president biden and they came dangerously close to a government shutdown that cost the economy billions of dollars per week and forced troops to work without pay. i think the american people deserve better. democrats hubs stop us from hurting every day americans that it is long past time for house republicans to reject the extremists. we should be working together to lower costs for and it is time for the chaos to end. turning to the topic of today's hearing, that it care has played a critical role in the lives of americans. medicare is the main source of health care for most of the seniors in our nation and disabled individuals and we must make sure it maintains the highest level of quality care. i have major concerns about the process leading up to this hearing. many of these drops are still half-baked. giving the broad array of topics and bills i am disappointed that we did not have adequate time to fully vet some of these policies and provide democratic input from the beginning. the republican majority has put forward a long list of bills that could cost billions of dollars without any proposed way of paying for them. just yesterday in a speech on the house floor, republicans expressed concern with medicare finances and decided their support for jordan because of the distant the decision to cutd funding to our programs. it is a pattern we see over and over again from republicans, pushing forward expensive changes and then demanding cuts to medicare that would cause seniors. medicare is not broke and it does not need major changes. it certainly does not need republican ideas to cut benefits, raise the retirement age or raise senior contributions. we need republicans to stop their infighting so congress can come together to find bipartisan solutions. with the policies before us, unfortunately, my republican colleagues have refused to engage with us constructively or propose a path forward. given the republican majority unproductive track record on the floor i remain concerned that we are not going to be able to successfully move a bipartisan legislative package of committee and onto the house floor. my republican colleagues reject that committee democrats request to include legislation that would directly expand access to care and reduce healthcare costs for seniors. the majority refuse -- led by representative greg. it would expand coverage for for seniors and lower out of pocket costs. these programs help low income medicare beneficiaries in roll in care and access benefits that lower their out-of-pocket cost. about 3.5 million been medicare beneficiaries have received assistance and the number of seniors has increased from 11.8 million in 2014 to 14.2 million in 2020. i am concerned that the totality of these would result in cuts to the medicare program and raise premiums. this will place undue burdens on the nation seniors and raise their, out-of-pocket cost. t democrats stand united in opposition to -- or premiums. we will continue the fight to protect the medicare program and thank you to all of our witnesses for being here. >> effect includes opening statements. we now turn to the panel for opening statements. we will begin with you, doctor seshamani. our first witness, director of senators for medicare and medicaid services. we have leslie gordon, director of the accountability office and mr. masi. doctor seshamani, you are recognize for your opening statement. >> thank you. chair rogers got three, ranking members, members of the subcommittee, you, for the opportunity to discuss the medicare program. before becoming the director for the center of medicare i took care of patients as an ear nose and throat physician and i saw the powerful impact that healthcare can have on health and well-being of individuals and their communities. i bring these stories with me to my current role now. our goals for medicare include driving high quality whole person care, accessing care and improving affordability and sustainability of trust funds and all of this is only possible through robust engagement with our partners and the communities that we serve. medicare payment policy is set in statute by congress and cms works within the confines of the law to establish payment policies for physicians and other healthcare professionals. one area of focus is transforming care through more holistic models where healthcare providers can care for people, not just treat the disease. over the last decade medicare has accelerated participation in value-based care models that reward better care, smarter spending, and improved outcomes. in 2022 the medicare shaved savings program save medicare roughly $1.8 billioncompared to spending targets of a year. this marks the sixth consecutive year of that savings. while the participating terror organizations or aco's maintained higher ratings for quality care then similarly sized physician groups. in july of 2023 cms proposed changes that would grow the e medicare savings program in order to improve access to chlorinated, efficient, high quality care for more people t with medicare. many of these changes were suggested by those providers currently participating in the program. or by those who wanted to participate but felt they could not. particularly providers in rural and underserved areas. we have also prioritized expanding access to care, particularly in behavioral health and telehealth, which isf critical to improving the health and well-being of medicare beneficiaries. following congressional action, cms has proposed sutures to allow marriage and family therapists and mental health counselors to enroll in medicare in order to independently treat people with medicare and be paid directly. cms has proposed payments for intensive outpatient programs, which are finalized both the critical care gap and the type of behavioral health services covered by medicare. following congressional action, medicare also permitted expanded access to telehealth for behavioral services including audio only for access or for those who are not able to use video. we know telehealth services have enabled individuals in rural and underserved areas to have improved access to care. we want to be sure that medicare covers these services. we remain concerned about the profound health inequities that have persisted in the united states for a rations. cms is working to advance health equity by designing, ro implementing, and operationalizing policies and programs that support health for all people served by our programs. by incorporating the perspective of lived experiences in integrating safety net providers, community- based organizations into our programs. and finally, cms is working to ensure medicare remains affordable for people and sustainable for future generations. the inflation reduction act makes medicare by expanding benefits, lowering drug costs, and improving sustainability for generations to come. the law provides meaningful financial relief for millions ot with medicare by providing access to affordable treatment and strengthening medicare both now and in the long run. moving forward we aim to continue to collaborate with congress and our other partners on areas where we can work together to drive meaningful change in the healthcare system. we are committed to ensuring we integrate the perspectives of the communities that medicare serves as well as the providers and the health plans that deliver healthcare into our policies. so thank you again for the opportunity to testify today. i am happy to address any questions you have. >> thank you for your testimony. we know turn it over to ms. gordon for opening statements. >> good morning. chair guthrie, rogers, ranking member and members of the subcommittee. i am pleased to be here today to discuss issues that affect physician payments and experiences in traditional fee- for-service medicare. with the medicare enrollment and spending projected to increase, controlling program spending remains a serious long- term financial challenge. physicians and other providers play an essential role in the growth of medicare expenditures alter the services they provide the services they order like diagnostic tests and referrals. but my statement summarizes most of recent research reports examine the geographic payment for services under the physician fee schedule and physicians and other providers participation in and experiences with the merit based payment system and advanced alternative payment models. first, in february 2022 geo reported on geographic adjustments to physician payments for physician time, skills and efforts focusing on geographic adjustment to the physician's work components under the fee schedule. the purpose of these adjustments is to account for sp differences in the cost of providing care across various geographic locations. specifically, medicare will pay more for a service and an area where approximate cost for a physician's time, skills, el effort are higher than the national average and less in an area where costs are lower. geo reported in 2022 modeling for the geographic variations generally accounted for physician earnings in a 90 of the 19 localities examined. however in 14 localities the adjusted value was below the level needed to reflect the geographic variation in physician earning and in 15 localities the adjusted value was above. we also reported that removing the physician work geographic floor would decrease overall payments by about $440 million , less than 1% of physician payments as of 2018 when we look at that. most of the effected payment localities would seek less than 2% decrease. turning my attention to the quality payment program. in2021 we reported on physicians and other providers experience under the merit incentive payment system. looking at the years 2017 through 2019. the merit-based incentive payment system allows eligible providers to earn performance- based payment adjustments. we found that at least 93% of providers qualify for a positive payment adjustments, less than 5% earned a negative adjustment. and since a few funds were available to it spread out across a large number of providers who earn positive adjustments, those positive adjustments were less than 2%. november 2021 we reported on physicians providers participation in advanced alternative payment models against 2017 -- 2019. the advance alternative payment models encourage providers to share in the financial rewards and risks of caring for beneficiaries. we reported the proportion of eligible providers to participated was lower among providers and rural healthcare shortage areas and others underserved areas compared to other providers. most providers however who participated were eligible to earn the 5% incentive payment regardless of practice. that summarizes the high level notes from these issues in -- and this concludes my prepared remarks so i would be happy to answer questions. >> thank you. i now recognize mr. masi for your opening statement. >> i am grateful for the opportunity to be with you today to discuss how to ensure patient access to care and minimize burden for providers. i am happy to provide information about relevant commission work that might be helpful as the committee considers these issues. as you know, medpac is a non- congressional party so we want to help you with the difficult decisions you must make each year. 10 of our commissioners have clinical training including eight physicians, a registered nurse, and a registered pharmacist. nine of our commissioners have high level executive experience with healthcare delivery organizations and it commissioners or academic experts, they publish frequently in peer review journals the commission is supported by a terrific staff with deep expertise analyze medicare issues of payment, access, and quality. i mention the credentials to emphasize that the commission has experience in different expert of the medicare program and the goal is to bring that experience to bear and to help congress improve programs for taxpayers and providers. just because we have that experience does not mean we have all of the answers. you can be assured that our agenda is a commission is the same as yours. a core part of the med pac statutory is fee for service to make sure that medicare beneficiaries have access to high-quality care. and to advise congress on what steps to take when payments are too low or too high. overall med pac has found that beneficiaries have access to services that are and we do several things to arrive at that fighting. we conduct focus groups of beneficiaries in urban and rural areas and groups with clinicians. we analyze medicare data and we compare all of our findings with other surveys and researchers. based on that assessment, over the last several years, the commission recommends that -- to support access to clinician nd services however, this march two recommendations were made on how to update medicare payments under the fee schedule. at first, the commission recommended after 2024 that medicare payments should increase by one half of the medicare economic index, which is a measure of inflation. that reflect a concern for how inflation has impacted the cost of running a practice. second, it was recommended there be an add-on payment thisb would target additional resources to support access for the most vulnerable patients and the providers that serve them. that was based on evidence that those patients can face barriers to care and be more ed expensive to treat. policy should be evidence-based and targeted to address specific problems to ensure that medicare resources are used efficiently. lastly, the commission recognizes the importance of removing redtape for providers as their time is best spent focusing on patient care. reducing administrative burden was one of the key reasons why in march 2018 the commission recommended that it be eliminated. it was burdensome for providers. we support other elements of macra that replace the sgr patient centered care delivery models. in our october meeting commissioners discussed alternative approaches to payments under the fee schedule and the future of the --. in the january meetings we will include updated information about access to care and payment recommendations to ensure continued access. i look forward to your questions. >> thank you for your testimony. we will begin the question period. first of all, we are not proposing anywhere to take and if it's away nor are we proposing to pay more. we are just as -- where the inflation reduction act was id going to hurt innovation for seniors that it also the scored savings from cvo were spent. they were spent outside of medicare to enhance subsidies to health insurance companies. we were just as passionate fighting that. we need to come together to help seniors and the baby boomers coming forward to make sure that medicare is sustainable. when they spent the money on enhanced subsidies, they knew this was coming and they chose to spend the money there. i want to make that point. so, ms. gordon, your reporting suggests there are more providers enrolled in incentive- based payment programs then advanced payment models. would do believe are the primary drivers for why there is such a big gap in enrollment in these programs and which has been more impactful from the perspective of driving more efficient spending for patients? >> so, we reported that there were a large number of providers enrolled in the program compared to the apm. and structurally, the programs are different. clash clinicians are eligible for -- and they are requested to participate or there are high -- a higher barriers or sort of some upfront cost and investment that needs to be made to enroll in the advanced apm. that might be why we see greater enrollment in the --. specks so what you think is more efficient? >> we have heard from stakeholders with regard that there were -- but, we have to look at why is it really driving. in the time we looked at it from 2017 through 2019 were not necessarily the quality measures were not necessarily indicative of the specialties that could be encompassed in a multi special practice. with the apm we also saw some challenges. >> thank you. doctor seshamani, -- . >> thank you for your question. we are implementing the inflection inflation reduction act consistent with the law and incorporating all of the feedback that we have gotten and will continue to get through the robust engagement with all interested parties. we laid out in our guidance for the negotiation program that we will be looking at the factors that are laid out in the inflation -- >> what about the rebates? should they be considered in the net price? >> in a the net price in part d? >> should the rebates be considered? >> in terms of how pbm's interact, we are prevented from interfering with that process. and we follow the law and implement the law consistent with the law in terms of the administration with the part d program. >> maybe that is something that we need to address. so, doctor seshamani, what are your primary goals with the the mips program and what do you think needs to be done to drive more with pbm's. >> thank you for the question. merit-based investment system is administered by my colleagues in the clinic for standard and quality. what i can say is we are very interested in driving participation and value best care. st looking across our program to align quality metrics so we can galvanize momentum to drive change on the ground. we would be interested in continuing to work with you. >> i would ask another question but if only got five seconds. i will yield back and recognize the ranking member from california for five minutes. >> you, mr. chairman and to the witnesses. i am frustrated. there are two things that i deal with consistently in my congressional district. and i don't think my congressional district is unique. number one, doctors are not reimbursed at -- with fair compensation. m therefore, they drop out. they can't afford to be in the medicare program. and then, the medicare beneficiaries in my district. they can't find, increasingly, with great difficulty, they can't find a doctor that excepts medicare patients. so, i know that we have the responsibility in terms of statutes and certainly the funding mechanisms but we are going to have to figure out how we pay doctors fairly so that -- frankly, so that it is fair. in the public interest that they will stay in medicare and treat patients. most medicare patients are not very sick. so, in these measurements that you have done, it really is -- i think for those that aren't very sick -- i'm not so sure what you have studied. i think we need to measure whate matters and i think the bookends that i just raised are at the heart of what we need to address in our country. because, when push comes to shove, if you don't have doctors in medicare then what can medicare me to a medicare recipient. they are not receiving anything. we have got some serious work to do relative to the dollars in this. where we can save money and where we are going to have to raise money. both of those areas can be uncomfortable, depending on the lens that they look through. in the march 2023 report, earlier this year, medpac estimated that medicare spends 6% more for medicare enrollees than if those that remained enrolled in original medicare. that translates into -- this is the saving side. $27 billion. $27 billion in overpayments this year alone. so, doctor seshamani and mr. masi, what is -- what action is cms taking to reduce these overpayments? and mr. masi, how does medpac suggest reducing the overpayments? we have got to look for saving money before we go out to consider where we raise other dollars so that medicare actually works for medicare recipients. >> you are absolutely right. on average medicare pays more for medicare advantage relative to fee for service. we have a number of recommendations to improve the value of the programs. i will highlight two. one, we would change the quality program to budget neutral like most fee for service programs and also restructure it to get more meaningful quality information for when beneficiaries pay for plants. number two, we have a recommendation to address coding on average plans. coded more intently. >> i did not hear you and i'm hanging on every word. we are talking about $27 billion in when you're alone. >> yes. the second recommendation, we would addressed coding where medicare advantage plans code more intensively than fee for service. that increases program spending and increases part d premiums for the fisheries. >> doctor? have you paid attention to those? >> absolutely. >> do you accept or reject them? >> we share your goals to access to goal and payment accuracy is an important aspect of that. >> i think both groups of conferences coming up so we need to --. >> you consummate your answer in writing so you can give me a lot of good information on that. >> the chair recognizes the chair of the full committee for five minutes. >> it has been four years since we have had a provider hearing so i am anxious to get to work. cvo released a report projecting medical care spending will tumble from $813 billion in 2023 two $1.5 trillion in 2023 alone. 48% accounted for spending. doctor seshamani, i did not see a proposals in the fy 2024 budget regarding spending in physicians in medicare part b to make sure there is access to physicians in rural areas or to reduce red tape. would you speak to whether or not the administration thinks that the status quo is acceptable for seniors right now and 10 years from now? >> i appreciate you raising this. it is a shared goal for us to ensure access to care for people in medicare, quality care, and to make sure that the program is sustainable. congress sets payment policy and we implement that consistent with the law and consistent with the law and raised are things that we have taken into consideration in our regulatory authority to do things about for example, rural health is a prayer for us. i personally, in my prior role, took care of people in a rural area. i also have traveled the country visiting providers in rural areas and i know how critical it is that they have access to care there. >> thank you. i will be looking for the specifics and we will have to follow up. the medicare trustees report discussed how more hip and knee replacements are being paid for through part b more than part a and we see projections being pushed out a few years. are there other services that cms things can be done and what -- while maintaining quality of service. >> thank you for that question. we share the goal that people should obtain the care that they need in the setting that is appropriate for them and we will continue to analyze data as you mentioned and we will be happy to continue working with you on this. >> i hear from doctors in my district about how rising inflation and redtape is making it harder and harder for them to stay in independent practice. this committee heard testimony this spring about consolidation in the healthcare system being one of the driving factors leading to increased healthcare cost. mr. masi, i understand hospitals get increases for inflation but doctors do not . can you talk about why that is? >> thank you for the question. that is correct. there are differences between how medicare sets and updates payments for physician services and how medicare sets and updates payments for hospitals. part of the reason may have to do with the unit of payment is more disaggregated under the physician fee schedule. as you know medicare will pay for more than 8000 different items under the fee schedule and in the past, congress has enacted policies that have tried to address the underlying incentives and volume. >> would you speak to how often those increases for inflation are calculated for hospitals versus doctors? >> under the inpatient prospective payment system, which updates payments for hospitals, they do receive an inflation up date every year. in the past, the commission as part of monitoring -- we have tended to find that the updates under the fee schedule have been sufficient to continue access but this year was different and we did recommend that payments under the fee schedule are --. >> what are your projections for the next 10 years? >> thank you for the question. this is an issue that was discussed at our october meeting. we will continue working on that in the coming months. >> more questions to come. i yield my time. >> the chair yields back and we recognize the gentleman from new jersey. >> medicare is the main source of healthcare for individuals with disabilities and i will continue to fight for that program. i am disappointed that my soul request to include hr as 360 today which would directly expand access to coverage and lower healthcare costs for the nation's most vulnerable low- income seniors. -- including the state health insurance program which helps our nation seniors enroll in medicare and receive assistance for prescription drug coverage that lowers out-of-pocket cost. i wanted to ask doctor seshamani, can you discuss the importance of these and how they help millions of low- income seniors. >> thank you for raising this. outreach is so important in the medicare program because ultimately we want to make sure that people are able to navigate the program, choose the option that works best for their health and financial needs so that they can take advantage of the benefits available. and the ship program is an important part of the outreach to include medicare. , one 800 medicare, and all of y the work that we do for our partners during open enrollment. >> millions of seniors qualify for the medicare savings program and the low income subsidy program that lower-cost. without these programs many could not afford the care that they need. i understand that these low income outreach and enrollment activities help them enroll in lis and help with out-of-pocket drug costs. is that correct? >> yes. and thanks to the inflation reduction act, it is expanding january 1, 2024 and that is a priority for us as we are in medicare open enrollment now. we want to make sure that people know that they should find out if they could be eligible for that assistance. >> i understand up to 3 million low-income seniors with disabilities qualified but are not enrolled. is that correct? >> that is correct that there aree definitely, across our programs, people who are eligible but not enrolled and that is why outreach is a priority for us. >> i think we have to expand and extend the so that low- income seniors and those with disabilities will be able to access the help that they need. in a msp and lis. i am disappointed that the republican majority refused to recognize these programs that have long-standing bipartisan support and have been extended 11 times over the past 15 years. it is critical that we reauthorize and extend funding in these programs and hopefully we can accomplish that at some point soon. thank you doctor seshamani. i yield back . >> the gentleman yelled >> and i do recognize the gentleman from texas, doctor burgess. >> i need to start off with s some unanimous statements from the medical association and american association of urologists. i have another study from the physicians advocacy institute detailing savings of more than $1 billion per year and finally an article from the washington post from september of this year about how medicare spending per beneficiary has leveled off for more than a decade. and i asked consent to add those to the record. i do want to thank our witnesses for being near. this is a very important hearing. i have been on this committee for a long time and i cannot remember us having a hearing specifically on the concept of proposing a legislative change to budget neutrality. certainly, we hear from doctors all over the country that the current medicare fee schedule is unsustainable and unpredictable. at this is due in part to budget neutrality. this mechanism often leads to across-the-board cuts and makes it harder for independent physicians, practices, to survive in that, of course, threatens access to care. three of us who are chairs of the doctors caucus, doctor murphy and doctor winston plan to introduce a bill and there is a draft that is part of today's hearing. it would increase the threshold allowing for corrections for overestimates and under underestimates of budget neutrality and require timely updates to prop this expensive relative value units. we have all seen what has happened to the cost of labor, california passed a minimum wage for healthcare workers for doctors were in practice. they are competing for workers against that same pool of laborers and again, the word unsustainable continues to creep into the conversation. i have worked with many people in this room on both sides of the dais and i hope we can get behind some of these commonsense solutions. thank you for being here today, doctor masi. does medpac believe it is important to have accurate data ? >> yes, the commission would agree that it is very important for medicare to set payment rates using ocular data on practice expense as well as work. >> one of the things that has come up today a lot is mips versus apm's. as we were trying to get rid of the sustainable growth rates there was concern that all doctors would be driven into aco and hmo because that would be the easy way to approach the problem but to allow small practices to continue practicing and to participate in a positive practice update. that was the reason for the merit-based incentive program. we have had one hearing in the last 4 1/2 years on the implementation of macra and we did not have any for four f years with this committee leadership.it -- griffith had a hearing on macra and one of the things that came up was a harvard witness suggested it was not possible for small practices to participate in a apm's but, mr. masi, i get that is actually a possibility? >> thank you for the question. the commission agrees it is important to transition providers and give them opportunities to participate in apm's. this is an area that the commission is working on and we discussed the apm bonus and we will continue to work to see how it can be restructured. >> i think it was suggested by ms. gordon that enhancing payments so that meeting the necessary informational structure infrastructure, so that would be possible, i mean, it's a big expense for a small practice. a one or two doctor practice to provide the infrastructure that is necessary to collect the data so, is that something you are willing to look at? >> yes, the commission is happy to work on this issue and support the committee. >> we do have to be concerned about the consolidation of small practices. consolidation in healthcare in general and this is one of the ways that we can tackle that. >> thank you. we are going to have one more set of questions. there are conferences and caucuses at 11. i think there is now a scheduled vote at noon. so if the witness will stay in contact with our staff will make sure that we move forward. we are going to recess after this question so we are balancing both sides. we have miss rochester. >> thank you for the recognition and thank you to our witnesses for the testimony. today we are considering healthcare provider policies including my bill increasing access to cardiac rehabilitation act. hr 2583. i want to say you go to my colleague representative adrian smith for his tireless work on this bill and acknowledged that he worked alongside our late colleague, john lewis, on this bill. it will increase patient participation itin cardiac and pulmonary rehabilitation programs, two life-saving services, by authorizing physician assistants, nurse iz practitioners and clinical nurse specialist to order them. these interventions reduce mortality rates, hospitalizations, and cost. unfortunately they have historically been underutilized due to a lack of referrals from physicians and inadequate follow-up after referrals. congress attempted to address this issue by authorizing certain additional providers to supervise cardiac and the bipartisan budget act of 2018. however, cms has indicated that while this policy change is an important step forward, they, quote, do not anticipate any significant increase in utilization of cardiac and pulmonary rehabilitation services and subsequent impact of the medicare program. we all know that these programs reduce mortality rates and hospitalizations and cost, but can you describe why on participation remains low in an these programs despite the potential benefits? >> i appreciate you raising this. we agree that cardiac and pulmonary rehabilitation are important and beneficial for medicare beneficiaries. we looked at literature and studies on utilization rates for the impact analysis of the proposed changes that would ll implement when you referred to with the partisan budget act of 2018 to allow pas, mps, and others to supervise these programs. we will continue to monitor utilization of these programs after implementation of this new requirement and can continue to work with you on this issue. >> can you just describe how cms concluded that allowing these groups to supervise these programs without the authority to put in orders may not increase participation, and what other potential solutions may increase access and utilization of cardiac and pulmonary --? w >> we used the literature and studies that were available on the utilization rates, and thise points to the need to continue to examine the utilization when these changes are made, and we would be happy to continue working with you on this, as we agree that cardiac and pulmonary rehabilitation is an important service for medicare beneficiaries to have access to. >> what is important here is a need the authority as well. i want to switch to primary care for the 1:30 i have left. delaware like other places are experiencing a shortage of primary care providers. that's why one of the primary sponsors of the bipartisan effort to restart the community health center program and why i serve as one of the cochairs of the primary care caucus. in delaware we've seen that ay while physicians, primary care physicians are accepting new patients for medicare and medicaid it's much lower. this is a big concern. so, in your testimony you describe certain financial pressures healthcare providers face including primary care providers that may influence their decision to see medicare patients. can you please highlight a few of those, dr. masi? >> thank you for your question. every year we monitor access the beneficiaries have to healthcare services, including clinician services, and this year we recommended an add-on payment to target additional resources to help support care. the key thing i want to point out is that we structure that add-on payment so that it would be higher for primary care clinicians when they provide services to low income medicare patients. we think that is an important way to target medicare resources to shore up access. >> i'm going to submit questions for the record, but along that line of implementing 2211 and the add-on, we've heard from some that it is not justified, not resourced base, costly, duplicative, and also leading to overpayment, so we would like to follow-up with you on your answers regarding that as well. thank you so much. >> we will all stay in touch and figure out what's moving forward, and exactly what the timing is going to be throughout the day. we appreciate you all being here in the second panel as well, now the subcommittee will stand in recess subject to the call of the chair.
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