the subcommittee will come to order, we will now resume with our second page, our witnesses for the onthe subcommittee will com to order. we will now resume with our second panel. our witnesses at the second panel today are -- glasses on, sorry about that. the president-elect, dr. deborah pat. executive vice president of texas oncology, mr. joe -- senior policy analyst for the paragon health institute and dr. matthew fiedler, the joseph a pechman senior fellow in economic studies at the breaking schafer initiative on health policy at the brookings institute. you are recognized for five minutes for your testimony. >> chairman guthrie, ranking measure anna g. eshoo , my name is stephen four. i'm a practicing family physician in jackson, alabama. i am the cofounder of the family medical clinic of jackson which is a rural health clinic, and the chief of staff of the medical hospital and local director of nursing home. as president-elect of the american academy of family physicians, i'm happy to be here today representing 129,600 positions of student members of the afp here going to do family member -- medicine over 35 years ago as a national health service corps scholar to help serve an underserved community. i went there, paid my dues, did my time. i did with the program meant to do. i stayed there and continued to serve the community. i stayed there ever since. my training has allowed me to develop long-term relationships with my patients and to deliver patient centered primary care. we are not called family medicine physicians just because we treat the whole family. we are called family medicine physicians because our patients are part of our extended family. being a rural family physician is incredibly rewarding. in the last several years, it has gotten much more difficult. my patients have more chronic medical problems that require complex ongoing care management. furthermore, they're looking to our practice to help with their depression and anxiety. meeting basic needs, navigating an increasingly complex healthcare system, but instead of providing primary care practices with support to meet the growing patient need, we are left struggling to stay afloat as payment shrink and administrative requirements multiply. our failure to invest in primary care is being felt across the country in patient outcomes, repeated challenges trying to find a primary care physician. data released just this week shows that over 16,000 primary care physicians have left the workforce over the past year, but as a country we've never needed primary care more than we do today. despite much higher spending per person, the u.s. spends less on primary care has the highest rates of people with chronic conditions, the lowest life expectancy and highest preventable death rates compared to our friendly country picket leads to or population health, better outcomes, and lower mortality rates. in other words, primary care is uniquely suited to help address the pressing healthcare problems we face today. i am pleased to see the subcommittee's attention on ways to better support patients and physicians, and appropriate payment for the comprehensive patient centered work we do in a tangible reduction in administrative workload. we are encouraged by steps medicare has taken to more appropriately value physician often visits. in 2024, cms has proposed another incremental step to better value primary care. the g 2211 add-on code would better account for the time, resources, and expertise involved with providing comprehensive primary care. primary care office visits are more complex and g 2211 is intended to recognize that. opportunities to meaningfully invest in primary care under our current system are rare. this is one of the few of them that we can use. i urge congress to support implementation of this code. however coding and billing challenges alone won't fix broken physician medicare payment systems. we need congressional action. i strongly urge congress to reform budget neutrality requirements, enacting annual inflationary update for physician payments. support physician practices moving into value-based models, and pass a lower cost or transparency act. the strengthening of medicare for patients goes beyond just improving payment. congress must address and administrative burden which has become totally unmanageable. my staff and i spend hours every day navigating prior authorization and step therapy requirements that prevent people from being able to access evidence-based treatment in a timely manner. thankfully the subcommittee has an opportunity to address some of these issues by first passing the improving seniors timely access to care act. performing step therapy and medicare and medicaid, requiring medicare part b coverage of all recommended vaccines so that we can give all vaccines in our office and not have to go to the pharmacy for that. standardizing quality measures across payers and programs. primary care in this country is at a tipping point, and congress can help to change that. improving payment and reducing the administrative burden went on only be an investment in primary care, but also for our patients and your constituents. thank you for the opportunity to provide this testimony. i look forward to trying to answer your questions. >> thank you for your testimony. dr. pat. recognized for five minutes for your testimony. i think your microphone, you probably have to hit the mike button. >> members of the health subcommittee i appreciate the opportunity to testify on this extremely important hearing on the prognosis of medical care in america. many miss dr. deborah patton i've spent the last 17 years seeing and treating breast cancer patients in austin, texas at texas oncology, a large private practice in the great state of texas. they also serve as an executive vice president of texas oncology and vice president and board member on the community oncology alliance. as you consider policies in today's hearing, i want you to consider the consequences of inaction. cuts pose real and serious threats to medicare beneficiaries accessing medical care. decreasing reimbursing causes a chain reaction that results in provider network inadequacy, decreased access to care, inability to manage staffing shortages, and didn't decreased quality of care for medicare beneficiaries, a disproportionate burden felt by nonhospital affiliated practices like mine. it's really feeling consolidation in the hospital systems that are driving up the cost of medical care for all americans. we face continued cuts in medicare reimbursement. since 2014, medical inflation has increased substantially every year, get medicare reimbursement is only decreased the ever widening gap between the inflation rate and medicare payment can be seen in the graph included in my written testimony. it shows it has risen by 28.4% while the conversion factors had a 5.4% decrease since 2014. we have issues of network adequacy, quality of care, and physician burnout. they are constantly cutting medicare reimbursement for physicians is the national consequences that are medicare beneficiaries as a result and decreased access of care through network inadequacy. i frequently have breast cancer patients in my clinic that i have to juggle and ask favors to get them to be seen by a primary care physician or another subspecialist, so i have to use my time. i have to refill their primary care medications and they frequently have gaps in care where no one is refilling their medications and they go without their diabetes or their hypertension medications. this causes care fragmentation, delays, and detours and inappropriate care. the pressure on physicians today's leading to increased physician burnout. according to a recent study, over 145,000 healthcare practitioners left the energy industry from 2020 to 2021. 71,000 of these were physicians. this is alarming. we face staffing shortages. this burden of declining reimbursement has been exacerbated by national crisis and shortages in healthcare staffing. just last week you might've seen the announcement by kaiser permanente that after a three- day strike they reached in a negotiated deal to reach payments by 21% over five years. as a physician in private practice facing decreased cuts, only challenged further by inflation, how would i pay for increases in staffing to continue to staff my clinics and be competitive? the natural consequence of this is breast cancer patients aren't able to get mammography. cancer infusion centers and radiation facilities aren't able to open to capacity because we have staffing shortages. we are on the verge of a major crisis in medical care, and -- fiddling as room birds. independent physician reimbursement cuts adversely impact the entire healthcare ecosystem. however because hospital systems receive an annual medicare inflation adjustment, the physicians in private practice do not and the ever widening gap between independent physicians and hospital reimbursement is contributing to consolidation of medical care and to the more expensive hospital setting. this is especially true with 340 b hospitals is a study of the top 340 b hospital showed that some markup cancer drugs are unbelievable at five times, meaning if you have a cancer drug that costs the hospital $5000, it can be marked up to $25,000. in addition, by ignoring hospital survey data, cms is overpaying 340 b hospitals by close to 50% contributing to a 6% premium increase for medicare beneficiaries that they will pay in 2024. we need to pass meaningful legislation. i want to underscore that is critical at this time for congress to fix the looming medicare payment cut as well as provide independent physicians with the much-needed medical inflation update. congress needs to make payments equitable in the hospital and practice settings bypassing site neutrality legislation and fixes to a broken 340 b payment system. additionally congress needs to address abuses by insurers and their pbm's including excessive prior authorizations that hinder quality and timely cancer care. as a doctor in private practice we need you to consider this legislation and make the change to improve the prognosis of medical care for americans, and actually fueled the chain reaction resulting in burnout, shortages, network inadequacy and fragmented and disrupted medical care for medicare beneficiaries. we need you to act now to improve the prognosis of the american healthcare system. thank you for your time and i'm happy to take any questions. >> thank you for your testimony. mr. albany's. did i pronounce that correctly? you are recognized for five minutes for your testimony. >> my name is joe alba knees, and i am a senior policy analyst at paragon health institute, a think tank dedicated to informing government programs. i want to thank you for inviting me here today in order to discuss how to improve policy and medicare he. my testimony today reflects my own views. medicare patient policy should reflect three key goals. first maintaining access to care, second minimizing costs, third improving payment accuracy. we should all be committed to securing seniors access to healthcare. 98% of physicians accept care rates and this percentage is increased over time. over policies that increase administrative burden or underestimate physician pay could undermine this. congress must also be constant than the fact that medicare is on an unsustainable trajectory and could reduce long-term cost growth. these costs fall directly onto the shoulders of beneficiaries. just last week, cms announced that part b premiums would increase by roughly 6% next year due to rising medicare spending. on average, seniors already spend about 20% of their social security checks on expenses and parts b and d alone. the fiscal sustainability medicare itself is also crucial. part b which covers physicians services is the fastest-growing part of medicare. medicare trustees project that this trust fund, which is mostly financed by general revenues will consume over 1/5 the federal income tax revenue by the end of the decade. rising costs will directly contribute to deficits, which may result in painful benefit cuts, tax increases, or economic harm to families in the future. finally, medicare payment policy directly distorts decisions in the healthcare sector. fee-for-service payment encourages a higher volume of healthcare procedures regardless of their quality. administrative price setting by government agencies is limited by data availability and bureaucratic decision-making processes which do not reflect the true value of the service. both congress and cms have historically struggled balancing these three goals with medicare payment policies. under macra, the per-unit upright -- price helps control overall spending, however the volume and intensity of such service on a per enrollee basis rose, and part b spending still rose in other areas. furthermore maintaining lower payment rates may compromise long-term participation by doctors. so far data from cms have found that access to physician services was stable or improving. however, congress could enact policies that would improve medicare payment policy on these dimensions for both beneficiaries and taxpayers. first, congress should offset any physician payment increases with other preppy savings. spending on outpatient hospital services come a part b drugs, and other areas has grown rapidly. commonsense policies like site neutral payments, reducing statutory overpayments on drugs, can save hundreds of billions of dollars without making any changes to seniors benefits. second, congress should adopt more market based pricing for doctors. the current process leads to observable air inpatient rates for certain services and disparities between specialties have reduced the supply of americare practitioners. simply increasing pay by inflation will not address these issues. market competition is a more efficient way to determine the economic value of the service, so gradual improvement is possible by tying medicare payment policy to rates negotiated by medicare advantage plans. third, congress should eliminate volume payment programs like mips and payment incentives for advanced participation. these policies have been the clearest failure macra and have been responsible for increasing clinician burden without improving value. a recent report has reaffirmed that pms have lost money for medicare instead of saving money. government experimentation and micromanagement in healthcare delivery is not a paths to success, and it does not make sense to subsidize participation in models that do not work. ultimately quality metrics are best when they enable seniors to make informed court choices between coverage and care options. this is only possible in medicare advantage by which has become increasingly popular in recent years. policymakers should ensure that it remains a viable option for seniors and encourage participation tween ma and fee- for-service. balance in policy goals is a difficult task, but removing government distortions rather than adding new ones would be a much more effective way of maintaining access to care, maintaining costs, and improving payment accuracy. thank you, and i look forward to answering questions. >> thank you for your testimony. i now recognize -- five minutes for your testimony. >> 13, my name is matthew fiedler. i'm a health economist and a senior fellow. i'm grateful for the chance to appear before you today to discuss ways to improve how medicare pays physicians. i want to begin by discussing the trade-offs involved in deciding how much medicare pays physicians. excuse me. broadly policy much balance two objectives. the first is ensuring that medicare beneficiaries can access high-quality medical care. the second is limiting the cost at higher payment rates -- the bear higher program costs on beneficiaries who bear premiums and cost-sharing, and even on the insured research finds pays more for physician care and medicare pays more. data on how well medicare beneficiaries are able to access physician care to balance access and cost. in that day and i want to highlight two facts. first, survey data show that most medicare beneficiaries do not currently report major problems accessing physician care. in 2022, ran 4/5 of beneficiaries to search for a new primary care provider said that either had no problem or only a small problem finding work. about nine in 10 is not a new specialist said the same thing. similarly about two thirds who sought care for an illness or injury reported never waiting longer than they wanted to to get an appointment. along all of these dimensions, medicare beneficiaries report comparable or slightly better access to physician care than the privately insured. second, medicare beneficiaries access to physician care has remained relatively stable even over a two decade period where costs have grown faster than medicare physician payment rates. this could indicate the changes in medicare payments currently only have a modest effect on access, or alternatively that other changes in the delivery system where offsetting slow growth in physician payment rates. looking ahead it is possible that the delivery system might respond differently to future payment changes than it did to past ones. perhaps especially if input costs outpaced payment rates indefinitely. additionally under current law, it will likely outpace payment rates by more during the next year or two than they did during the typical year in the past two decades. the data i'm speaking to here also don't address outcomes other than access like quality. nevertheless this recent history does suggest that there is some scope for medicare's physician payment rates to grow more slowly than input costs in the years to come without a decline in access. in the time i have left i want to briefly highlight four structural changes to how medicare pays physicians that are worth considering regardless of the policymakers. the first is eliminating the merit-based incentive payment system or mips which is failing its goal in improving the quality and efficiency of patient care, but is improving compliance costs for decisions. since mips would make it cheaper for physicians to treat medicare beneficiaries, it would be a low cost way of addressing concerns that medicare's payment rates are inadequate. the second is retaining bonuses or a pms rather than allowing these bonuses to decline sharply as scheduled under current law. in contrast to mips, well designed a pms do appear to improve the efficiency of patient care, and the current payment bonus encourages the model uptake and gives flexibility to improve design. the third is insulating future physician payment rates from inflation shots but in a budget neutral way. physician payment updates are currently fixed in law, so shocks to economy wide inflation can cause adjusted inflation rates to be higher or lower than currently affected. -- by specifying the payment updates should equal the medicare economic index minus inappropriate fixed percentage. the fourth with takes me beyond physician payment per se is adopting site neutral payment for ambulatory services as this subcommittee has considered at other points this year. the benefit of site neutral payment in terms of reducing costs and removing incentives for consolidation are likely familiar, so i will not repeat them, but i will note that side of service payment differences will likely grow over time if medicare's physician payment rates continue to grow slowly in years to come, which will magnify the importance of shifting to site neutral payment. thank you again for the opportunity to testify. i look forward to your questions. >> thank you very much. i concludes the testimony. we will now move into members questions. i will recognize myself or five minutes. i want you to clarify something really quick, dr. fiedler. you said 4/5 of people, medicare patients don't have trouble finding new primary care physicians. that means a fifth of them do. you presented that kind of that was a positive number. from my perspective that's awful. a fifth of medicare patients, when they lose their primary care doctor, or their doctors retire, are struggling to find a new physician. is that what you said? >> that's correct. so i think the question is relative to what, and it's a far better number than we observed with private insurance, then there is a separate question to what extent would increase in payments actually address the problem. >> yeah. the reality is then it's a chicken and an egg right? we have a shortage of primary care physicians because of reimbursement challenges. i think we can agree to disagree , but it's a chicken or the egg. you don't pay doctors enough, they don't go to rural america, and people can't find their dr. >> i think -- >> you are saying that payment doesn't matter, but i'm saying that's the root cause of the problem. >> i think it is possible that payment matters to some degree. in particular i think we do observe that those access measures are somewhat better for specialty care and primary care, so that might be consistent with the view that payment does matter at the margins. i think what is true is, given that we've seen a large decline in payments without a large deterioration in access by the question is how much does it matter for access. >> i know you're an economist, but economists need to take a tour through rural southern indiana and you might change your view. he was upset about specialist, two thirds of seniors, and in the last number was just over 50% of seniors. can you clarify those? because again, those are awful numbers. he said they were positive, but they seem pretty negative. >> this is a number of people, two thirds is the number of people who reported never waiting longer than they wanted to for an appointment. >> so at urdu. >> but many of those people are responding -- >> fair enough. >> there is a trade-off between how much can you improve access for a given amount of -- >> fair enough. >> dr. patt , i understand you run your own practice, and due to a variety of factors, many medical specialties are facing cups -- cuts of up to 10% this year. as an independent physician, can you share what an 8 to 10% cut would mean for your ability to operate a physician praxis -- practice, and what that might mean for patients? in your testimony you talked about that briefly, but can you clarify that even more? >> when we have decreases in reimbursement, you know, that has a trickle-down effect to everyone that we employee. in texas ontology -- oncology, we employ about 6000 employees. it's important for us to give appropriate competition increases to stay competitive. otherwise those who have greater funding resources will take them away and they aren't able to keep appropriate staffing. the natural consequence of the cut is that we aren't able to pay her staff appropriately at a competitive rate to stay staffed appropriately. >> you also talked about the pressure that independent practices felt, feel, to sell to health systems. in fact my medical practice we sold to hospital in 2005. we got to a point where he couldn't sustain an independent cardiology and cardiac surgery practice. it's worse today. in that context, site neutral payment and other things, i've had conversations with hospitals and health systems that don't really feel like this is, had an impact on the physician ability to stay independent, and also has not been a major factor in consolidation. can you talk about how that dynamic, the difference in payment, the payment disparity, has an impact on consolidation, and physicians having a hard time staying independent? >> absolutely. thank you for the opportunity to answer the question. it's a very clear correlation. if our reimbursement is less, we can't pay staff as much. we are in a competitive environment of staffing. there is a nursing shortage throughout the country. if a competing hospital is able to pay them a large signing bonus and increase their compensation, they take away her staff and we aren't able to stay open. then we operate less efficiently. then if you aren't able to stay financially viable, there is always an attractive offer to sell your practice to the hospital system, and that is how consolidation occurs. at some point it becomes more financially viable to transition , and really it's not a closure of the practice. it's more just changing the shingle, and all of the insurance contracts to double. so that consolidation is a natural increased in the cost of care. it is not in america's best interest to see that happen. >> thank you very much. my time has expired. i now recognize the ranking member, ms. eshoo , for 5 minutes. >> thank you, my friends, dr. bucshon . i listen very carefully to your comments, to dr. fiedler . it seems to me, and i might be wrong, but my take away from some of the things that you said was that in not taking into consideration the impacts, and they are lasting, from covid. i mean article after article after article after editorial speaks of physicians in our country who just left their practice, just left their practice. we have heard in different forums, testimony here, of professions being hollowed out, and then explore what we can do to bring in a whole new wave of professionals, so you don't make mention of that. you say well two thirds, one third, sounds rosy. i agree with dr. bucshon. there is something missing and what you said. i don't know when you put those numbers together, and that they are all rosy. i don't think so. and i, you know, i am a real commonsense person. all of us here have heard the testimony from professionals. we know what is going on in our own communities. we are not making this up. may be you can go back and take a look at it and come back and give us something else to take a look at. we've heard a lot today about improving patient access to care. cms released data from a survey showing 92.5% of medicare beneficiaries reporting no trouble accessing care. i don't know where they got this from, but i get a different answer in my district. dr. furr and dr. patt. you are both doctors. in your experience, tell us how come you know for the record, tell us how doctors are reacting to the decreasing medicare reimbursement. are more doctors retiring? turning away from medicare patients? we really need to get this on the record here. it's not that i don't, i'm asking you questions that i think i know the answer to, but i want this on the record, and dr. fiedler, while most medicare beneficiaries report they are able to see their doctors , i don't know when this was, the survey or whatever was taken. when was it? >> the data i am speaking to our from 2022. >> well, that's almost 2 years old. at any rate, how did geographical differences come into this? how do they play into it? is there much of an effect as a result of them, and how does reimbursement play a role in addressing the access issues, so you can split up the time, 1:36 . >> the geographical floor is very important. if it's lowered and taken away for world physicians in particular, in a rural area, not only are you in a rural area, we are usually taking care of more low income patients, disadvantage patients, so you don't have the payer mix that balances that out. >> how often are those geographical designations reviewed? i remember many years ago, i mean, i got into such a protracted battle because i had to, because one of the counties in my congressional district board the designation of being rural, except that was when medicare was established. it earned that "rural" designation in 1966, and we were losing doctor after doctor after doctor. it was pennies on the dollar. how often is that reviewed? >> i'm not sure how often it's reviewed. i do know the floor is going to go away at the end of this year so it's critically important that congress act and keep that floor from going away. from practicing in a rural area, it is not cheaper to live in a rural area particularly after covid. gases no cheaper. hiring employees is not cheaper. i have a number of my patients who are now travel nurses. i can't afford to have them, because they are getting money that is being cade to cape cod and other areas. it's not cheaper. that's why we need to have that floor and not let it go away. >> i think mr. chairman that my time has expired. dr. furr , i will send you my questions in writing, and you can respond in that manner, and thank you to each one of you for being here today. i know our schedule has been rocky and not all that predictable, but thank you for being here this afternoon, and i he got back mr. chairman. >> and i recognize -- for five minutes. >> i'm glad we can discuss proposals and look to minimize disruptions to care for seniors and provide the ability for medicare providers. i'm particularly glad we have prioritized preventing additional consolidation in the healthcare sector so far this congress, and i am pleased my bill that providing relief and stability for medicare patients act was noticed for today's hearing. my bill hr 30 674 which i leave with representative cardin's aims to prevent office-based specialty cuts that were adversely affected by the clinical labor pricing. i believe these cuts, some upwards of 25%, have only fueled further closures of these community providers, and worsened consolidation that ultimately hurt patient access as they end up in more expensive settings. i see this all over my district. i want to submit a letter further record from a coalition of providers in support of my legislation that would provide some relief and also submit a statement for the record from the society for vascular surgery discussing its support for hr 3674, and the need to avoid disruptions in care for medicare beneficiaries. i ask for unanimous consent that both be inserted into the record mr. chairman. >> without objection. >> my question is for dr. pat. thank you for your testimony on behalf of the oncology community. you know the importance firsthand about maintaining community-based settings for patients. and you tell us what the impact on office-based providers would be if we don't work to alleviate these cumulative year- over-year cuts in the physician fee schedule, and can you tell me what impact it would have on patient access? thank you. >> thank you for that question. i think that will have many implications if the cuts are not alleviated. i think the natural consequence is that we are private groups that are in community practice and aren't able to stay viable, and then not able to have competitive staffing resources. when that happens, we have to close treatment times and not be open to the most of our capacity. that decreases access and also furthers consolidation. i think efforts to move reimbursement in your legislation, thank you for leading it, would go a long way to improve that, and make community practice more sustainable. i also think that aside from those individual changes that the site of service disparity poses a continued challenge to the threat of consolidation, and when you have consolidation happen, you are going to have access to care issues for medicare beneficiaries and all americans. >> i see that, and i know the patients in my district preferred the community care for a lot of reasons. beyond my bill, i also want to think the chair for putting up legislation i co-lead with representative hudson and many of the bipartisan members of this committee, the saving access to laboratory services, hr 2377 which would provide a much-needed permanent solution to clinical laboratory reimbursement for medicare. we must prevent these cuts from happening while prioritizing lobster statistical sampling changes that protect public health and innovation. lastly, i wanted to quickly think the chair again for including the empower act, hr four 870 to help the physician therapy workforce, the physical therapy workforce in this case, and i hope that we can go further in a future hearing by discussing my bipartisan bill hr 16 17 to prevent interruptions in physical therapy act as well. i look forward to working with the chairman and the committee on the simple important legislation. and i hope it is considered soon. physical therapy is so important particularly for medicare patients. i yield back. >> i now recognize dr. ruiz. five minutes. >> thank you mr. chairman. medicare is our nation's promise to seniors, the establishment of the medicare program was intended to ensure that seniors have affordable access to the healthcare they need when they need it, and when they need it most in their elderly years, and medicare needs work. seniors should not have to wait to receive necessary medical services. they should not be turned away by doctors family because they are covered by medicare. the fact that we are having this hearing today is a testament to the reality that the system is broken, and we need to take action to protect the patient's and medical professionals participating in the medicare program. we need to protect and strengthen medicare for seniors. we need to address a major barrier to care for patients, which is the physician reimbursement rate, the medicare participation for the physicians charged with providing these cares. for years, physicians have been experiencing cuts for their medicare reimbursements, year after year, even while other medicare providers have experienced increases for inflation. is he from 2001 to 2023, inflation adjustment payments for physicians declined, declined by 26%, even amid the rising cost of running a medical practice, cuc this widening gap. on top of that, physicians received 80% across the board cut to their medicare conversion factor in 2023, and this is after the burnout and the experience that they had during the pandemic, and physicians are facing another potential 3.36% cut in 2024. why does this matter? all of you have said this eloquently. we have a physician shortage crisis already in our country. most pronounced in rural underserved areas. when you on top of that inhibit the ability for a physician to provide care for their patients and not meet their bottom line, they are going to practice elsewhere where they are going to get a higher reimbursement rate, or they are going to choose the insurances that are going to reimburse them the most , and they will drop medicare, and that will leave our patients without a physician for them. this is about patients am i not physicians. this is about putting patients first and ensuring that they have the doctors and the medical professionals able to take care of them and keep their doors open, especially in underserved areas. so the physician fee schedule is broken, and we can't afford for doctors to close their doors or take fewer medicare patients because they can't afford to treat them. tying medicare reimbursement rates to rising inflation will go a long way towards protecting physicians and ensuring reliable access to care for patients. that is why my bipartisan bill with dr. bucshon and dr. miller meeks. dr. bucshon was here earlier. the hr 2474 strengthening medicare for patients and providers act will adjust medicare physician reimbursement rates based on inflation by tying reimbursements to the medicare economic index. so considering the trending decline in physician payments rates, dr. fiedler, had you see this impact patient access and quality of care in the future. >> as the saying goes, predictions are hard especially about the future. i do think one of the striking features of the last two decades is that patient access and data care has been remarkably stable even during a period where physician payment rates have lagged behind. >> and that is a testament to the physicians who care about their patients, and will practice and take care of them and treat the patient first and foremost, so i appreciate that, but there are some challenges for them to do that. since we have limited time, i will ask you to answer that with my office in writing if you can because there is another , another bill that i am a cosponsor of, and i want to send a strong message to our chairman to please have a hearing on this bill, and to please pass it through committee. i know that ranking member anna g. eshoo is in support of this as well, and i think we can pass a good bipartisan bill immediately to address this issue, but the hr 5526, the seniors access to critical medications act of 2023, which i am a cosponsor, will allow physicians to help mail their medications to their patients. we have a lot of patients with mobility and transportation issues. this will help strengthen medicare by enabling seniors to receive their medications without the onerous barriers that it takes for them personally to go and get the medications themselves. with that i know i ran over my time. thank you for your grace and i yield back. >> the gentleman yields back. the chair now recognizes dr. burgess for five minutes. >> i want to thank our witnesses for being here and your forbearance and what has been sort of a disjointed day. dr. furr, i'm not sure if you are here earlier in the hearing. i talked about one of the bills that is the subject of this legislative hearing, the provider reimbursement stability act of 2023, current medicare fee schedule over and over again, unsustainable and unpredictable. this is due in large measure to what is known as budget neutrality, then mechanism often leads to across-the-board cuts, and making it harder for practices to survive. so, with what you have heard about that this morning, can you speak to how provisions and that would stabilize and promote ask her or see within the physician fee schedule? >> we need to get where the physicians are not going against each other and that is what budget neutrality does. when you have that conversation, because i definitely needs to change. part of what you have in there changing the cabin where the changes is incredibly important. i think it would go a long way. >> so that, that threshold has not changed since 1992, and the adjustment for constant dollars on the medicare spend currently would result in a significant increase in that threshold, and that you feel would be beneficial to the practicing physician? >> yes, sir. >> dr. patt, i can't thank you enough for being here. i know you had to take the train late last night. i know it was a lot for you to get here, and we really do appreciate that. in your written testimony you mention examples of how consolidation leads to rising healthcare costs. right now i'm working on a discussion draft that will allow for physician owned hospitals, 35 miles from an existing hospital or critical access hospital to open or expand. i'd like to remind everyone, this is a draft. i'm working on a few technical changes, but let me just ask you the general question. do you think physician ownership could be beneficial where healthcare is limited? >> i do. i would be very supportive of that idea. >> a very succinct answer. dr. furr, let me ask you the same question? >> most family physicians can't afford to run a hospital but if they can afford it and own it i have no problems with that. >> but who better to establish a facility in a rural area or in underserved area than someone who actually knows what a hospital is supposed to be, and what a well-run hospital looks like, and the fact that we are precluded from that activity by virtue of our professional degree, and the people in this community have heard me say it over and over again. it is wrong that a hospital can own a physician and the physician can't own a hospital. it makes no sense. in a free country, it should not be that way. i do know that there are concerns on both sides of the dais, and i will just say mr. chairman before i yelled back that i think the solution allows physicians to maintain activity in the business of healthcare while providing patients access to the care they need will allow doctors to continue to be able to afford to stay in practice when they have so many things working against them. in the interest of time i will yield back. >> the gentleman yields back. the chair will now recognize -- for questions. >> thank you very much for holding this very important hearing. i agree somewhat with some of the comments my colleague just made. it seems like in this country you can be a lawyer and own the practice, the law firm, but if you are a doctor you cannot own a hospital. it sounds like we trust lawyers more than doctors in this country. anyways, hopefully we can get to some good policy on that. this congress, i am proud to co- lead the providing relief and stability for medicare patients active 2023, along with my energy and commerce committee colleague, get this, republican bill rakas. we are collating on that bill as well as representatives murphy and davis. this bill would mitigate significant cuts to office- based specialists by increasing non-facility practice expense relative to value units or rv you for procedures performed in office-based settings that utilize high-tech medical devices and equipment. i believe this is important to ensuring that we preserve access to office-based care settings, many of which face a very real possibility of closure or consolidation. management associates have found that office-based specialists including radiologists, radiation oncologists, vascular surgeons, and radiologists have been subject to cumulative cuts on the physician fee schedule since 2006. this is simply not sustainable. i worry that patient care will suffer because of it. our focus should be in building robust systems that ensure our communities can access the care they need. i just spoke to an oncologist who owns a small practice, and he was mentioning how difficult it is, but i interrupted him and said okay, if your practice were to close, how far would your patients have to go to be able to get your service? he said 60 miles in one direction and 95 miles in one direction. that is rural america. i say that because i care about access for all americans. they represent part of los angeles. you can go a mile or two in any direction, and you are going to find doctors. you go a few more miles, an oncologist, et cetera. i just want to point out that please don't think that if we represent a big city we don't care about rural america. as well, i don't think that my colleagues who represent rural america don't care about people in big cities either. i just wanted to point that out. i have a question for dr. pat, sorry, deborah pat. in your testimony you note that decreasing reimbursement causes a chain reaction that results in provider network inadequacy, decreased access to care, inability to manage staffing shortages, and decreased quality of care for american seniors and other medicare beneficiaries. what is the impact of the sustained clinical labor cuts especially in medically underserved communities? >> thank you for the question. i think that these cuts will result in doctors not being able to staff appropriately, which overburdened the doctor and makes doctors exit the workforce. i think we have observed this, that when practices are subject to close, there is frequently consolidation of medical care. the natural consequence of that is it drives up healthcare costs . i think there are a number of factors that all influence access to care and the cost of care at the end of the day that will be harmed by not making change today. >> thank you. it's important that we focus also on the healthcare workforce so that we can get an adequate environment out there. physicians surveyed in my home state of california found that 87% of physicians expressed that low medicare reimbursement and high cost of practice in california are negatively impacting physician recruitment and retain mint. i'm sure that's not just for california. that is for the rest of the country as well. congress must work collaboratively to ensure that physician workforce is equipped to address the needs of the communities they serve, especially if we want to ensure that her healthcare workforce is as diverse as the community as they serve. questions for dr. fiedler. in your testimony you mentioned that evidence suggests that reductions in medicare physicians payments rates it potentially affects who enters the medical profession. can you expand on this, and what do you expect that the impact would be on workforce diversity? >> there is some evidence, particularly regarding specialty choice, but it likely also affects how many total people enter into the profession. i think the question then is how large those effects are, and how to balance the resulting increase in supply physician services from payment rates against the costs that are imposed on taxpayers and beneficiaries and potentially in people with private insurance. >> sounds like we need a better efficient system. i just ran out of time. i yelled back. >> the chair now recognizes mr. carter from georgia. >> q mr. chairman and thank you all for being here. as we all know, we have a healthcare worker shortage here in america, and we certainly have it in the state of georgia as well. as a consultant for nursing homes for many years, nursing homes have been especially impacted by the healthcare shortage. it's something i'm very concerned about. healthcare provider shortage is one of the biggest challenges facing our healthcare system and our nation right now. we all know that. in fact there was a recent survey that said the u.s. will face a shortage of up to 139,000 physicians in advanced practitioners by 2033, including shortfalls in both primary and specialty care. you know, i don't know that it is the total reason, but i would submit to you that more than any other agency that the ftc has failed the american public by allowing consolidation in healthcare like they have. i would submit to you as a pharmacist at the primary reason for high drug cost is the consolidation, the vertical integration that exists in the drug pricing chain , where the insurance company owns the ppm that owns the group for the purchasing organization then owns the pharmacy, then owns the doctor. dr. furr, do you know who employs the most physicians in america right now? >> not for sure, but i would guess united healthcare. >> you are absolutely 100% correct. united healthcare employees more physicians in america now than any other organization, and it's not just pharmacy. it's also, it's also in the healthcare system. it's the hospitals. now look, i'm not opposed to anybody making money. i know we live in a capitalistic society. i get it and i understand all that. we had a meeting mr. chairman here with the energy and commerce committee. it wasn't a hearing, it was a meeting. we had the congressional budget office. we had the director and 20 staff members. i asked him that question. i said give me one example of where consolidation and healthcare has saved money. crickets. nothing. one example where consolidation and healthcare saved money. whether you are a democrat, a republican, or an independent, you all want the same thing in healthcare picu and accessibility, affordability, and quality. consolidation has done away with all of those i would submit to you. now, i'm not saying we don't have quality healthcare. we do. we have the best healthcare in the world right here in america, but the consolidation that has gone -- you know, and i don't expect for you to tell me, but i'm going to tell you voting for for president, and that is going to be teddy roosevelt, because we need somebody back here who will busted up, and he will do a better job than most of these people can alive. i'm just telling you. let me, let me ask you, dr. furr , what kind of misaligned incentives do you think that we have right now in healthcare that is causing some of these shortages? >> i think so many of the things and the things that when you talk to our physicians, the biggest thing is the administrative burden. as you know working as a pharmacist, when administrative burden started out, that was a high cost item, so overusing pet scans and devices, now we are doing pre-authorizations for generic drugs, just because they changed their formulary, w the drug. they wouldn't even tell me what drugs they would cover. what drug do they cover? we will let you know if it goes through. we need to do it two or three times. give me half a shot, in
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