[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
THE EXTENDERS POLICIES: WHAT ARE THEY AND HOW SHOULD THEY CONTINUE
UNDER A PERMANENT SGR REPEAL LANDSCAPE?
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
JANUARY 9, 2014
__________
Serial No. 113-111
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
RALPH M. HALL, Texas HENRY A. WAXMAN, California
JOE BARTON, Texas Ranking Member
Chairman Emeritus JOHN D. DINGELL, Michigan
ED WHITFIELD, Kentucky Chairman Emeritus
JOHN SHIMKUS, Illinois FRANK PALLONE, Jr., New Jersey
JOSEPH R. PITTS, Pennsylvania BOBBY L. RUSH, Illinois
GREG WALDEN, Oregon ANNA G. ESHOO, California
LEE TERRY, Nebraska ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
PHIL GINGREY, Georgia JIM MATHESON, Utah
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio JOHN BARROW, Georgia
CATHY McMORRIS RODGERS, Washington DORIS O. MATSUI, California
GREGG HARPER, Mississippi DONNA M. CHRISTENSEN, Virgin
LEONARD LANCE, New Jersey Islands
BILL CASSIDY, Louisiana KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia BRUCE L. BRALEY, Iowa
CORY GARDNER, Colorado PETER WELCH, Vermont
MIKE POMPEO, Kansas BEN RAY LUJAN, New Mexico
ADAM KINZINGER, Illinois PAUL TONKO, New York
H. MORGAN GRIFFITH, Virginia JOHN A. YARMUTH, Kentucky
GUS M. BILIRAKIS, Florida
BILL JOHNSON, Missouri
BILLY LONG, Missouri
RENEE L. ELLMERS, North Carolina
Subcommittee on Health
JOSEPH R. PITTS, Pennsylvania
Chairman
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
ED WHITFIELD, Kentucky JOHN D. DINGELL, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
MIKE ROGERS, Michigan LOIS CAPPS, California
TIM MURPHY, Pennsylvania JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee JIM MATHESON, Utah
PHIL GINGREY, Georgia GENE GREEN, Texas
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey JOHN BARROW, Georgia
BILL CASSIDY, Louisiana DONNA M. CHRISTENSEN, Virgin
BRETT GUTHRIE, Kentucky Islands
H. MORGAN GRIFFITH, Virginia KATHY CASTOR, Florida
GUS M. BILIRAKIS, Florida JOHN P. SARBANES, Maryland
RENEE L. ELLMERS, North Carolina HENRY A. WAXMAN, California (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
C O N T E N T S
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Page
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 2
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 4
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, opening statement............................... 5
Witnesses
Glenn M. Hackbarth, J.D., Chairman, Medicare Payment Advisory
Commission (MEDPAC)............................................ 7
Prepared statement........................................... 9
Diane Rowland, Sc.D., Chair, Medicaid and CHIP Payment and Access
Commission (MACPAC)............................................ 30
Prepared statement........................................... 32
Michael Lu, M.D., M.S., M.P.H., Associate Administrator, Maternal
and Child Health Bureau, Health Resources and Services
Administration (HRSA), U.S. Department of Health and Human
Services....................................................... 57
Prepared statement........................................... 59
Naomi Goldstein, Ph.D., Director, Office of Planning, Research
and Evaluation, Administration for Child and Families (ACF),
U.S. Department of Health and Human Services................... 66
Prepared statement........................................... 68
Answers to submitted questions............................... 223
Submitted Material
Statement of the American Hospital Association, submitted by Mr.
Burgess........................................................ 102
Pallone documents................................................ 110
Pitts documents.................................................. 128
Statement of the Federation of American Hospitals, submitted by
Mr. Griffith................................................... 219
THE EXTENDERS POLICIES: WHAT ARE THEY AND HOW SHOULD THEY CONTINUE
UNDER A PERMANENT SGR REPEAL LANDSCAPE?
----------
THURSDAY, JANUARY 9, 2014
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Joe Pitts
(chairman of the subcommittee) presiding.
Members present: Representatives Pitts, Burgess, Shimkus,
Murphy, Blackburn, Gingrey, Lance, Cassidy, Griffith,
Bilirakis, Ellmers, Pallone, Dingell, Capps, Matheson, Green,
Barrow, Christensen, Castor, Sarbanes, and Waxman (ex officio).
Staff present: Gary Andres, Staff Director; Noelle
Clemente, Press Secretary; Brenda Destro, Professional Staff
Member, Health; Brad Grantz, Policy Coordinator, Oversight and
Investigations; Sydne Harwick, Legislative Clerk; Robert Horne,
Professional Staff Member, Health; Katie Novaria, Professional
Staff Member, Health; Monica Popp, Professional Staff Member,
Health; Chris Sarley, Policy Coordinator, Environment and
Economy; Heidi Stirrup, Health Policy Coordinator; Tom Wilbur,
Digital Media Advisor; Ziky Ababiya, Democratic Staff
Assistant; Amy Hall, Democratic Professional Staff Member;
Elizabeth Letter, Democratic Assistant Press Secretary; Karen
Lightfoot, Democratic Communications Director and Senior Policy
Advisor; Karen Nelson, Democratic Deputy Committee Staff
Director for Health; and Anne Morris Reid, Democratic
Professional Staff Member.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. The subcommittee will come to order. The chair
recognizes himself for an opening statement.
This subcommittee has played an integral role in advancing
a permanent repeal of the SGR and implementing a replacement
policy for Medicare reimbursement to physicians. We reported
out Dr. Burgess's Medicare Patient Access and Quality
Improvement Act of 2013, H.R. 2810, by voice vote, and the full
committee reported it out favorably by a vote of 51 to 0 last
July.
As we move ahead with a permanent SGR fix, we also need to
examine the expiring Medicare/Medicaid Children's Health
Insurance Program--CHIP--and Human Services' provisions that
have traditionally moved with the SGR.
The purpose of today's hearing is to look at these
extenders and evaluate whether some of these short-term
provisions should be made permanent and, if so, how best to
accomplish this.
The list of extenders includes the following: the floor on
Geographic Adjustment, or GPCI, for physician fee schedule,
Ambulance Transitional Increase and Annual Reimbursement
Update; Therapy Cap Exceptions Process, Special Needs Plans,
Medicare Reasonable Cost Contracts, National Quality Forum--
NQF; Qualifying Individual--QI program; Transitional Medical
Assistance--TMA; Medicare Inpatient Hospital Payment Adjustment
for Low-Volume Hospitals; Medicare-Dependent Hospital--MDA
program; Medicaid and CHIP Express Lane Eligibility; Children's
Performance Bonus Payments; Child Health Quality Measures,
Outreach and Assistance for Low-Income Programs, Child Health
Quality Measures, Family-to-Family Health Information Centers,
Abstinence Education, Personal Responsibility Education
Program; Health Workforce Demonstration Program; the Maternal,
Infant, and Early Childhood Home Visiting Programs; and Special
Diabetes Program.
In our current budget climate, and with the Medicaid
trustees predicting insolvency as early as 2026, hard decisions
will have to be made. A determination that a policy should be
made permanent must be based on data-driven analysis that
justifies the extenders' continued existence.
I am looking forward to hearing from our witnesses today,
particularly MedPAC, which has come up with its own criteria
for evaluating these provisions, which includes the effect
possible action would have on program spending relative to
current law, whether such action would improve beneficiaries'
access to care and quality of care, and whether action would
advance delivery system reform.
This is a time for us to be very prudent, even skeptical,
given the enormous cost of these policies and do our job on
behalf of the taxpayers to ensure every dollar spent is
reviewed for efficacy.
Thank you, and I yield the remainder of my time to Dr.
Burgess, vice chairman of the subcommittee.
[The prepared statement of Mr. Pitts follows:]
Prepared statement of Hon. Joseph R. Pitts
The Subcommittee will come to order.
The Chair will recognize himself for an opening statement.
This Subcommittee has played an integral role in advancing
a permanent repeal of the Sustainable Growth Rate (SGR) and
implementing a sound replacement policy for Medicare
reimbursements to physicians.
We reported out Dr. Burgess' Medicare Patient Access and
Quality Improvement Act of 2013 (H.R. 2810) by voice vote, and
the Full Committee reported it out favorably by a vote of 51 to
0 last July.
As we move ahead with a permanent SGR fix, we also need to
examine the expiring Medicare, Medicaid, Children's Health
Insurance Program (CHIP), and human services provisions that
have traditionally moved with the SGR.
The purpose of today's hearing is to look at these
``extenders'' and evaluate whether some of these short-term
provisions should be made permanent, and, if so, how best to
accomplish this.
The list of extenders includes the following:
Floor on Geographic Adjustment (or GPCI) for
Physician Fee Schedule,
Ambulance Transitional Increase & Annual
Reimbursement Update,
Therapy Cap Exceptions Process,
Special Needs Plans,
Medicare Reasonable Cost Contracts,
National Quality Forum (NQF),
Qualifying Individual (QI) Program,
Transitional Medical Assistance (TMA),
Medicare Inpatient Hospital Payment Adjustment for
Low-Volume Hospitals,
Medicare-Dependent Hospital (MDH) program,
Medicaid and CHIP Express Lane Eligibility,
Children's Performance Bonus Payments,
Child Health Quality Measures,
Outreach and Assistance for Low Income Programs,
Family-to-Family Health Information Centers,
Abstinence Education,
Personal Responsibility Education Program,
Health Workforce Demonstration Program,
The Maternal, Infant, and Early Childhood Home
Visiting Programs, and
Special Diabetes Program.
In our current budget climate, and with the Medicare
Trustees predicting insolvency as early as 2026, hard decisions
will have to be made.
Any determination that a policy should be made permanent
must be based on data-driven analysis that justifies the
extender's continued existence.
I am looking forward to hearing from our witnesses today,
particularly MedPAC, which has come up with its own criteria
for evaluating these provisions, which includes the effect
possible action would have on program spending relative to
current law; whether such action would improve beneficiaries'
access to care and quality of care; and whether action would
advance delivery system reform.
This is a time for us to be very prudent, even skeptical,
given the enormous costs of these policies, and do our job on
behalf of the taxpayers to ensure every dollar spent is
reviewed for efficacy.
Thank you, and I yield the remainder of my time to --------
----------------------------------.
Mr. Burgess. Thank you, Mr. Chairman, and I do appreciate
that you started your opening statement with the acknowledgment
that the reason we are here today is because of the real
progress that has been made on the repeal of the Sustainable
Growth Rate formula, which has been a problem for a lot of us
for a long time, so the cake is literally in the oven baking
and today we are going to talk about what else may go into that
before the process is completed.
There are certainly a number of Medicare- and Medicaid-
related policies that every year plague providers because of
the uncertainty that it brings to the program participation by
provider payment each year. Not all of these policies are under
our jurisdiction. Many are some that have proven successful but
many of these programs are under our jurisdiction and many of
them have proven successful such as the Special Diabetes
programs and the Special Needs Plans. Others are essential to
guaranteed access to care in States like Texas with large rural
areas such as the Medicare-Dependent and Low-Volume Hospital
programs. Still other extenders are necessary to block
misguided policies like the Medicare therapy cuts. Capping
rehabilitative access made no sense when it was first passed
several years ago, and guess what? With the passage of time,
nothing has improved. It still makes no sense. Doctors should
be able to provide their patients with the option of therapy
and never fear that either prior to or after surgery a patient
will not be able to access the therapy services that they
require.
So certainly, Mr. Chairman, I am appreciative of the work
that this subcommittee did in moving the SGR reform along as we
were the initial subcommittee that passed real, meaningful
Sustainable Growth Rate reform out of subcommittee on to full
committee. Other jurisdictions have taken up that matter but it
all started here with you, Mr. Chairman, and I am appreciative
of that.
I would also ask unanimous consent to submit the testimony
of the American Hospital Association for the record as well,
and yield back.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. The Chair now recognizes the ranking member of
the subcommittee, Mr. Pallone, 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairman Pitts.
I am pleased we are having this hearing today to discuss
the temporary payment policies and programs we typically
extended every year alongside the SGR. I thank our witnesses
also for being here today to contribute to the discussion.
This subcommittee has an important role in reviewing and
evaluating health care policies and the extenders provisions
that will contribute to the health care communities' abilities
to better serve beneficiaries under Medicare and Medicaid.
In many ways, extenders support the health care framework
envisioned in the Affordable Care Act. They work through
various mechanisms to support increased access to health care
and to encourage higher quality and more efficient patient
care.
In spite of all that, we move beyond the unworkable process
of legislating extenders policies year to year. We need to set
these policies up for success by providing a better sense of
stability, and that is not to say that I think we should every
provision permanently but moving towards a 3- to 5-year end
date in some cases will better enable the subcommittee to
conduct proper oversight and consider making changes
periodically based on data collected over a sufficient amount
of time.
In addition, we look to make changes to some of these
policies but, more importantly, as we look to offset the costs
associated with both the SGR and extenders, we must not cost-
shift onto vulnerable patients who rely on these programs.
I just wanted to take a moment to highlight some extenders
and how they help our Medicare and Medicaid programs, and this
is not an exhaustive list, but certainly they are ones that I
would like to work to urge this committee to extend. One is the
Qualifying Individual, or QI, program in Medicare, which
assists certain low-income Medicare beneficiaries by covering
the cost of their Medicare Part B premium. This program helps
reduce financial burdens and thereby improve access to needed
health care services for low-income Medicare beneficiaries who
do not quality for Medicaid. In New Jersey, 40,000 people were
able to get this needed financial assistance in 2013.
Another is the Transitional Medical Assistance, or TMA,
program, which allows low-income families on Medicaid to
maintain their Medicaid coverage for up to one year when their
income changes as a result of transitioning into employment.
The TMA program helps keep people continuously insured,
allowing for consistent access to primary care and prevention
services.
I also wanted to highlight two payment policies that we
implemented in the ACA. The Medicaid Primary Care Physician
Bonus Payment augments the low physician rates in Medicaid
compared to Medicare. Research has shown that higher Medicaid
payments increase the probability of beneficiaries having usual
source of care and at least one visit to a doctor. This is an
important policy that I believe should be extended because,
unfortunately, we still need time to understand the impact of
the program in a meaningful and empirical way. I also believe
that there are physicians who are essential to the Medicaid
program such as neurologists, psychiatrists and OB/GYNs that
aren't included in the bonus payment but should be.
We also included in the ACA performance bonuses for States
that increased enrollment of children in Medicaid and
streamlined enrollment procedures for Medicaid and CHIP. New
Jersey was one of 23 States that received a bonus payment in
2013 through this program. Minimizing barriers to enrolling in
coverage makes a difference in how many children are enrolled
each year and ultimately whether they receive their prevention
services and medical care they need.
And finally, I want to mention the Family to Family Health
Information Centers, or F2F grant program. F2Fs assist families
of children and youth with special health needs in making
informed choices about health care, which in turn promotes
improved health outcomes and more effective treatments. So F2Fs
provide a unique service in that they are staffed by family
members who have firsthand experience in navigating special
needs health care services and that is why I have sponsored a
bill, H.R. 564, to extend F2F funding through 2016 and will
continue to advocate for its inclusion in any SGR package.
These are just a few examples of the many extender
provisions that we must discuss as we move forward with an SGR
fix. I have been pleased by the recent progress made on SGR,
Mr. Chairman, and I stand ready to work with my colleagues on
both our committee and Ways and Means and with our Senate
counterparts to permanently repeal and replace the SGR and
continue these important extender provisions.
I don't know if Ms. Capps would like my last 30 seconds.
All right. Then I yield back, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman. Our Chair is not
here, so the Chair recognizes the ranking member of the full
committee, Mr. Waxman, 5 minutes for an opening statement.
OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mr. Waxman. Thank you very much, Mr. Chairman.
My colleagues, this Congress seems to be, I hope, poised to
eliminate the SGR and make it a program that will no longer be
in existence so every year we don't have to go through the
torture of trying to make sure that the harmful consequences of
not extending it would be averted. All three committees, two in
the House and one in the Senate, have voted--our Committee
voted unanimously--on the SGR. I hope we can get it across the
finish line and let us get this job done.
The SGR issue has often served as a vehicle to address
Medicare, Medicaid, the Children's Health Insurance Program and
additional public health-related programs, which contain
similar time limits. These provisions have been collectively
referred to as extenders or extender policies. When we
permanently repeal and replace the Medicare SGR policy, we must
also address these associated extender policies. These policies
seek to protect vulnerable patient populations and the
providers and health programs that serve them, so we can't
afford to leave them out in the cold and in jeopardy of being
terminated.
In Medicare, we have policies that need to be extended
relating to therapy caps and Special Needs Plans. Those have
been discussed; they are well known. There are six public
health extenders, some which have a long history of bipartisan
support, and I am generally supportive of these public health
programs, but I do want to note my reservations about extending
the Abstinence Only program.
But I want to focus on the Medicaid and CHIP issues, which
are often overlooked. Those policies help secure affordable
coverage, boost enrollment of eligible children, and streamline
administrative processes for States. For example, there is an
Express Lane program. It gives States the option of relying on
income data already in use for other federal programs, helping
reduce bureaucracy and lower State administrative costs. This
should be a permanent option for the States. The Transitional
Medical Assistance and Qualified Individual programs are
indispensable for low-income families. We must end the annual
extender roller coaster and ensure this coverage is secure
going forward. The CHIP bonus payments have been successful at
getting States to adopt simplifications and find and ways to
get people enrolled, get kids enrolled. Twenty-three States,
more than half of them with governors who are Republicans, have
qualified under this program. We should continue it through the
current CHIP reauthorization. And also, I have heard a great
deal from family doctors and pediatricians about the Medicaid
primary care bonus. It is something that would provide
stability and adequate payment for physicians comparable to
what we do in Medicare, and there is no better way to assure
access and provide an alternative to the emergency room for
care than making sure that doctors, especially family care and
pediatricians, will have the extra payment to allow them to see
these patients.
So I am glad we are holding this hearing, and I want to
yield the balance of my time to my friend and colleague from
California, Ms. Capps, who has a number of public health
provisions that are in this bill that are very meritorious.
Mrs. Capps. Thank you very much. Thank you, Waxman.
And I want to just simply add my thanks to the chairman and
Ranking Member Pallone for holding this very important hearing
today.
You know, we have had many discussions of how to move past
the flawed SGR system, and I have frequently shared my views
that we can't and must not ignore the important health care
extenders, many of which have been mentioned already. These
typically go along with SGR patch legislation, small technical
but critical policies that make a world of difference for
health care providers and their patients.
I just want to stand ready to work with my colleagues on
each of these issues, especially those that have been already
mentioned--the Medicare therapy cap, the Medicaid primary care
bump, the many critical Medicaid and public health care
extenders that we are considering today, and again, thank you
for yielding your time and also for holding the hearing today.
Yield back.
Mr. Pitts. The Chair thanks the gentlelady. That concludes
the opening statements of the members.
I would like to thank all of the witnesses for coming
today. We have one panel. On our panel today we have Mr. Glenn
Hackbarth, Chairman of the Medicare Payment Advisory
Commission, MedPAC. We have Dr. Diane Rowland, Chair, Medicaid
and CHIP Payment Access Commission, MACPAC. We have Dr. Michael
Lu, Associate Administrator, Maternal and Child Health Bureau,
Health Resources and Services Administration, U.S. Department
of Health and Human Services. And finally, Dr. Naomi Goldstein,
Director, Office of Planning, Research and Evaluation,
Administration for Children and Families, U.S. Department of
Health and Human Services.
Thank you for coming. Your prepared testimony will be made
part of the record. You will have 5 minutes to summarize your
testimony, and that will be placed in the record.
At this point I will recognize Mr. Hackbarth for 5 minutes
for his summary.
STATEMENTS OF GLENN M. HACKBARTH, J.D., CHAIRMAN, MEDICARE
PAYMENT ADVISORY COMMISSION (MEDPAC); DIANE ROWLAND, SC.D.,
CHAIR, MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION
(MACPAC); MICHAEL LU, M.D., M.S., M.P.H., ASSOCIATE
ADMINISTRATOR, MATERNAL AND CHILD HEALTH BUREAU, HEALTH
RESOURCES AND SERVICES ADMINISTRATION (HRSA), U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES; AND NAOMI GOLDSTEIN, PH.D.,
DIRECTOR, OFFICE OF PLANNING, RESEARCH AND EVALUATION,
ADMINISTRATION FOR CHILD AND FAMILIES (ACF), U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
STATEMENT OF GLENN HACKBARTH
Mr. Hackbarth. Thank you, Chairman Pitts, Ranking Member
Pallone and Vice Chairman Burgess. I appreciate the opportunity
to talk about MedPAC's recommendations on these issues.
As the chairman noted, there is a long list of Medicare
provisions under discussion here and it is a diverse list. I
won't try to summarize our substantive views on those
provisions. Instead, what I will do is describe the criteria
that we used to evaluate provisions.
We looked at them in two batches. First, there was a 2010
request from the Congress focusing on some temporary Medicare
extenders, as they are known. By definition, all of these
provisions increase spending above the current law baseline. In
evaluating those provisions, what we did was ask the question,
whether there is evidence that provision in question improves
access to care, quality of care or enhances movement towards
new payment models.
We also had a 2011 request from the Congress to evaluate
various special payment provisions that apply to rural
providers. There we used a similar test. We asked whether the
provision in question was targeted so that it provided support
to isolated providers necessary to assure access to care for
Medicare beneficiaries, whether the level of the adjustment
provided was empirically justified and whether it was designed
to preserve some incentive for the efficient delivery of care.
These tests that we applied are admittedly stringent tests but
we believe that they are consistent with our statutory charge
to make recommendations to the Congress that are designed to
assure access to high-quality care while also minimizing the
burden on the taxpayers.
We think a stringent test is particularly appropriate in
the current context of SGR repeal. As the committee well knows,
we have been long-time advocates of SGR repeal, well over a
decade now. We are heartened by the progress that has been made
towards repeal and recognize an important part of the remaining
challenge is the financing of repeal, so we think a stringent
test on the extenders is an appropriate test in this context.
So I welcome questions from the committee. Those are my
summary comments.
[The prepared statement of Mr. Hackbarth follows:]
[GRAPHIC] [TIFF OMITTED]
Mr. Pitts. The Chair now recognizes Dr. Rowland 5 minutes
for her summary.
STATEMENT OF DIANE ROWLAND
Dr. Rowland. Thank you, Chairman Pitts, Ranking Member
Pallone and members of the subcommittee. I am pleased to be
here today to share MACPAC's expertise and insights as the
committee considers extension of several legislative provisions
affecting Medicaid and the Children's Health Insurance Program,
CHIP.
MACPAC was authorized in 2009 and began its work in 2010 to
provide the Congress with analytic support on a wide range of
Medicaid policy issues and CHIP issues. The focus of our work
is on how to improve the efficiency, effectiveness and
administration of Medicaid and CHIP, to reduce complexity and
improve care for the over 60 million beneficiaries with
Medicaid and CHIP coverage. During the coming year, we will be
looking at the implementation of the Patient Protection and
Affordable Care Act and the coordination of Medicaid, CHIP, and
exchange coverage. We will be looking at children's coverage
and the status and future of the CHIP program, at cost
containment and payment system improvements underway in the
States for Medicaid, at issues for high-cost, high-need
enrollees, and on Medicaid administrative capacity. But today I
will focus on the issues that are up for reauthorization and
extension.
Specifically, one of the areas the Commission has looked at
carefully is Transitional Medical Assistance, or TMA. TMA
provides additional months of Medicaid coverage to low-income
parents and children who would otherwise lose coverage due to
increased earnings and helps to promote increased participation
in the workforce, a goal of all of us. It was originally
limited to 4 months and has since 1990 been raised to a 6- to
12-month period through the extenders we are discussing today.
This provision applies to the lowest-income Medicaid
beneficiaries who qualify under the welfare level guidelines
and indeed helps to reduce churning between Medicaid, employer-
based coverage and uninsurance. This churn is disruptive for
the plans that service these patients, providers and the
government entities that process these changes as well as for
the beneficiaries themselves. MACPAC recommends eliminating the
sunset date for the Section 1925 TMA that allows the 6- to 12-
month coverage and also provides States with additional
flexibility to do premium assistance as people transition from
Medicaid to the workforce.
We also have recommended that when States expand Medicaid
to the new adult group under the Affordable Care Act, they be
allowed to opt out of Transitional Medical Assistance because
in that case there would be no gap in the coverage they would
receive either through Medicaid under the new options or
through subsidized exchange coverage.
With regard to Express Lane Eligibility, we looked at ways
in which the program can be streamlined and eligibility can be
improved and see that the Express Lane Eligibility provides
children with enrollment under CHIP and Medicaid with an
express vehicle so that it eliminates some of the duplication
that goes on in program determinations. Thirteen States have
implemented this method of establishing eligibility, and we
will continue to monitor the use and effectiveness of this
approach and are in the process of reviewing the December 13th
report by the Secretary of Health and Human Services and will
provide our comments on that report to the Congress.
In terms of the CHIP program and outreach and eligibility,
we see that bonus payments have provided a strong incentive to
the States to improve outreach and enrollment processes for
children and now many of these strategies are required in the
new eligibility and enrollment processes being implemented
effective in 2014. So we will look at the potential
restructuring of the bonus payments to try and see how those
need to be restructured in light of the changes under the
Affordable Care Act.
We also strongly support developing policies that will help
us improve the way to measure the quality of care for children
including the requirement in the extenders to develop a core
set of child health quality measures. There is no other way to
really be able to compare the quality of care being provided or
to assess it without some standardization of the methods used,
and we know that you will be looking for us to do such
comparisons and really strongly support having the data and
ability to do that.
With regard to the Qualifying Individual program and the
Special Needs Plans, we really have been looking very carefully
at the importance of the role that Medicaid plays as a
wraparound for Medicare beneficiaries, especially helping the
very lowest income to not only afford their premiums but to get
better and more integrated care, and we will continue to try
and work to assess ways in which we can improve the
coordination and delivery of care for individuals who are
dually eligible and very low income.
So in conclusion, we will continue to keep Congress
informed of our progress in examining these issues. We look to
try and find ways to reduce administrative burden and
streamline the programs as well as provide better care to the
beneficiaries for better investment of the dollars that this
government puts into this care.
Thank you very much for having us today, and we look
forward to continuing to share our work with you in the future.
[The prepared statement of Dr. Rowland follows:]
[GRAPHIC] [TIFF OMITTED]
Mr. Pitts. The Chair thanks the gentlelady and now
recognizes Dr. Lu 5 minutes for a summary of his testimony.
STATEMENT OF MICHAEL LU
Dr. Lu. Thank you, Chairman Pitts, Ranking Member Pallone
and members of the committee. Thank you for the opportunity to
testify today.
HRSA focuses on improving access to health care services
for people who are uninsured, isolated, or medically
vulnerable. The agency collaborates with government at the
federal, state, and local levels to improve health and achieve
health equity through access to quality services and a skilled
health care workforce.
I am pleased to provide an overview and update on two of
our programs: the Maternal, Infant, and Early Child Home
Visiting program, which I will just refer to as the home
visiting program, and the Family to Family program.
The home visiting program, administered by HRSA, includes
collaboration with Administration for Children and families,
supports voluntary evidence-based home visiting services during
pregnancy and to parents with young children up to age 5.
Providers in the community work with parents who voluntarily
sign up to participate in the program to help them build
additional skills to care for their children and family.
Priority populations include low-income families, teen parents,
family with a history of drug use or of child abuse and
neglect, families with children with developmental delays or
disabilities, and military families.
The strength of the overall program lies in an evidence-
based approach, decades of scientific research which shows that
home visiting by a nurse, a social worker or early educator
during pregnancy and in the first year of life improves
specific child-family outcomes including prevention of child
abuse and neglect, positive parenting, child development and
school readiness. The benefit of home visiting for the child
continues well into adolescence and early adulthood. For
example, previous work in this area has shown that among 19-
year-old girls born to high-risk mothers, nurse home visiting
during their mother's pregnancy and in their first 2 years of
life reduce the 19-year-old's lifetime risk of arrest and
conviction by more than 80 percent, teen pregnancy by 65
percent, and led to reduce enrollment in Medicaid by 60
percent.
In addition, a number of studies indicate home visiting
programs have a substantial return on investment. The most
current one funded by the Pew Charitable Trust found that for
every dollar invested in home visiting, $9.50 is returned to
society.
Early data collected by HRSA found that within the first 9
months of implementation in 2012, the program provided more
than 175,000 home visits to 35,000 parents and children in 544
communities across the country. Preliminary data from 2013
indicates that more than 80,000 parents and children are
receiving home visiting services, and the program is now
available in 650 counties across the country, which is 20
percent of all the counties in the United States. States and
communities are the driving force in terms of carrying out this
program. With our support, States and communities are building
capacity in this area and have demonstrated improved quality,
efficiency and accountability of their home visiting programs.
States have the flexibility to tailor their programs to serve
the needs of their different communities and populations.
States are able to choose from 14 evidence-based models that
thus fit their risk communities needs capacities and resources.
We have taken a number of steps to ensure proven
effectiveness and accountability. HRSA and ACF provide ongoing
technical assistance to grantees and promote dissemination of
best practices by supporting collaborative learning across
States. Additionally, we closely monitor States' progress. The
data are collected on an annual basis, and by October 2014,
States are expected to demonstrate improvement in at least four
out of the six benchmark areas.
Additionally, HRSA administers the Family to Family Health
Information Center program with centers in all 50 States and
D.C., which provides support, information, resources and
training to families of children with special health care
needs. These centers are staffed by parents of children with
special health care needs. These parents provide advice and
support and connect other parents to a larger network of
families and professionals for information and resources. The
centers also provide training to professionals on how to better
support families of children with special health care needs and
assists States in developing and implementing family center
medical home and community system of care for these children.
HRSA closely monitors program effectiveness. A 2012 Family
Voices report supported by HRSA on the activities and
accomplishments of these centers indicated that between June
2010 and May 2011, so a 1-year period, approximately 200,000
families and 100,000 professionals received direct assistance
and training from these centers. Greater than 90 percent of the
families reported being able to partner in decision-making,
better able to navigate through services and more confident
about getting needed services.
I appreciate the opportunity to testify today, and I will
be pleased to answer any questions that you may have.
[The prepared statement of Dr. Lu follows:]
[GRAPHIC] [TIFF OMITTED]
Mr. Pitts. Thank you. The Chair now recognizes Dr.
Goldstein 5 minutes for summary of her testimony.
STATEMENT OF NAOMI GOLDSTEIN
Ms. Goldstein. Thank you for the opportunity to be here
today. I plan to speak about three programs my agency oversees
as well as our collaboration with Dr. Lu and his colleagues on
evaluating the home visiting program he described.
Each of these programs uses knowledge from past research,
and in keeping with direction from Congress, we are carrying
out evaluations to continue to learn about effective approaches
for meeting the goals of these programs. We aim to make our
evaluations rigorous so the results are sound and credible and
also relevant and useful for policymakers and practitioners.
First, the Health Profession Opportunity Grants program
funds training in high-demand health care professions for low-
income people. It uses a career pathways framework based on
past research. The program has funded 32 grantees including
five tribal organizations. Of those people completing a
training program, over 80 percent have become employed. The
most common training is preparation for jobs such as nursing
assistant or orderly, short courses that can be the first step
in a career pathway. Last year we published three reports on
the implementation of these grants and the outcomes for
participants. Grantees are using a range of creative
strategies. For example, one grantee in Pennsylvania is using
Google Hangouts for real-time tutoring in a highly rural
service area. We plan to release additional reports this year
and next. We are also studying how the program affects
participants' education, employment, and earnings.
Second, the Personal Responsibility Education program is
designed to educate youth on both abstinence and contraception.
The statute reserves the majority of funds for program models
that are evidence-based or substantially so. All models must
provide medically accurate information. HHS sponsors a
systematic review to identify programs with evidence of
impacts. So far, 31 program models have met the review
criteria. We continue to learn about what works. We recently
released a report describing State choices about program design
and implementation such as how they define and how they reach
target populations. Further findings from the national
evaluation will be released over the next couple of years. We
are also studying the impacts of four local program approaches
to address gaps in the evidence base.
Third, in the Abstinence Education program, States are
encouraged to use models that are evidence-based, and again,
all models must provide medically accurate information. In
2007, HHS completed an evaluation of four local abstinence
programs, which found no effects on abstaining from sex. The
study also found no effects on the likelihood of unprotected
sex. However, three abstinence models are among the 31 teen
pregnancy prevention models that meet HHS evidence criteria.
The Abstinence Education statute provides no funding for
research and evaluation. However, HHS is supporting evaluation
of abstinence education through some of its broad teen
pregnancy prevention activities. For example, one Virginia
grantee of the Personal Responsibility Education program is
evaluating an abstinence curriculum.
Finally, Dr. Lu mentioned our collaboration on the home
visiting program. The statute reserves the majority of funding
for home visiting models that meet evidence criteria. The
statute also requires continual learning through a national
evaluation and other activities. HHS sponsored a systematic
review of evidence similar to the review of teen pregnancy
prevention evidence. So far, 14 home visiting models have met
the review criteria.
The design of the national evaluation has been informed by
an advisory committee of experts required by the statute. Most
recently the committee reviewed and endorsed plans for a report
to Congress due in March 2015. The evaluation is using a
rigorous random assignment design to assess the effectiveness
of the program overall and of the four home visiting models
most commonly chosen by the grantees.
I hope these brief descriptions convey some sense of the
accomplishments of these programs and of our ongoing efforts to
learn and improve.
Thank you again for inviting me to testify. I would be
happy to address any questions.
[The prepared statement of Ms. Goldstein follows:]
[GRAPHIC] [TIFF OMITTED]
Mr. Pitts. The chair thanks the gentlelady for her
testimony and now we will begin questioning. I recognize myself
for 5 minutes for that purpose.
Mr. Hackbarth, I believe that this committee needs to be
diligent in its spending priorities and consider every one of
these policies carefully before deciding whether they warrant
extension. Many constituencies are advocating for making these
extenders permanent. In your testimony, you lay out a set of
criteria to use when considering these extenders. Using your
criteria, do you believe that all or the majority of these
extenders warrant extension?
Mr. Hackbarth. Certainly not all. I haven't done a count so
I would be reluctant to say whether a majority are not, but we
think many should not be extended.
Mr. Pitts. In your opinion, based on your criteria, do you
have a couple of programs that Congress needs to look at with a
very critical eye as we begin this review?
Mr. Hackbarth. Well, we just focus on the world of payment
provisions, some of which are permanent and some of which are
temporary and under consideration here. As I said in my opening
comments, we did an extensive review of Medicare rural health
issues, which was published in June 2012, I believe, and part
of that was to examine the special payment provisions against
the criteria I mentioned in my opening comments, namely are
they targeted to isolated providers, are they empirically
justified and do they retain some incentive for efficiency, and
we found a number of those provisions to not.
So let me focus in on one in particular. There is a
temporary Low-Volume Adjustment in the Medicare program. This
is a hospital payment adjustment for providers that have low
volume. There are a couple serious problems with that
adjustment. First of all, it is based only on Medicare
discharges. If the issue we are trying to address is small size
and a lack of economy of scale, the appropriate index of that
is total discharges, not Medicare discharges. In addition to
that, it looks to us like the magnitude of the adjustment is
too large. And then finally, it is not directed only at
isolated providers so hospitals that are in close proximity to,
say, a Critical Access Hospital can qualify for the Low-Volume
Adjustment. In fact, there are some hospitals like Sole
Community Hospitals that can in effect double-dip, get special
payments as Sole Community Hospitals and also low-volume
payments as well.
Mr. Pitts. Thank you. I want to commend you for putting
forward the criteria you referenced in your testimony. I
believe it will be helpful to me and others on this committee
as we consider the extenders before us today.
Dr. Rowland, like MedPAC, does MACPAC have a similar set of
established criteria by which to weigh the Medicaid extenders
that consider issues like cost and taxpayer burden against
current benefit that the policy delivers to beneficiaries? And
if not, how do you take into account issues of cost and other
important considerations that MedPAC is advocating?
Dr. Rowland. Well, we are obviously a much newer body than
MedPAC so have begun to try to establish the criteria by which
we would look at the various policies. One of the strongest
criteria is, does this policy promote efficiency, effectiveness
and reduce complexity in the programs. So we looked at these
various extenders in terms of their role. The only area in
which we have made strong recommendations is around
Transitional Medical Assistance, or TMA, and we are continuing
to look at the others both in terms of their cost but also in
terms of their impact on beneficiaries on State administration
and on federal dollars and spending.
Mr. Pitts. Thank you.
Dr. Goldstein, we only have 30 seconds, but I understand
that ACF provides technical assistance to grantees on a number
of issues. However, very little of that assistance includes how
to encourage more teens to choose abstinence or sexual risk
avoidance. Please describe the technical assistance that you
provide on abstinence compared to other topics such as
contraceptives.
Ms. Goldstein. I am actually not prepared to address that
but I will be glad to take that question back to my program
colleagues and provide an answer for the record.
Mr. Pitts. All right. Now, the committee published a report
that analyzes abstinence or sexual risk avoidance programs, and
it describes over 22 peer-reviewed studies that show
statistically significant evidence of the positive impact of
these programs. Are you familiar with that report?
Ms. Goldstein. I am.
Mr. Pitts. And have you, or would you share it with
grantees as part of the technical assistance?
Ms. Goldstein. Again, I will take that back to my program
office colleagues and provide an answer for the record.
Mr. Pitts. Thank you. I have gone over time. I now
recognize the ranking member, Mr. Pallone, 5 minutes for
questions.
Mr. Pallone. Thank you, Mr. Chairman.
I have a number of documents on the extenders that I wanted
to ask unanimous consent to enter into the record. I am not
going to read them all because it would take up my whole 5
minutes but I can maybe hand you the sheet here.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pallone. Thank you.
I had a question initially of Dr. Lu. I have been a strong
supporter of the Family to Family Health Information Center
program in the past and the program has helped so many families
in my State and across the country manager their special health
care needs, and that is why I introduced a bill that would
extend the funding for these centers into 2016. I was also
pleased to see the Senate went even furthering their SGR bill
by extending the program until 2018 and included $1 million
increase.
So my question is, in addition to helping families with
special health care needs, I was wondering if you could talk a
bit more about some of the contributions that the F2F program
has made to our overall health care system.
Dr. Lu. As you mentioned, Congressman Pallone, these
centers are unique in that they are staffed by parents of
children with special health care needs, so as parents, they
understand the challenges, the issues that other parents face.
They know the system. They can provide advice and support and
they can connect other parents to this larger network of
families and professionals for support. They can help the
families find the best health care providers. They also partner
with providers, and in doing so they can really improve on the
outcomes as well as cost-effectiveness of the care for a very
vulnerable population of children.
Mr. Pallone. I think you kind of answered my second
question, but could you just talk a little bit more about how
the Family to Family Health Information Center program is
different from other HRSA programs and how the staffs are
uniquely qualified to help families with special care needs? I
know you kind of answered that but----
Dr. Lu. Yes, that is right, and because it is unique in the
sense that they are staffed by parents themselves, and in terms
of the support, the information, the resources, the training
that they can provide from their firsthand experience, I think
that is irreplaceable.
Mr. Pallone. All right.
Mr. Chairman, the work of these Family to Family Centers
has long been supported by members on both sides of the aisle
so I am hopeful that the program can be continued when the
committee addresses the extenders.
I wanted to ask Ms. Rowland a question also about the
CHIPRA bonus payments. CHIP enrollment performance bonuses
established by CHIP have incentivized States to more
effectively administer their CHIP programs as evidenced by the
growing number of States receiving these bonuses each year. For
the fiscal year 2009, 10 States received bonuses for a total of
$37 million. In fiscal year 2013, 23 States received bonuses
for a total of $307 million. So I think it is important to
continue providing incentives to States to more effectively
administer CHIP. In order to qualify for these bonus payments,
States have to implement five of eight enrollment best
practices or simplifications. While the ACA has now required
some of these best practices, States have not uniformly adopted
all of them, and there is a lot more work to do. Express Lane
Eligibility, Presumptive Eligibility and 12 Months Continuous
Enrollment are all very important for enrollment and retention
of children in coverage, in my opinion.
So I just wanted to ask you, wouldn't you agree that
working to encourage States to adopt these simplifications is
critical and that the availability of the enrollment bonus is
in part responsible for getting States interested in adopting
these best practices?
Dr. Rowland. Well, I think we have learned a great deal
about the quality of these best practices and that is why some
of them are now required. And I think to continue to look at
ways to encourage States to do outreach and effective
enrollment of the eligible but not enrolled children is an
important way to reduce the uninsurance of children. So
certainly being able to maybe look at some other incentives to
provide in the bonus payments that perhaps if the State chooses
to eliminate its waiting period for CHIP, for example, that
that would be another thing that you might want to add on to
qualifying for the bonus payments. But I think that really
gives you the ability to give States a true incentive to go out
and find many of these eligible but not enrolled children, and
we really just need to look at ways to structure those bonus
payments so that we are trying and testing all of the ways to
smooth and streamline enrollment.
Mr. Pallone. Thank you.
You know, I just wanted to mention, Mr. Chairman, currently
the CHIP is authorized for 2015 but I believe we should extend
the bonus payments for the life of the program, and I agree, as
we get evidence from the ACA, we want to retool and qualify the
threshold but for the time being to encourage States to keep
making gains in coverage. It would make sense to keep the
program going. And it is also true that of the States that have
qualified, more than half are led by Republican governors, so
this is a program that has good results in both red States and
blue States. I hope we can continue it. Thank you, Mr.
Chairman.
Mr. Pitts. The Chair thanks the gentleman. I would also
like to do what you did, and I will just give you the list. I
have a number of letters that I would like to submit for the
record. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. All right. The Chair recognizes the vice chair
of the subcommittee, Dr. Burgess, 5 minutes for questions.
Mr. Burgess. I thank the chairman.
Dr. Rowland, let us stay on the issue of Transitional
Medical Assistance for a moment. Now that the Affordable Care
Act has been implemented and we are all lying in the elysian
fields of Obamacare, is the TMA even necessary any longer?
Dr. Rowland. Well, sir, I think it depends on what the
option that the State chose to pursue. So certainly in the
States that have chosen to do the expansion of coverage, there
is a way to eliminate the gap as earnings go up because the
coverage can be continuous. But as you know, half of the States
have not opted to pursue the extension of eligibility for
adults that is coming through the Affordable Care Act, and in
those States, Transitional Medical Assistance is particularly
important because it would enable individuals to really get the
ability to go into the workforce.
Mr. Burgess. I thank you for the answer. So if I understand
you correctly, the extension of Transitional Medical Assistance
should only be for those States that are non-participating in
the Medicaid expansion, as is their right under the Supreme
Court decision.
Dr. Rowland. Well, Transitional Medical Assistance at the
4-month level exists for all States. This is about whether it
should be extended to the 6 to 12 months, which also provides
States with some additional flexibility to do premium
assistance as people transition into the workforce. So it gives
States the ability to really move people from Medicaid into
private insurance, and I think that is a very important aspect
of Transitional Medical Assistance.
Mr. Burgess. Yes, I think that was actually--I have to
interrupt you for a minute because my time is limited. I think
that was actually a flaw in the Affordable Care Act. We can
talk about that. But for continuation of Transitional Medical
Assistance, really it seems to me that that is only necessary
in those States that did not participate in the Medicaid
expansion, again, which was their right under a Supreme Court
ruling.
Dr. Rowland. Correct, except if you are concerned about the
cost, there actually is a higher cost for the federal
government to individuals in the States that do the transition
to the Affordable Care Act coverage because there it is 100
percent federal financing as opposed to the shared financing
that goes on for Transitional Medical Assistance. So the----
Mr. Burgess. Again, forgive me for interrupting, but that
is a temporary state also and we all know that the FMAP for
those States that are participating is going to have to change
at some point in the future. There is a limit to how much money
the Chinese will loan us for that program.
Now, you mentioned churning, and I think that is an
important issue and one that I don't think was ever completely
well thought through as the Affordable Care Act was discussed
because you are going to have people that continuously earn at
different levels during the course of a year, and 137 percent
of federal poverty level may sound great when we talk about it
here in a committee or in a federal agency, but in real life,
there are people whose income may fluctuate wildly throughout
the course of the year. When we had the hearings on the people
affected by the blowup of the Deepwater Horizon, we had a
hearing down on the Gulf Coast of Louisiana. We heard from a
shrimper who earned a fantastic amount of money during the
month of May but the rest of the year he is flat broke. So he
is going to transition from Medicaid into an exchange and then
back into Medicaid. That seems terribly inefficient as a way to
structure that. So your program prevents that from happening?
Dr. Rowland. It would help maintain coverage throughout the
period so that during these lapses where one month there is a
lot of income and the next month there is less, you have
continuous eligibility during that period so it eliminates
having to transition and really helps managed-care plans to be
able to more effectively provide continuous care as well as
reduces State administrative burden.
Mr. Burgess. Forgive me. I don't think it is our role to
help managed-care plans.
Dr. Lu, let me just ask you a question because in both your
spoken and your written testimony, you talk about a study among
19-year-olds. Their lifetime risk of arrest was significantly
lowered. What period of time did this study comprise?
Dr. Lu. The study, I believe, was a longitudinal follow-up
of these children and families over a two-decade period.
Mr. Burgess. Correct. It would have to be two decades if
you are dealing with a population of 19-year-olds who received
home visits during their gestations with their mothers, but you
cite a lifetime arrest risk as being diminished. I mean, most
of us expect to live longer than two decades when we are born,
so how actually have you compiled those figures? Is there some
way to project the lifetime risk of arrest or conviction at age
19?
Ms. Goldstein. I can speak to that. The lifetime arrest
record that Dr. Lu referred to is as long as their life had
been so far, so it was through the age of 19. It was not a
projection beyond that point.
Mr. Burgess. Very well. I thank you for clarifying that.
Mr. Chairman, I will yield back.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the ranking member of the full committee, Mr.
Waxman, 5 minutes for questions.
Mr. Waxman. Thank you very much, Mr. Chairman.
Dr. Rowland, I want to draw your attention to a provision
that was enacted into law this past December that I fear will
have serious consequences for access to care in Medicaid. We
all agree that Medicaid should not pay for care that someone
else is liable for, and the statute has protections to ensure
that States can recoup when other parties are liable
financially. But for pediatric and neonatal care, for more than
20 years the law had required States to pay promptly and chase
other sources of payments later. This is to ensure children,
infants and pregnant women could get access to care promptly
with no delay. The law was changed in December to say that
States must delay payments to those providers for up to 90 days
while they chase other potential sources of payment. Congress
would be outreached if anyone proposed delaying payments to
Medicare physicians for 90 days for a service provided. I am
concerned this change in law will have a negative impact on
providers' willingness to participate in Medicaid and will harm
access to care for children and infants. Could you comment on
this?
Dr. Rowland. Well, as you know, this committee has long
been concerned about access to care for Medicaid beneficiaries
and the willingness of physicians to participate in the
program. One of the areas that MACPAC has been looking at is,
what are the barriers that prevent more primary care and
specialists from participating in the program, and we learned
from that that payment delays and inability to get payments
processed is one of the identifiable issues that doctors raise
about why they are unwilling to participate in this program. So
I think one really needs to look at whether such a delay in
payment would affect the access to care that is so important
given Medicaid's substantial role today in paying for nearly 50
percent of all births in the country and a high share of the
neonatal care. This is critical to look at.
Mr. Waxman. It seems just logical, and we should expect
that that is going to happen if we are going to delay payments
just to delay payments when we don't it anywhere else and there
is no reason to delay it.
Mr. Hackbarth, last month this committee held a hearing
where we heard from a number of stakeholders about how the
changes to the Medicare Advantage program under the ACA were
affecting patients, and if you listened to some of the
testimony you would think that Medicare Advantage was withering
on the vine and that beneficiaries are no longer able to choose
among private plans as they had before. I would be interested
to hear MedPAC's perspective on the current state of the
Medicare Advantage plans. Are plans really in such dire
straits?
Mr. Hackbarth. Well, enrollment in Medicare Advantage
continues to grow and last year increased about 9 percent.
Medicare beneficiaries continue to have a large choice of
different options. The average per county is now 10, which is
down slightly from the year before. Just this week, the CMS
actuaries reported that in 2012, for the population newly aging
into the Medicare program, over 50 percent of the new Medicare
enrollees chose a Medicare Advantage plan, which I think is a
potentially significant milestone.
Mr. Waxman. Let me ask you about the parity between an
Advantage plan and Medicare fee for service. Can you tell us,
did the Affordable Care Act set Medicare on a path to parity
between FFS and Medicare Advantage or do you believe that
Congress should stick to the ACA reforms and continue moving
forward, or is there any justification for repealing these
reforms?
Mr. Hackbarth. We have long advocated, Mr. Waxman, going
back more than a decade that there be financial neutrality
between Medicare Advantage and traditional Medicare. We
continue to believe that that is the wise course. The
Affordable Care Act moves in that direction, and we would
encourage Congress to stick with that course. We expected that
with fiscal pressure resulting from the reduction in benchmarks
that in fact plans would respond in part by lowering their
costs if in fact the bids have fallen concurrent with
tightening of the benchmarks. So it is evolving pretty much as
we expected and we urge you to continue on this path.
Mr. Waxman. I know there was a recent recommendation for
additional changes to Medicare Advantage payments from the
Commission. This deals with how Medicare Advantage plans
offered by employers to retirees are priced. Could you describe
this recommendation and why you believe it is important?
Mr. Hackbarth. We haven't quite yet made the
recommendation. It is up for consideration at our meeting next
week where we will be voting on recommendations for our March
report to Congress. The issue here is that the bidding system
used for employer-sponsored plans is different, and there is
basically no incentive for plans to bid low in the employer-
sponsored area, which results in higher payments for Medicare.
So we are looking to options for using market bids that come
from the rest of Medicare Advantage programs to set payments
for the employer-sponsored plans that would reduce Medicare
outlays somewhat by using those market-based bids.
Mr. Waxman. Thank you, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the gentleman from Illinois, Mr. Shimkus, 5 minutes
for questions.
Mr. Shimkus. Thank you, Mr. Chairman, and welcome. It is a
great hearing and it is important to remember extenders and of
course tied with the SGR.
So I have got a chart. It is the budget numbers for, I
think if we do this right, 2012 just to keep this debate in
perspective. And if you look at it, the budget is $3.45
trillion. Of that, Medicare is $251 billion--no, Medicaid is
$251 billion, Medicare is $466 billion. Those are 2012 numbers.
So my first question is to Mr. Hackbarth and Dr. Rowland.
We don't move any of these extenders, and they lapse. What
happens to the solvency debate of Medicare and Medicaid? How
much does that improve the extended life of these programs and
how many days or months? Mr. Hackbarth?
Mr. Hackbarth. Mr. Shimkus, I don't have in my head what
the total spending impact of all of the various temporary
provisions is. I don't know if my colleagues have it here. If
not, we could get you that number.
Mr. Shimkus. OK. But you understand where I am headed to
with this question, I am sure.
Dr. Rowland, do you--and I am going to go back to you in a
minute but do you have a response to that?
Dr. Rowland. The only estimate that we have is that the
Congressional Budget Office has estimated that making the
Transitional Medical Assistance provision permanent would
reduce federal Medicaid spending.
Mr. Shimkus. But in the billions, in the hundred billions
or in----
Dr. Rowland. In the $1 to $5 billion over a 5-year period.
Mr. Shimkus. OK. So the point being is this. These
programs, and we can debate the relevancy, in our federal
budget, mandatory spending is driving our national debt. These
will really hardly affect the solvency debate on both Medicare
and Medicaid. Mr. Hackbarth, would you agree with that?
Mr. Hackbarth. They are not large relative to these
numbers. Another potential reference point is how do they
compare to the cost of repealing SGR, in other words, how much
do they add to the challenge of financing SGR repeal. That is a
number where it looks a lot more significant relative to----
Mr. Shimkus. Obviously, because proportional.
Dr. Rowland?
Dr. Rowland. Yes, these are compared to total Medicaid
spending. These are very small, but they still represent
obviously spending that helps----
Mr. Shimkus. So the overall debate, which we try to raise
all the time and I have been talking about since 1992, if we
don't get a handle on our mandatory spending programs, they
will end up consuming the small blue portion, which is our
discretionary budget. We will continue to have these budget
fights. We will continue to try to squeeze because the red
areas are going to continue to grow unless substantial,
significant reforms occur, which is--and we, since I have been
here since 1996, I started talking about this in 1992, we are
unwilling to make those tough choices to have a Medicare
program for future generations and to have a Medicaid program.
And I fear for the future. That is just the macro debate. I am
glad we are having this debate, but it gives me the opportunity
to put real numbers on the board because real numbers matter
for our children and our children's children, and as Dr.
Burgess said, who is subsidizing our debt, also foreign
countries.
Let me go then to, I represent about a third of the State
of Illinois, pretty big area, 33 counties. I would hope in
these evaluations that we understand distances, the importance
of rural health care providers in 30 to 45 miles and what is
that cutoff. So in essence, the Medicare-Dependent Hospitals
and the Low-Volume Hospitals, I understand these reforms, but
the importance of this debate for rural America is, there is
nowhere else to go. They are it. And if they don't have the
volumes, as you mentioned, to justify their existence, we need
to figure out how to make sure that those doors stay open.
Mr. Hackbarth. We emphatically agree, Mr. Shimkus, that we
need to preserve access for Medicare beneficiaries that live in
areas that are not sparsely populated. Our point, though, is
what need to do is make sure we target our assistance to those
isolated providers, and if we target it well, we can actually
provide more assistance, more effective assistance than if we
spread our available dollars loosely over a larger number of
providers, many of whom are not necessary to assure quality
care.
Mr. Shimkus. And Mr. Chairman, if I could just make this
final statement. It is not a question. But Dr. Hackbarth, you
are only one who raised the ground ambulance extenders, and I
think you raised the point, and I think as we look at that,
there has to be a time frame by which we get real data and
reevaluate that data.
Mr. Pitts. Mr. Dingell for questions.
Mr. Dingell. Good morning, Mr. Chairman. Thank you for your
courtesy and for holding this hearing today. It is very
important. And I want to thank our panel members for being
here. I am not going to be asking questions today because I
want to make a few observations about the urgent need to get
SGR reform over the finish line.
I would like to observe that SGR reform is urgently
necessary because without it, the whole problems of Medicare
and our taking care of health care in this country in making
the Affordable Care Act is going to suffer terribly as will the
people.
Now, every year for the last decade, the Congress has
stopped in to reverse severe cuts in reimbursements for
physicians wisely mandated under Medicare as mandated by the
SGR. Due to our failure to fix this fatally flawed payment
system, doctors and other medical providers have experienced
enormous uncertainty and have been able to plan for the future,
and the country and medical system has suffered because of it.
Last year the Congress made bipartisan, bicameral progress in
repealing and replacing the SGR with a new system that provides
stable payments for doctors in the short term and incentivizes
them to move the alternative payment models forward in the long
term.
It is really a shame that we weren't able to put this in
because of budget matters without having to address the
question of how we are going to pay for it because it solves a
problem that was created by some very unwise actions by the
Congress. The legislation is going to make a significant
contribution to the change in our efforts to provide health
care for our people and it will award doctors for their
performance rather than for the quantity of the work and begins
to take steps away from the fee-for-service system, parts of
which are so badly broken.
I am confident that the three bills passed by this
committee, the Ways and Means Committee, the Senate Finance
Committee can be reconciled and sent to the President's desk
before March 31 deadline but there are still hurdles to be
overcome.
I want to commend the members of the committee, the
leadership of the committee and the other committees in the
House and Senate for the leadership which they gave in this
matter and for the vision and for their hard work and for the
decency with which they worked. This hearing is an important
contribution to resolving the problem, and I want you to take
my commendations, Mr. Chairman, for your part in all that has
been done, and I want you to appreciate not only what you have
done but what others have done to bring us to this point.
I want to observe that it would be a terrible calamity if
we don't carry this thing across the finish line. I want to
make it very clear that Medicare beneficiaries should not have
their benefits reduced or cost increased to pay for the reform
of SGR. Both sides must be willing to compromise and all
persons must understand that the resolution of this problem
will probably not be perfect from anybody's view but at least
we will make progress in getting rid of something that is
causing us vast difficulty in achieving our purposes. So our
goals must be responsible compromise, and I have observed over
the years, compromise is an honorable activity and it is
something which will make this institution work.
Second, I am very pleased that the so-called extenders and
the policies that are traditionally considered a part of the
short-term Medicare physician payment formula patches are the
focus of today's hearing. You have been very perceptive in
doing that, Mr. Chairman, and I thank you.
I am also pleased that the Senate Finance Committee
included many of these critical extenders in their permanent
SGR bill. Many of the extenders provide critical benefits to
Americans across the country, especially Medicare and Medicaid
beneficiaries, people who have great need of these things. We
must not forget about these critical programs as Congress moves
forward with SGR reform. Specifically, the Qualifying
Individual program, Transitional Medical Assistance, Express
Lane Eligibility and CHIP bonus payment programs must not be
allowed to expire and should be extended as part of the long-
term SGR bill. Congress should consider extending many of these
programs on a permanent basis, given their proven track records
and the fact that the annual SGR patch will not be available as
a vehicle in the future.
Furthermore, I hope that the Congress will consider
reinstating Section 508 wage classification that expired in
2012. I also believe that the Medicare primary care payment
increase should be extended as well.
In closing, I hope we can build off the momentum we
generated last year to get a long-term SGR bill across the
finish line while not leaving extenders beyond. I look forward
to continue to working with you and all my colleagues, the
leadership on this committee and the leadership in the House
and Senate to get this bill to the President's desk before the
March 31 deadline.
Mr. Chairman, there are great accomplishments that have
been made in this matter. We have taken major steps to solve a
terrible problem which has been inhibiting responsible
consideration of health care for the American people, and I
hope that we don't lose this opportunity because we let some
kind of partisan or other misfortune create difficulties for
us.
Again, I commend you. This is an example of how oversight
should work, and I thank you for your leadership.
Mr. Pitts. The Chair thanks the gentleman and thanks him
for his leadership and cooperation on this issue of repeal and
reform of the SGR. Thank you for the sentiments you have
expressed, and I share those with you.
Now the Chair recognizes the gentleman from Pennsylvania,
Dr. Murphy, 5 minutes for questions.
Mr. Murphy. Thank you, Mr. Chairman. I thank the panel
here.
Mr. Hackbarth, you have talked about a number of things
with quality, and quality and value are of great concern to all
of us, but I want to talk about some of the issues of
readmission rates and also deal with some of the measures. For
example, reports have come out from Medicare about readmission
rates for such things as heart attack, pneumonia, hip and knee
replacements. I don't think we have those same things on a
pediatric level, do we, Dr. Lu or Dr. Goldstein? Do we look at
readmission rates for pediatrics? OK.
But on the Medicare level, what we have to be concerned
about is that when people have a chronic illness, we know a
small portion of folks on Medicare, for example, make up a
large portion of the cost, particularly those with chronic
illness. I think 90 percent of the cost is caused by chronic
illness. And when you have a lot of chronic illness, you also
have a 50 percent higher rate of depression. You have untreated
depression and chronic illness, you double the cost.
So along those lines, MedPAC has recommended new criteria
for payment to rural hospitals. Now, under MedPAC's criteria
recommendations, should a facility with fewer than 100 beds and
approximately 60 percent of discharges under Medicare qualify
for the Medicare-Dependent Hospital Payments program?
Mr. Hackbarth. Mr. Murphy, we think that the Medicare-
Dependent Hospital program suffers from some of the issues that
I have referred to earlier. For example, it is not targeted at
isolated hospitals, and so a Medicare-Dependent Hospital can
receive these higher payments, these subsidies, if you will,
even when it is in close proximity to say, a Critical Access
Hospital.
Mr. Murphy. But I think some of those are in danger of
being changed. One of my concerns with Medicare is how it does
not pay for coordinated care. For example, Southwest Regional
Medical Center in Greene County, Pennsylvania, used its
Medicare-Dependent Hospital funding to provide case management
services for patients upon discharge. So if you were to
eliminate those payments, could it not lead to readmissions of
patients who had trouble following their discharge orders?
Mr. Hackbarth. Well, we absolutely share your concern about
better care for complicated patients, many of whom have
multiple----
Mr. Murphy. I just want to make sure there is funding to
help them.
Mr. Hackbarth. Well, we don't think that this sort of
program is the best way to attack that problem. We think that
mechanisms like accountable care organizations where an
organization assumes responsibility for a full range of
conditions.
Mr. Murphy. This hospital I am talking about is way outside
of a 25-mile boundary from a Critical Access Hospital, and when
I look at what is happening here--and let me go to something
that was recently in the Baltimore Sun. They talked about 500
patients in the State of Maryland with psychiatric problems
account for $36.9 million a year with regard to psychiatric
services because one of the problems that occurs is when
someone has a psychiatric problem such as psychosis and they
have a co-occurring symptom of that called anosognosia, which
means they are not aware they have a problem. That also occurs,
for example, in stroke victims who may have a right-sided
problem in a stroke, and if the left side of their body doesn't
work, they do not even know that the left side of the body
doesn't work. And with psychiatric symptoms, they may not
realize their hallucinations or delusions are not real.
So what happens when they are discharged from a hospital,
they stop taking their medication, and it is essential in these
cases that there is someone who is working with them. Now, that
is in Baltimore, but the example I am giving is hospitals in a
very rural area. I just want to make sure we have mechanisms in
place to look at coordinated care, and the reason for that is,
as long as we are using measures such as readmission,
readmission alone can't be the criteria because sometimes
readmission is a symptom of the disorder where we are not
maintaining that coordination. So what advice, where could we
go with this in improving this?
Mr. Hackbarth. Well, again, I think the clinical problem
that you are raising is a really important one, not just for
the individual patient but for the program. Our goal is to
address the needs of the patient in the most effective way
possible. We don't think that poorly targeted subsidies, some
of the money from which might be used for good purposes, is the
best way to deal with a systemic problem such as you have
identified. So if we have a finite amount of money to spend,
which we do, we need to be very careful. So one thing that has
been done recently in post-discharge care is to create a code
where clinicians will be paid for coordinating care post
discharge. That is a much more targeted response to the
clinical problem as opposed to paying more for Medicare-
Dependent Hospitals.
Mr. Murphy. Well, let us continue to work on that together.
Thank you, Mr. Chairman.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the gentlelady from California, Ms. Capps, 5 minutes
for questions.
Mrs. Capps. Thank you, Mr. Chairman, and thank you,
witnesses, for your testimony today.
Drs. Lu and Goldstein, the Affordable Care Act established
several new programs that you described in your testimonies,
the Personal Responsibility Education Program, or PREP, and
also the Maternal, Infant, Early Childhood Home Visiting
program, as well as the Health Workforce Demonstration
Projection for Low-Income Individuals. I am interested in all
of these.
You mentioned that comprehensive evaluations are ongoing.
From your testimonies, even as we await results of these
comprehensive evaluations, early indications seem to me that
these programs are successful, and importantly, they are
grounded in sound evidence. Could you each just say a word, if
you will, a very brief description on the successes of these
programs thus far and how these three programs are informed by
available evidence? Let us start with you, Dr. Lu, but also Dr.
Rowland just for a minute each.
Dr. Lu. I can share about the home visiting program. As I
mentioned, the home visiting program is built on decades of
evidence on its effectiveness, and as of 2013, we are now
reaching and serving more than 80,000 parents and families in
738 communities, and that is two-thirds of all the communities
identified by the States to be in the highest risk for adverse
health outcomes in the country.
Mrs. Capps. Let me just turn to you, Dr. Rowland, for one
of the other programs, if you would.
Dr. Rowland. We mostly looked at the way in which Medicaid
care can be coordinated and clearly have looked at the fact
that case management and integration of services is really
critical, especially for coordinating the care for people with
behavioral problems.
Mrs. Capps. OK. Dr. Lu, I was a long-time visiting nurse,
and I know firsthand of the benefits home visiting can have on
high-risk pregnant women, children and families, helping them
be healthy, make healthy choices, accessing critical health
care services and supports needed to have healthy babies. I am
referring now to a program in my district. The San Luis Obispo
Department of Health delivers a nurse family partnership model,
which has shown long-term improvements in child health and
educational achievements as well as family economic self-
sufficiency. The home visiting program supports States in
expanding these programs and services to reduce poor birth
outcomes, preventable childhood injuries, all the good things
that happen along with these home visits, issues that affect
all of us as taxpayers. So I just want to get on the record
what is at stake if this program is not continued, Dr. Lu.
Dr. Lu. Well, if the program is not continued, families
will be losing services that are proven to improve maternal-
child health outcomes and have all the positive benefits on
positive parenting, children's cognitive, social, emotional and
language development as well as school readiness. Also, the
investments that States and communities have made to build up
the service systems and capacity will be lost if the program is
not continued.
Mrs. Capps. Right. Dr. Goldstein, in your testimony you
mentioned that States receiving Title V funding for Abstinence
Only Until Marriage Education programs are encouraged but not
required to use evidence models that are medically accurate.
This differs from the statutory requirements in PREP hat say
these programs which teach both abstinence and contraception
must be evidence-based and medically accurate. Could you
elaborate on the difference in the evidentiary standards for
these two programs?
Ms. Goldstein. Certainly. The statutes require that
grantees in both programs provide medically accurate
information. The PREP program also requires that services be
evidence-based or substantially incorporate elements of
evidence-based programs. The Abstinence Education program does
not have such a requirement although we have encouraged
grantees to use evidence-based approaches, and as I noted,
there are evidence-based models for a range of approaches to
teen pregnancy prevention including both comprehensive sex
education and abstinence education.
Mrs. Capps. Thank you. I was very much involved with a
school-based program for teen parents when I was in my
community as a school nurse, and I have such vivid images of
these young women and parents incredibly strong and hardworking
but if they had had appropriate medically accurate information,
education, empowerment, they could have delayed these
pregnancies and they could have still been really good parents
but they would have had time to complete their preparation for
the future, setting up a more viable economic future for their
families and children, and that is why I believe our
investments in PREP are so critically important.
I thank you again, all of you, for your testimony today,
and I yield.
Mrs. Ellmers [presiding]. The gentlelady yields back. I now
call on Dr. Cassidy from Louisiana for 5 minutes.
Mr. Cassidy. I was 15 minutes behind, so anyway. Oh, my
gosh, Madam Chair, can I defer and come back because I was
thinking I had two more people head of me?
Mrs. Ellmers. OK. That would be fine. The gentleman yields
back for a later time. Mr. Griffith from Virginia, 5 minutes.
Mr. Griffith. Thank you, Madam Chair. I appreciate that.
As we prepare to permanently repeal and replace the SGR, I
believe we must also address two vital extenders, and we have
talked about these previously in testimony today, the Medicare-
Dependent Hospital and the Low-Volume programs, which are
critical for my constituents and my rural hospitals in
southwest Virginia. If these programs are not extended,
Virginia hospitals in total will lose about $10 million and
most of the hospitals that qualify are in my district, but $10
million in Medicare reimbursements next year at a time when
they are already being hit hard by new costs, deep cuts to
Medicare, other programs, and an economic crisis which is
exacerbated by the Administration's new regulations and what
many of us refer to us as their casualties in the war on coal.
This combination of factors have already resulted in one of my
rural hospitals closing in Lee County and at least eight of the
remaining hospitals in my district benefit from these two
essential programs. They keep the hospital doors open in some
economically distressed areas that are pivotal to vital access
to care for my rural constituents. I have got Smith County,
Russell County, the Lonesome Pine Hospital in Big Stone Gap,
and I invite you all to go see the soon-to-be-a-major-motion-
picture-based-on-the-book-of-the-same-name, Mountain View in
Norton, Pulaski, Buchanan, Tazewell, and Wythe. These are not
hospitals that are necessarily close to a lot of other
hospitals.
Mr. Hackbarth, let me go ahead and ask you something. I was
reading your testimony, and you talked about several programs
that were based on how many miles one hospital was away from
another. Do you know, is that done on a map or is that done on
road miles? And the reason that is important of course is
because when you come from a mountainous district, if you just
look at the flap map sitting in your office, two hospitals
might only be 15 miles away but it might be a 45- to 50-minute
trip.
Mr. Hackbarth. I will have to check this, Mr. Griffith, but
I am pretty sure that it is road miles, and my recollection is
that the regulations also take into account unique conditions
like mountains and difficulties and certain times of the year,
but I will verify that and get back to you.
Mr. Griffith. And I appreciate that because oftentimes we
see that in the areas. People say well, yes, there is another
pharmacy just down the road if one closes. Well----
Mr. Hackbarth. I come from a mountainous area also.
Mr. Griffith [continuing]. It may be just down the road but
it might not be easy to get to.
Knowing a little bit about my background, do you think that
district and other districts like mine would be hurt if the
provisions were not extended or made permanent, particularly
talking about Medicare-Dependent Hospital and Low-Volume
programs?
Mr. Hackbarth. Well, I can't obviously address the
circumstances of your district. I don't know it. But again, our
emphasis is on maintaining access for beneficiaries in remote
areas. I think we are in complete agreement on that. And what
we want to do or what we urge the Congress to do is with that
goal in mind focus the subsidies on the institutions that are
truly necessary to provide care in isolated areas, and right
now we are concerned that some of these provisions including
the Medicare-Dependent Hospitals and the Low-Volume Adjustment
are not well targeted, and I would emphasize again in
particular the Low-Volume Adjustment is problematic because
even if you accept the premise, which we do, that there are
economies of scale in the hospital business, in small
institutions, many therefore have difficulty keeping their
costs down. The right measure of that is not just Medicare
discharges, it is the total discharges. This adjustment is
based on Medicare discharges alone. So a hospital that has
relatively few Medicare discharges can get a big adjustment
whereas a smaller institution as more of an economic problem
doesn't get the adjustment because it is a different mix of
public and Medicare discharges. That is not fair, in addition
to not being----
Mr. Griffith. And that may very well negatively impact my
hospitals because we have a disproportionate number--based on
the rest of the country, we have a lot of older folks that live
in our communities. We have had some counties that have
depopulated of mostly the younger folks and so there is a
disproportionate number of senior citizens in a number of the
counties that are also rural and underserved. So I look forward
to working with you on these formulas.
My concern is, as you might imagine, as we negotiate this,
I don't want to lose anymore hospitals. We are hoping that we
can replace the one that is gone but the parent company of two
of the eight that I mentioned has announced today that they are
looking for new ways to do things in the future and may even be
seeking out a strategic partner because they are having some
difficulties dealing with the new environment we are in, with
the new laws passed in health care, with the economic situation
in southwest Virginia and east Tennessee, and with lots of
other things that are putting pressure on the hospitals and so
anything that we can do as we find a better formula, that is
great. I just don't want to see us taking away one of the items
that is helping these hospitals survive in these small
communities.
Mr. Hackbarth. Well, if I could make a suggestion, the Low-
Volume Adjustment that we are discussing here today is a
temporary provision. There is a permanent Low-Volume Adjustment
that already exists, and we believe it is structured in a way
that is much better targeted, and so that is the foundation to
build on for the committee.
Mr. Griffith. I thank you, and I yield back.
Mrs. Ellmers. The gentleman's time is expired. The Chair
now recognizes Mr. Green from Texas.
Mr. Green. Thank you, Madam Chair, and I appreciate our
panel being here. In fact, I know I met and worked with Dr.
Hackbarth and Dr. Rowland at the Commonwealth retreat that you
do every year, and I would encourage my colleagues to consider
that. It is in February. Now, I have to admit, it is not the
south of Florida this year but it is in Houston, Texas. But you
will hear, it is bicameral, bipartisan, and bicommittee,
because we typically in our committee don't deal with Ways and
Means or Education and Workforce but you will have different
members, and we can really come and problem-solve in an
informal setting.
The Affordable Care Act takes a number of important steps
to broaden access to health care, especially for people who are
working and are unable to receive employer-sponsored insurance
or afford individual market plans. While the number of
uninsured is already decreased, some challenges remain, and I
want to follow up on my colleague, Dr. Burgess, talking about
the Transitional Medical Assistance churn. That churn is due to
a small change in income and an individual will be switched
from being eligible for Medicaid and be eligible for now
subsidized coverage in exchanges. Switching back and forth
between insurance coverage can mean a change in benefits,
participating providers and pharmacies and out-of-pocket
expenses, not to mention the administrative paperwork for the
State or an insurance company or a doctor's office.
One of the programs to help reduce churning is the
Transitional Medical Assistance, and Ms. Rowland, I understand
that MACPAC has recommended Congress make TMA permanent in part
because of this churn factor. Could you elaborate? And I know I
am following up and I want to address some of Congressman
Burgess's issues, but is that the reason because the
recommendation from MACPAC?
Dr. Rowland. Well, we have tried to look at how to make
transitions between coverage smoother and more streamlined, and
one of the ways clearly is to help the lowest-income Medicaid
beneficiaries who qualify through the 1931 provisions, which
are the old welfare-related categories be able to maintain
coverage, and we have looked at the time period, and the 12-
month period really does provide for continuous coverage that
allows them to go into the workplace and back and forth and the
income volatility of individuals at that very low income and
the income spectrum is very important to take into account to
try to keep care continuous so that people don't have to end
treatment and so that the States don't have to continually re-
administer the benefits.
Mr. Green. Because it raises administration costs plus the
cost to the patient.
And Dr. Burgess talked about in States, for example, Texas
didn't expand their Medicaid and also does not have a State
exchange. The TMA is really important in those States to make
sure it happens, but even States that have their own state
exchange or use the Medicaid expansion could use transition
assistance.
Dr. Rowland. We believe that the Transitional Medical
Assistance is critical in the States that have not expanded
coverage to keep people from going to uninsurance from one
dollar of increased income. In the States that have elected to
go forward with the expansion, the expansion will provide for a
way to transition from Medicaid coverage on the income side to
either the exchange or to the new Medicaid coverage options. So
the Commission has recommended there that we consider giving
States the ability to opt out of TMA if they are able to assure
that transition, and that is an issue that we will be looking
at in the future as well.
Mr. Green. And I know one of the concerns is a 12-month
continuous eligibility to make sure there is not a gap in
coverage, and I know in States like Texas, who has a 6-month
for Medicaid and SCHIP also but Congressman Barton and I both
have legislation to make sure that continuous coverage would be
12 months because if you have people that are low wealth, they
are not going to come in every 6 months, and particularly if
they are ill, they will have that lapse in coverage and they
will show up at one of my emergency rooms and cost much more
than having that continuous coverage.
The Medicaid primary care bump helps ensure that sufficient
access to Medicaid providers as enrollment increases. The ACA
requires States to raise their Medicaid fees to Medicare levels
at least for family physicians, internists, pediatricians and
primary care. Can you comment on the impact of that that lack
of this parity between Medicare and Medicaid provider rates on
physician participation. I know particularly because, for
example, in Texas, TRICARE pays the lowest, Medicaid pays a
little more and then Medicare pays more. Of course, private
sector pays more. But to have that Medicaid and Medicare would
help us actually have more physicians accept more Medicaid
patients, I think.
Dr. Rowland. Well, one of the things that the Commission
has looked at is in fact what are the incentives for physicians
to participate within the Medicaid program and what are the
barriers. And clearly, low payment rates and delayed payments
are two of the issues that prevent many of the primary care
doctors as well as specialists especially to participate in the
program. So I think that looking at the fees that are paid or
the payment levels for Medicaid are a very important piece. We
have to look at the role managed care is now playing and so we
really need to understand more about the payment levels within
managed care plans, and we believe that improving access to
primary care is of course a critical part of the Medicaid
program and one that is very important to make sure we get full
participation there. But the----
Mrs. Ellmers. The gentleman's time is expired.
Mr. Green. Thank you, Madam Chair. I know we ran over time,
but I appreciate the committee having this hearing today so
hopefully we will come back and visit it again. Thank you.
Mrs. Ellmers. Thank you. Now the Chair recognizes Dr.
Gingrey for 5 minutes.
Mr. Gingrey. Madam Chair, thank you very much. I would like
to also thank the witnesses. One very famous person once said
there is nothing more permanent than a temporary federal
government program. I think that was probably President Reagan,
but of course, it could have been my good friend, Chairman
Emeritus Dingell. I did like what he said this morning in
regard to SGR and the bipartisanship and all the work that has
gone into that, and we continue to push to try to get that
across the finish line in the next couple of months hopefully.
I agree with him 99 percent of the time but I am not sure I
agree completely with his remarks, don't leave the extenders
behind.
As I said, there is nothing more permanent than a temporary
federal government program. Our constituents need to realize
that one of the most important things we do other than passing
legislation is oversight of current legislation and temporary
programs and indeed maybe even all programs that probably
should be looked at every 10 years, every 5 years, and say hey,
do we need to continue to do this, is it serving its purpose or
is it time to end this program, even if it was permanent, but
certainly on these temporary programs like these extenders, I
think we need to look at a lot of them and question whether or
not we need to go forward.
And let me then direct my question to Mr. Hackbarth. I will
direct all my questioning to you. As an example, one such
program, group of programs, are in the Medicare ambulance add-
ons. In reviewing the data around ambulance service
availability in the Medicare program, what have you found? For
instance, have you found growth in the number of providers or
has there has been a decrease, or to put it another way, has
there been any evidence of service inadequacy in regard to the
ambulance program?
Mr. Hackbarth. Yes, we found no evidence of inadequate
service. We found on the contrary evidence of growth in
service, both in terms of the number of trips paid for but also
significant new entrants, a lot of private capital, some big
private equity firms buying into the ambulance business. This
is one area where we do not have Medicare cost reports, and one
of the things that we do when we don't have cost report
information is look at the market for signals. When big money,
smart money is buying into an area, it is usually a sign that--
--
Mr. Gingrey. So you are getting some ominous signals in
regard to that. And I want to draw your attention to the
ambulance extender title temporary increase for ground
ambulance services under the Social Security Act. My office has
been approached by a number of constituencies who want to make
this extender permanent, and my staff confirms for me that this
provision and its spending was never, never intended to be made
permanent. Can you tell me, Mr. Hackbarth, if Congress intended
this extender to be a temporary provision and do you believe
the data supports making the policy permanent?
Mr. Hackbarth. Dr. Gingrey, are you referring to the 2 and
3 percent add-on payments for urban and rural ambulance
providers?
Mr. Gingrey. Yes.
Mr. Hackbarth. That is a temporary provision and one that
we don't think needs to be extended based on our analysis. We
have suggested, however, that the rates paid for non-emergency
transport be decreased and then use that money to fund higher
payments for emergency transport, and the reason for that
change is, we see a lot of this new entry that I referred to is
really being targeted at non-emergency ambulance transport.
Mr. Gingrey. Yes, but with urban transports accounting for
76 percent, an increasing share of claims, and non-emergency
ambulance transport most common in the urban areas, do you
still believe that urban adjustments are needed?
Mr. Hackbarth. No, we do not but we do recommend that there
be this recalibration of the rates for emergency and non-
emergency rates.
Mr. Gingrey. Mr. Hackbarth and all of the panelists, thank
you. I want to yield the remaining 22 seconds to my colleague
from Tennessee, Ms. Blackburn.
Mrs. Blackburn. Well, I thank the gentleman for yielding,
and since the time is so short, I will just say, reliable
ambulance services are very important to our district. We have
watched very closely the add-on payments. We think they are
necessary for rural districts like mine, and the Low-Volume
Hospital Adjustment is something for our rural hospitals we are
very concerned about. Those are things that in my district we
would like to see those made permanent, and with that, I yield
back to the gentleman from Georgia.
Mr. Gingrey. I yield back.
Mrs. Ellmers. The gentleman yields back. The Chair
recognizes Dr. Christensen from the Virgin Islands for 5
minutes.
Mrs. Christensen. Thank you, Madam Chair, and thank you all
for being here with us this morning to discuss these important
extenders.
I want to follow up on Congressman Green's questioning
about the primary care bonus. The ACA boosted payment for
primary care services for 2 years so that it would equal the
Medicare payment rates, and I think that is an important step,
and I believe it is something that is worth continuing into the
future.
Dr. Rowland, the Commission doesn't have a recommendation
yet on this policy, and I know there has been some concern that
it is has been difficult to set up the payment changes,
especially for policy, which at the moment, at least, is only
short term, and to me, this further illustrates why important
policies like the primary care bonus shouldn't really be
temporary, it should be permanent. Could you comment on how the
short-term nature of some policies can cause a disincentive for
action?
Dr. Rowland. Well, clearly, the 2-year period for the bump-
up in primary care payments is an important test of what the
increase in payments will do to access to care, and that is
something that it is too early to really evaluate but also what
we know from programs is that it takes time to change
incentives and so in that the short 2-year period, they really
have not given enough incentive to many of the physicians who
participate knowing that it may expire after 2 years. So I
think it is very important to both look at what the effect of
it has been, and then there has been some concern within the
Commission about whether that payment bump limited to primary
care physicians is really getting at some of the other gaps in
participation, especially among specialty care, and especially
among mental health and behavioral health providers.
Mrs. Christensen. Yes, I would share that concern. You
know, as you said, it is too early to really evaluate what
impact those bonuses have had on access to care, and I am
worried that some people would argue that we need more data
before we decide to go forward with continuing this policy,
which might set up a catch-22 because under current law, the
policy will end before we might have adequate data. Given what
we know about underpayment in Medicaid, it would seem highly
unlikely that payment parity would cause a decrease in access
or cause beneficiary harm. Can you comment on that?
Dr. Rowland. Well, clearly, we do need time to look at what
the effect of this has been but we also know that Medicaid
payment levels have been extremely low in many areas and that
this increase is likely to be one that will continue to be
there for physicians and attract them, and we really need to
look at the availability of primary care services and how to
boost that as we try to decrease the use of emergency rooms.
Mrs. Christensen. Dr. Goldstein, as we know, disparities
exist in different teen population groups for sexually
transmitted disease and teen pregnancies, so we are really
pleased that under PREP, there is a focus on those vulnerable
populations to reduce the incidence of both the pregnancy and
the SDIs. Could you comment on the kinds of populations that
PREP prioritizes and within that, what populations of States
chosen to target?
Ms. Goldstein. Yes, the most common targeted population
among States is in high-risk areas that have above-average
rates of teen birth or sexually transmitted infections. Some
States are also focusing on specific vulnerable populations
such as Hispanic youth, African American youth, youth in foster
care and in the juvenile justice system.
Mrs. Christensen. OK. And PREP specifically sets aside a
small portion of funding to implement and evaluate innovative
strategies in order to expand the menu of effective programs
among the vulnerable or marginalized young people. What is the
process for evaluating these emerging strategies and the
associated timeline for findings?
Ms. Goldstein. All of the grantees in the Personal
Responsibility Education Innovation Strategies program are
being evaluated. A few of them are included in a federal
evaluation project, and reports on impacts are expected in
2016. The rest of the grantees are conducting their own
evaluations. HHS is providing technical assistance to ensure
that these evaluations are rigorous. The evaluations are
designed to meet the HHS evidence standards, so when they are
finished, the results can be reviewed for evidence of
effectiveness, and we expect the grantees' evaluations will
have impacts in 2016 as well.
Mrs. Christensen. Thank you. I yield back.
Mrs. Ellmers. The gentlelady yields back. The chair
recognizes Dr. Cassidy from Louisiana for 5 minutes.
Mr. Cassidy. Thank you, Madam Chair.
Mr. Hackbarth, just to follow up briefly on what Mr. Waxman
said, in fairness, the cuts to the MA program, only 4 percent
of them have actually been implemented so far. This is not a
question; it is a statement. I gather the demonstration
projects, which GAO criticized the kind of worth of,
nonetheless have mitigated the cuts as of up to now and they
actually don't begin to be implemented until frankly
substantially this year and by 2019 there is estimates of
decreased enrollment in MA plans because of this. That is not a
question per se. It is just a kind of useful correction to Mr.
Waxman's misleading.
Now, next, as regards the fully integrated Medicare
Advantage programs, I see Senate Finance only wants to continue
those D-SNPs which are fully integrated. You make the
recommendation that we continue all of these programs. Is that
a fair statement?
Mr. Hackbarth. No, we recommend continuation of the fully
integrated, those that assume both clinical and financial
responsibility.
Mr. Cassidy. Got you. So if they are two-sided risk, they
would then be allowed to continue?
Mr. Hackbarth. Well, all Medicare Advantage plans----
Mr. Cassidy. Are two-sided risks, right? So tell me, when
you say fully financially integrated, what do you mean by that?
I am sorry.
Mr. Hackbarth. Well, that they assume under a global
payment responsibility for providing all of the covered
services.
Mr. Cassidy. But from what we just said, that would be all
of those plans, correct?
Mr. Hackbarth. In the Medicare Advantage program, yes, they
are by definition all assuming financial risk. The issue on D-
SNPS is, do they assume responsibility for both Medicare and
Medicaid benefits.
Mr. Cassidy. Correct.
Mr. Hackbarth. And what we see is evidence that
organizations that assume responsibility for both types of
benefits actually can improve care and reduce costs. If those
two are separate and there isn't that integrated
responsibility----
Mr. Cassidy. I see. So when you say integration, you mean
between Medicaid and Medicare, the dual-eligible population?
Mr. Hackbarth. Exactly.
Mr. Cassidy. Got you. That makes sense to me. I agree with
that, and I think that is a positive policy.
Let me move on to the ambulances. My colleagues have
addressed this. But when I turn one ambulance service, they
said the growth in the non-emergency services is because
basically they are going out, finding somebody who has had a
hypoglycemic episode, they do a finger stick, they find their
glucose is low, they give them sugar, if you will, of some
sort, they wake them back up. They don't transport them; they
leave them there. And actually they are providing some basic
services and saving money on the ER visit, if you will. Now,
have you been able to look globally to see, one, if this is
true, and two, if they are providing these services, does it
decrease the Part A amount, for example?
Mr. Hackbarth. I don't know about the specific example that
you have described. My understanding of the Medicare payment
rules for ambulance is that Medicare only pays if the patient
is transported, so in the example you describe, if the
ambulance goes out and doesn't transport the patient anywhere,
then I don't think it is covered under the ambulance policy at
all.
Mr. Cassidy. Got you. And you also mentioned the difference
between certain geographic locations as regards the frequency
of transport for things like end-stage renal disease.
Mr. Hackbarth. Absolutely.
Mr. Cassidy. That seems like that would be variable upon
poverty rates, upon degree of MA penetration that might provide
services.
Mr. Hackbarth. I am sure that there are a lot of factors
that go into that variation but the variation is----
Mr. Cassidy. But can we understand that unless we actually
do some sort of statistical analysis correcting for rates and
poverty, for example----
Mr. Hackbarth. Well, we have not tried to do any sort of
multi-variant analysis of the variation but I would be very
surprised if poverty alone explained the sort of variation that
we are talking about. We are talking about 20-, 30-fold
variation across States.
Mr. Cassidy. I get that. I will just say, coming from a
State in which there is high levels of poverty, some of the
poorest regions in the country are in Louisiana, I can
understand how your rate of poverty may be 30-fold relatively
to a suburb in New Jersey, a rural suburb.
Dr. Rowland, I am very intrigued by this integration of
Medicaid and Medicare, the dual-eligible population, and I know
that you referenced that, and you referenced that in your
testimony. Can you give any preliminary results as to whether
aggregating, or what are the preliminary results in terms of
aggregating payment in terms of increasing coordination of
care?
Dr. Rowland. Well, clearly there are efforts at the State
level to try to integrate Medicaid services with Medicare
services. We also have the financial alignment demonstrations
that are now out in the field but there are no results back
from them. In fact, most of them are just in the process of
being launched.
What we have been looking at is how do you provide for
better coordination of care, and as Mr. Hackbarth has noted,
there is some evidence that when a plan integrates both sets of
services, that they are more able to maintain them. We are
particularly concerned about how to merge the behavioral health
aspects together with the medical care in plans and have been
looking not so much just at the dual-eligible population but at
Medicaid's responsibility for people with disabilities, which
includes many individuals who need that merger.
Mr. Cassidy. If you have preliminary data on that, I would
love it if you would share that with us.
Dr. Rowland. We will share it with you whenever we have it.
Mr. Cassidy. I yield back. Thank you.
Mrs. Ellmers. The gentleman yields back. The Chair
recognizes Mr. Matheson from Utah for 5 minutes.
Mr. Matheson. Thank you, Madam Chair, and thanks for
holding this hearing.
I think we all want to have a permanent fix to the SGR
issue, and our committee has passed out a bill last year, and
we have had Ways and Means and Senate Finance look at this as
well and move legislation, and I think we all desire that
outcome of fixing this problem with SGR but it is really
important we are having this hearing because we have to figure
out how we are going to handle a lot of these extenders that
have always been associated with these temporary one-time
fixes, 12-month advances, 6-month advances, SGR. We had all of
these extenders, and what are we going to do if we don't have
that regular process on SGR anymore? How are we going to handle
these? So I applaud this committee for holding the hearing
today.
I have heard from so many providers and patient groups
about their concerns about specific programs in a world where
the SGR issue has been permanently fixed, and I want to say
that I am actually going to keep my comments pretty brief, and
I don't even have any questions for you. I just want to raise a
couple of quick issues and I will yield back after that.
I do think that there are a number of these extenders that
have been traditionally attached, as I said, to the SGR patch
and we ought to talk about how important they are and what we
do to fix them, critical programs like the Special Diabetes
program, which has widespread, bipartisan support to providing
funding for diabetes research, or the Maternal, Infant and
Early Child Home Visiting program, which we have heard about
earlier in this hearing. It helps provide coordinated resources
to expectant new parents, improves newborn health and works to
increase economic self-sufficiency. I think those are just a
couple of examples of many of these programs in our discussion
today which work to save money. They remove potential cuts to
providers. They are going to maintain better access to
beneficiaries and they provide really important services to
certain at-risk populations.
So I am glad we are going through regular order, Mr.
Chairman. Again, I applaud you for holding this hearing and I
appreciate our panel coming here today and I look forward to
continuing to work on these extenders, and I will yield back my
time.
Mr. Pitts. The Chair thanks the gentleman, and with
unanimous consent would like to enter into the record a
statement by the Rural Hospital Coalition. Without objection,
so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. The Chair now recognizes the gentlelady from
North Carolina, Ms. Ellmers, for 5 minutes for questions.
Mrs. Ellmers. Thank you, Mr. Chairman, and thank you to our
panel today on this very important issue regarding SGR.
Dr. Hackbarth, I have a question in relation to some of the
situations with the 2014 CMS changes that are coming with the
physician fee schedule. In 2013, MedPAC reported to Congress
that ``if the same service can be safely provided in a
different setting, a prudent purchaser should not pay more for
that service in one setting than in another'' and then it goes
on to discuss some of the payment variations.
But in the 2041 CMS Medicare fee schedule, it seems to be
doing the exact opposite. Can you expand on that and explain
the thinking behind that?
Mr. Hackbarth. Mrs. Ellmers, is there a particular example
in the CMS proposed rule that you----
Mrs. Ellmers. I am particularly concerned with oncology
services, but certainly any of the outpatient services that can
be provided in a hospital or outside in an outpatient setting
or ambulatory care, the difference.
Mr. Hackbarth. Yes. So you correctly stated what our
principle is, which is that we shouldn't pay higher rates for
hospitals if the same service can be safely provided in lower-
cost settings, and we are in the process of making
recommendations to the Congress to move Medicare policy in that
direction. We made a recommendation about evaluation and
management services a couple years ago. At this upcoming
meeting next week, we are looking at an additional batch of
services, many cardiology services, for example. CMS doesn't
always agree with our perspective on issues, and this is an
example where I think there have been some differences of
opinion.
Mrs. Ellmers. OK. And too, I cited oncology services and
some of the outpatient services but I am also concerned about
reimbursement for some of the Medicare therapy services. Now,
earlier--and I actually kind of crossed this off my list
because I think you really referred to those changes coming
more in the accountable care organizations. Is that true as far
as the therapy cap issue?
Mr. Hackbarth. So what we have recommended on outpatient
therapy, we don't believe that there should be hard caps
imposed on therapy services. That said, we do think that after
some point, additional services should be subject to review
before they occur, which is an approach very similar to what
private insurers typically use in outpatient therapy.
Mrs. Ellmers. OK. And just lastly, and this is really more
of a comment and a question for you as well, I continue to be
concerned about the physician reimbursement in relation to Part
B payments through hospitals or Part A payments through
hospitals with the upcoming CMS changes. I am afraid that with
the trend that is moving forward that this is going to affect
the viability of Medicare to our seniors, and I just want to
get your reassurance if you can commit to continue to work with
my office on making sure that MedPAC, that we work in
conjunction to make sure that reimbursement is----
Mr. Hackbarth. I would be happy to
Ms. Ellmers. Thank you. Thank you, sir, and I yield back
the remainder of my time.
Mr. Pitts. The Chair thanks the gentlelady and now
recognizes the gentlelady from Florida, Ms. Castor, 5 minutes
for questions.
Ms. Castor. Well, thank you, Mr. Chairman. I would like to
thank you as well for organizing this hearing today and I would
like to thank all of our witnesses for your service and
attention to the health and well-being of American families and
to our ability to provide health services in the most efficient
manner.
I think most people understand that children have a better
chance of success in life if they are healthy and they have
consistent access to a pediatrician and the doctor's office and
those important checkups, and health services provided under
Medicaid have simply been fundamental to ensure that millions
of American children do get those vision tests, the wellness
checkups, immunizations in a consistent fashion, whether they
are growing up healthy or they have certain special needs.
I want to make sure everyone is aware that in the Congress,
we have a very active Children's Health Care Caucus. I co-chair
the Children's Health Care Caucus with my Republican colleague,
Representative Reichert of Washington, and with the help of the
Children's Hospital Association, First Focus, the American
Academy of Pediatricians and others, over the past 2 years we
have had educational sessions on Medicaid for members and for
professional staffers here on Capitol Hill, and I wanted to
extend the invitation to all of my colleagues and to everyone
in attendance today to attend those sessions, and we get into a
lot of the detail that we are discussing here today.
A number of members have brought up the issue of access to
Medicaid. We know that over time there has been a real problem
with enough providers to serve the population, and one good
thing the Congress did a couple of years ago was to bump up the
Medicaid reimbursement to doctors. Implementation didn't go as
quickly as we wanted it to for primary care providers.
Fortunately, HHS finally finished that, and we were able to
include pediatricians and pediatric specialists, which I think
is very important to children's health care.
But Dr. Rowland, can you tell us the status of
implementation across the board now that HHS has that complete?
Have States been able to implement it?
Dr. Rowland. Well, we think that most States have been
moving forward with implementing it. The Commission is in the
process of obviously looking at what can be learned from the
State experiences and we will be going out to re-interview some
of the States that we talked to earlier about how
implementation has been proceeding. Unfortunately, data is
always delayed beyond where we would like it to be. There
aren't any specific data yet on what the impact has been on
changes in terms of participation of physicians in the program.
The one issue that the Commission, however, has discussed
and raised is whether that provision needs to also be broadened
to other providers who help provide those primary care services
and do not fall within the definition in the statute and
especially to look at some of the specialists that are so
important especially where there are intense pediatric needs
and real shortages.
Ms. Castor. I think that is going to be a very important
challenge for us moving forward and we should at least extend
it now, and then based upon your data and recommendations go
further to make sure that people are getting the care they need
under Medicaid.
And we all have the goal of improving the overall
efficiency of Medicaid and the Children's Health Insurance
Program. One tool States have to assist them towards this goal
is the Express Lane Eligibility. This efficiency simplifies and
streamlines the application and renewal process by allowing
States to use eligibility information obtained from other
income checks like the School Lunch program or SNAP, and we all
get annoyed when government or you go to the doctor's office
and they are asking you to fill out paperwork again and again,
the same information, and the Express Lane Eligibility helps
reduce that duplicative paperwork. So I understand now that 13
States have proven to be real leaders in cutting paperwork and
were able in doing that to reach thousands of more children and
make sure they can get to the doctor's office.
This sounds very promising, but 13 is still pretty low. I
know the Commission has not formally opined on Express Lane
Eligibility but there is promising evidence. Could you tell us
in terms of increasing enrollment as well as reducing State
administrative costs how effective the Express Lane Eligibility
has been?
Dr. Rowland. From what we can learn so far, it has been an
effective way of shifting people from one program's eligibility
determination process into the Medicaid program itself, so it
has boosted enrollment in those States. It is now being looked
at for adult eligibility in two States to try to see if under
the waivers they have been granted through the ACA they can
facilitate getting parents into coverage as well, and I think
that the more we can simplify and streamline our eligibility
processes and use electronic transfers to get more people
covered without having to go through, as you say, reapplying,
reapplying and reapplying, the better off both beneficiaries
will be as well as the States that try to administer these
programs.
Ms. Castor. Thank you very much.
Mr. Pitts. The Chair thanks the gentlelady and now
recognizes the gentleman from Florida, Mr. Bilirakis, for 5
minutes for questions.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
Thanks for holding this hearing, and I want to thank the panel
for their testimony as well.
Mr. Hackbarth, the March 2013 MedPAC report included
recommendations to permanently reauthorize integrated dual-
eligible Special Needs Plans which include the Fully Integrated
Dual-Eligible Special Needs Plans and a second successful model
for integration. In the second model, one managed-care
organization administers a Medicaid plan and a dual-eligible
Special Needs Plan. The same Dual-Eligible beneficiaries are
enrolled in both plans, and integration occurs at the level of
the managed-care organization across the two plans.
Question. Why is it important that we retain this model in
addition to the FIDE SNPs, and can you tell us about the
benefits of this model and why MedPAC included a more broad
definition of integration?
Mr. Hackbarth. Well, the ultimate goal, as you say, is to
get somebody to assume the responsibility for integrating
Medicare and Medicaid both financially and clinically, and we
allowed different paths to that because there are various types
of issue that arise at the State level that may not make the
fully integrated single plan model work in every State. Plans
approached us and said that this dual plan model where the same
beneficiary is both in the Medicare SNP and the Medicaid plan
and they do the integration can work as well. In trying to be
flexible, we wanted to accommodate that.
Mr. Bilirakis. Thank you. Second question for you, sir.
Does the current star rating system penalize Special Needs
Plans by rating them against all Medicare Advantage plans
rather than against the SNPs?
Mr. Hackbarth. We have not looked specifically at that
question. I would think the answer is probably not but again,
we haven't studied that.
Mr. Bilirakis. Would creating a more appropriate star
rating system that is tailored to the specific population D-
SNPS be more representative of their quality performance and
provide more accurate information to beneficiaries?
Mr. Hackbarth. We can look at that. As I say, we haven't
studied that.
Mr. Bilirakis. When do you plan to?
Mr. Hackbarth. We don't have any specific plans. I am
saying we can take a look at that.
Mr. Bilirakis. Can you please follow up with me on that?
Mr. Hackbarth. Sure, I would be happy to do that.
Mr. Bilirakis. I think that is very important. Thank you. I
appreciate it very much.
Thanks, Mr. Chairman. I yield back.
Mr. Pitts. The Chair thanks the gentleman and now
recognizes the gentleman from Virginia, Mr. Griffith, for a UC
request.
Mr. Griffith. Thank you, Mr. Chairman. I would ask for
unanimous consent to submit a statement from the Federation of
American Hospitals for their support of the rural extenders
that I talked about.
Mr. Pitts. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pitts. That concludes the questions of the members who
are present. We will have some additional questions, the
members will, and we will send those to you. We ask that you
please respond promptly.
It was a very important hearing today. Thank you for the
testimony that you have given to the members.
I remind members that they have 10 business days to submit
questions for the record, and so they should submit their
questions by the close of business on Friday, January 24th.
The Chair thanks everyone for their attention, and without
objection, the subcommittee is adjourned.
[Whereupon, at 12:07 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
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