patients but also medicaid all providers medical providers one of the greatest obstacle confronting small health care practices is the fiscal problem in the medicare program with the baby boomer generation entering retirement medicare spending will increase exponentially over the next ten years if wards are on their way to ensure access to health care remains while also meeting the long term financial issues facing the program one of the top priority is seeing the upcoming months is the dressing to schedule cuts in free speech and free payments on july first to see him payments for medicare services are scheduled to be read by t point six percent without options the scots will continually only on a d s predicted that the total reduction will be about forty one percent by twenty sixteen but dr payments will on their mind of whose precision foundation of medicare for karen and future generations of seniors creating unnecessary barriers to care for all the americans and am a survey found that sixty percent of doctors believe this year's caught alone will force them to limit the number of new medicare patients they can treat this hearing today will examine how any solution must account for small health care practices in crafting a fix a unique circumstances so small healthcare providers must not be ignored it is clear that they could be the most severely affected doctors survey by the american college of b c sions said caught will force them to postpone purchases for their practice to recon see their plans to upgrade health information technology to all their providers one further saying they will reduce their staff or get out of patient care altogether unfortunately the administration has taken the position that they caught are necessary even if it could mean loss of access for our seniors in finding a solution to the deuce problem c m hear the concerns of medical professionals here today on across the country on the potential implementation of these cots as well as ways to need to gate their impact these includes reducing the paperwork burden and provid how should it be done and what does it mean for of precisions the senate has outlined a plan that will delay the medicare physician payment caught for eighteen months i support their effort to address this problem in the near hearing our witnesses will shed light on the steps they believe should be taken it is also my hope that the panelists will provide insight on the short long term impact the cots could have on the provided community in many ways if we see sions community that is are aligned with those of the seniors that receive care the committee wishes to hear these concerns and how we can work together for a proper remedy i look forward to today's testimony and i thank all the our nation recognize that small medical practices are critical to the country's overall physical and mental health and like all other small businesses essential to our economic wellbeing i'd like to extend a special thanks to each of our witnesses who have the witnesses especially helpful and i also want to specially thank tom de angelus is from the greater cincinnati area who also be testifying this morning data on medical practice size show that physicians and patien continue to prefer small practice settings the small setting allows the physician to have control of medical decisions making our medical decision making and is most conducive to the relationship of trust and confidence between physician and patient the practical preference of the small practice setting suggests that any medicare physician fee system must be feasible and easily operable in a small practice setting the managed care backlash is also driving the insurance industry toward traditional insurance principles that instruct insurers like medicare to manage financial risk and allow providers to manage care the insurers for a reason to seize management emphasize this change in behavior with only cautious and limited outreach to physicians the current medicare physician fee schedule is clearly flawed since its inception in two thousand and two the sustainable growth rate formula has required the government to reduce physician fees since two thousand three congress has passed and the president has signed laws that have prevented the reductions from actually taking place the current system rewards the physician for seeing as many patients as possible and sometimes performing excessive services and example this practice is the use of a cat scan sometimes rather than an x ray for example several studies have confirmed that expensive or excessive services do not necessarily lead to better quality outcomes a costs go up in their medicare we strop or unrealistically low they're engaged in a vicious cycle that forces them to see more and more patients to take in the same amount of money medicare pays its providers based on quantity without rewarding those providers who improve quality in fact medicare pays more when poor care results sometimes in preventable services this need to be changed today access remains good for beneficiaries accessing current physicians and for those seeking new physicians continued efforts to monitor and protect medicare beneficiary access are warranted the medicare physician fee schedule should be restructured to place a greater value on the quality of care and the efficient use of resources attention should also be given to improve health i t efforts making electronic medical records available to patients physicians w cut down on unnecessary tests help doctors provide better care and offer economic benefits to taxpayers and the federal budget we have an excellent panel of witnesses as i mentioned before here today and i look forward to hearing their thoughts i want to thank the million americans welcome sir thank you mr shabbat distinguished members of the committee thank you for inviting me today to discuss medicare physician payment continued improvement in quality and access of health care for medicare beneficiaries and all americans requires the active participation of physician and in order to ensure that participation medicare needs to appropriately compensate physicians for the services they provide to people with medicare but how we pay also matters we need a payment system that will support high quality care and avoid preventable cost to the program and to society simply adding expensive payment updates to the current system would be extremely expensive from a financing standpoint and would not promote better quality or more efficient care the current system has the effect of directing more resources to care that is not of the highest quality such as duplicative tests and services or hospitals readmissions and it doesn't do as good a job as possible in treating those with chronic conditions that's why payment reform is also so critical for medicare beneficiaries who are impacted in several ways not only are they impacted by access issues but they also are threatened by rapid growth in expenditures that could make services an affordable growing physician cost directly impact medicare beneficiaries through increased par premiums co insurance and premiums for supplemental coverage the current medicare part b premium stands at ninety six dollars and forty cents per month as med pac recently noted over the one nine hundred ninety nine through two thousand and two time period the part b premium grew by an average of five point eight percent per year cost of living increases for social security benefits averages two point five percent per year since two thousand and two the part b premium is creased even faster by thirteen point five percent in two thousand and four seventeen point four percent in two thousand and five thirteen point two percent in two thousand and six and five point six percent in two thousand and seven right now twenty nine percent of an individual social security check is applied to pay medicare premiums co insurance and deductibles the recent medicare trustees report notes that the medicare part a trust fund will be insolvent by twenty nineteen that's eleven years from now that means if you are fifty five fifty four years old today the trust fund will be insolvent that you are eligible for medicare for medicare part b the trustees noted that annual spending growth rate of nine point six percent for the past five years per year is kind of course an uncertainty for medicare beneficiaries and physicians is why c m s has been working with congress in the physician community over the past several years to provide a better way to pay physician our work centers around new concepts in the area of value based seen with the goal of transforming c m s from its current role of a passive payer service into an active purchaser of high quality efficient care nobody disputes the fact there are problems with the current statutory formula for calculating annual physician payment updates to date we have seen short term fixes instead of a comprehensive strategy for long term reform the problem with this approach is that it runs up the tab and makes the next scheduled cut even larger case in point as people have noted already this july the law requires doctors fees to be cut by ten point six percent physicians face another five percent cut on july and january one two thousand and nine and every year thereafter for the next decade we have c m s are very concerned by this tremendous uncertainty and this band aid approach causes in terms of level physician level participation in the program particularly for the small practice chairwoman noted in order to move forward with physician payment reform we have embarked on the following initiatives first were addressing the inappropriate payment rates for certain individuals services in the physician setting in two thousand and six we completed the third year review of physician payments this resulted in a major rebalancing that provides for higher payments to primary care physicians second we are looking at creating larger bundles of payment for care across the entire episode of care we now believe this holds real promise for higher quality particularly the area of hospital readmissions and greater efficiencies third we have a shared savings demonstration that rewards physician practices for achieving higher quality outcomes and savings the demonstration is showing already impressive result and we will be launching new electronic health records and medical home demonstrations fourth we're looking at better ways to measure physician resource use with actual reports being issued to physicians on how they compare with similar physicians in terms of their resource use and then finally we have the physician quality reporting initiative up and running physicians are beginning to report on evidence based quality measures and the first payments into the system will be made to physicians the summer program is an important building block towards value based purchase and said physicians system for physicians to be sure none of the steps that i and others will be presenting today represent the proverbial silver bullet everyone is looking for to address physician payment reform if this was easy it certainly would have been done long ago when many of these issues are technically complex they represent the best thinking we and others have at this time and importantly there is a growing consensus among all stakeholders that this is the right direction for the medicare program so thank you again for the opportunity to testify on the medicare physician payments c m s appreciates this committee review of this issue and we look forward to continuing to work with you in congress on this very important issue thank you and the chair  this is going to be a tough debate and a lot of tough question we have to ask ourselves i hurt and it's going to take all the all the stakeholders talk about this some of the things i heard from a medical professional last week sixty two percent of all medical costs occur in the last two weeks of life if that's true i'd like to know that and then that sparks a debate is how and nobody really wants to talk about this but how we deal with end of life issues and are we going to change   and then comparing apples to apples i don't know if i have a question but if you could address any of these things that you know who's giving what health care when i go in a standard of care and i don't know what i'm really asking but we've got to start comparing apples to apples here and you know i look at maybe it's a system we've got to be able to talk out loud without getting your head chopped off or bringing these issues up but you know one person's insurance policy or health care policy is same as the next person's and standard across system but maybe in those first ones about end of life issues form maybe that helps a lot of good thoughts there and i think you're kind of swirling around the area where all of us have been kind of grappling with on these issues because if you really look at the current physician system and as economists say economists would say you get what you pay for so nobody should be surprised that we have this great volume in this intensity of services for physician payment because when you really step back and look at it it's a piece work system you know it's a fee schedule we pay on seven thousand different codes in the system and what are all the economics and incentive piece work system it's to do more and then you have this s g r cap on top of that which basically penalizes all physicians equally so if your physician that's practicing in an efficient way and someone else as a practicing inefficient you get hit just as hard as the guy that's inefficient so it's really kind of in that regard is how it looks forward so a lot of things that we're doing on  demonstrations and some of the programs we've already started build infrastructure start to get that one is dealing with this issue in terms of cost very ration around the country the folks up at dartmouth elliot fisher and dr wynberg have done some wonderful work about looking at great variation around the country and a lot of it about in the whole life care and we see sometimes three or four fold difference in terms of spending in different parts of the country as you indicated with no material difference in terms of the outcome so one of things we're really working with pretty collaboratively with position communities really to measure because if you really don't measure you can't really improve and so we're looking at new measurement outcomes new quality majors efficiency measures we can start to major this and where physicians can compare themselves one to another to see how they're performing to see if we can get rid of some of this variation out there so there's a lot of different swirly activities out there but i think you're asking the right questions is is how do we fundamentally begin to kind of look at where the gaps are and care address those gaps and improve and part of the i think fundamental foundation of what we're doing as a measurement in the future start paying for outcomes not just pay madam i want to compliment my colleague because i from indiana i think he's got a right this is a huge serious problem i'm in a district in the country number one as a member of congress with the most senior sixty looked at continued cuts but yet ninety to ninety five eighty five percent their practice our medicare their expenses continue to go up in terms of taxes insurance and med mel and all these things and i know at the end of the year a lot of felt they're going to go out of business if they had that cut so we're talking about these additional cuts that we're talking about and i think there was some thought early on with medicare would be twenty thirty percent of your practice but in areas like florida in my area sure different parts of the country it's evolved to eighty five ninety percent the government there working for the basically working for the government so the bottom line i just don't see they can attract a new doctor to our area that they've had one of the you know three hundred thousand population county they were tell me in one medical society they can attract new physicians even come to the area because it doesn't make any sense so i guess i want to get back to the whole point of you know what are we going to do what's the answers as you see it to these cuts and i think my colleague from indiana says it's tough to deal with this but we really got to put you know be truthful with the american people and put all these things on the table across the board because again the first baby boomers turning sixty two and to get seventy eight million to follow we need to get real about that right now those are very good points and you know and i think probably what you see in your district is much more than anybody else because of the numbers you laid out is the fact that for the medicare program to be successful to really serve the seniors in this country we need the active participation of physicians so interesting there was a report that came out last year that said basically eighty percent of all health care spending is driven by physicians because they're the ones that order tests they're the ones that admit patients are the ones that discharge so we have to have active participation by physicians to be part of this program as you well indicated depending on the physician specialty there part of medicare payer mix could be very low to very high almost one hundred percent of our business but the way that we guarantee active participation by physicians is to have predictability and stability in the payment system and we have neither right now so i can understand that uncertainty that you're physicians are feeling and others are out there and quite frankly these are these are professionals that ought to be treated better by all of us as we go forward and so what we can do with this program to try to manage that to get better as we go forward is going to be absolutely key one of the things that we're really trying to deal with some of our other demonstrations here is really trying to look more thoughtfully in terms of the overall payment system in the medicare program you know right now when you look at medicare part b it's pretty much silo it's just you know a physician spend more to try to take care for a patient more effectively they get they see their payments cut as a result of the s t r because spending exceeds a target but yet because they might be managing someone with diabetes much more effectively they might spend a little bit more to manage it more effectively but they say that trip to the emergency department they say that hospitalization the overall system costs come down as a result of that how do they get to be accounted for that how do we reward them for that and we're looking at new ways to do that i think that's a good effort for the future and where we need to be going with this program and i think we're getting some good support by the physician community help us think those issues through add one other quick question oh we've got to go vote but one of my doctors called me reaching out to the community and said a lot of these young physicians are coming out with hundreds of thousands of dollars of debt out of medical school and then they're trying to pick up a practice in additional debt the set up an office and again i just wanted to said how in the world to expect anybody go into this profession with the realities are dealing with so it's kind of a follow on question but somewhat maybe just what you cover but i do i think that's a good point in a real concern as well because what we really need right now in health care is more primary care physicians and if they're looking at that kind of debt they're probably going to choose specialties that are not primary care and that is going to be a problem in terms of access in the future so we've got to make sure our payment systems are fair that the reward physicians across the board and that we don't create medicare bill signed into law to ensure a fee stations receive the proper payments on july first in terms in order for us to be able to work with our contractors to get  programs put in place probably mid june would give us ample time in the ready to go on july one for a seamless transition so there'd be no interruption in payments and can you talk to us about what step has  taken to be prepared for either a reduction or the possibility of a congressional change to the formula we will certainly be working very close with congress to make sure that if there is a if there is a reduction it is hard wired into the system now and that would go forward if there is one change by congress we would hopefully be able to anticipate that again to make it a seamless transition as possible so either way we hope to be prepared  foster has looked at the medicare economic and on a regular basis and they believe that continues to be a good indicator for growth in this area at this time if there's new information that they can be looking at the new information proxy for determining the inflation increase but i would absolutely agree with the practices have changed over time and as a result of that through the system through the american medical association relative value up the real work is done with the r v s system and the relative value updates that are evaluated by the rock the relative value of the american medical association that's where the real activity is in terms of what payments are out there in terms of new technology the work the physicians put in in terms of the services those are change on a regular basis and what we did actually in two thousand and six we did a five year review the statute requires for us every year five years to review the codes to work with the a m a and other physicians specialties to do that they made a number of substantial changes to that and we accepted all of those so it is accurate as we can possibly be for this time for the real activity for the payment schedule in terms of the inflationary update that i like growth in the volume of medicare precision services for two thousand and five and two thousand and six was just three point six percent which is only about half the growth rate projecting their two thousand and six report i since the payments reflected of manpads finding what we saw between about two thousand and two to about two thousand and five two thousand and six double digit increases in physician payment and it has begun to level off this last report in terms of the volume of services that are out there but it's still growing at rates that are much greater than other parts of the medicare program and certainly growing at rates that are far far higher than the overall its drops i would think that where we are right now in terms of trying to change the way we pay physicians is not the debate that is before us i think the real issue before us is how we go about making those changes i think everybody within organized medicine certainly most in congress believe that it is time to have a change in the way we pay to start paying for value not volume of services so even if we're seeing lower growth rates over the last couple years i don't think that should stop us or deter us from trying to find a better way to get better value and better quality in terms of our health care system i don't think that anyone is no one here saying the opposite the problem when you say that we need  providing to attract those to enroll into the medicare c m s service i would agree with your statement there that we do need to make sure that this this program this particular physician fee schedule continues to evolve and i think it has over the last several years as we move forward and particularly on the issue of primary care physicians again in two thousand and six when we did the five year review the rock came forward with  extraordinary recommendation in order change values for what we call in encodes evaluation of management codes which are primarily the codes used by by primary care physicians it's the time that physicians spend with patients were mostly in primary care many of those codes went up twenty thirty percent we accepted all those and so we are working hand in glove with the physician community to try to make those changes and make them as accurately as we possibly can i have a question and i will come back and th when we started and taking this up again obviously it was out of our control we had votes on the floor and we very it's very common to get interrupted in committee meetings with votes on the floor typically it's forty five minutes maybe an hour unfortunately two hours is what you all had to wait and the chair and myself obviously have no control over that but i know how that can wreak havoc in your schedule for a day and how long you think you might have to be here and that sort of thing so  our sympathies for you having to put up with that inconvenience a speaking of being as mr mr coon relative to congress in the way we've dealt with reimbursement issue and  depend upon this and the patients as well when year after year we have a tendency and the cuts are out there reflected in either the president's budget or perhaps our budget that by the end of the year the fix comes very late and so people don't know what it's going to be and for planning purposes and everything else i'm sure that there's some negative impact could you discuss that and how what kind of problem that is sure you're absolutely right congressman that it probably is very disruptive for some physicians because they want to make plans in terms of their practice whether it's to buy a new piece of equipment or invest in say an electronic health record or something like that the fact that they don't have predictability and stability in their payment system to know how they would amortize that out over the years in the future does create real disruption that's out there also i think it's disruptive in the area in terms of medicare beneficiaries to know whether a physician might take someone who now becomes age sixty five and want to take on additional medicare beneficiaries as patients or whether a physician may want to participate in the medicare program that's out there so i think for any business person in this country regardless whether it's health care anything else they need predictability and stability and under the current physician fee schedule and the payment system we have now they're not getting that right and we've unfortunately seen that the fact that this that's in the system occurs year after year whether it was in republican control or democratic control now it seems to be not really a political saying it's just the way it works up here in congress or doesn't work and and i think really congress needs to get its act about it together so people can be a little more  it can depend upon things to come and be able to plan in advance how how can what can we do about rewarding inefficiency in there and they're rewarding efficiency and therefore encouraging more of it one of the best ways that we've really looked at is that we really need to measure in this area and we need to really get this set of quality measures as well as  resource use measures that we can really kind of look at that efficiency if you look at the medicare payment system now at least for physicians we pay on volume we don't pay for value and we don't really know what kind of outcomes that we're getting as a result of that and that's what we see this great variation in terms of care across the country and in a lot of cases great inefficiency in the system that's out there so i think one area is the development of measures in the physician community i think particularly led by the american medical association's consortium is doing a very good job of developing new quality measures thinking about efficiency measures as we go forward but it's more than just measuring it it's really then to attach payment to it to really try to drive the incentive as we go forward and i think that's the next hill we all have to cross but i think we're doing a very good job of building the infrastructure to get the measures in place the next question is then how do we deploy those measures and ultimately do we make those publicly available because that's part of the accountability as well as transparency is part of this too thank you what was the participation rate in the physician question under pique your eye which began in july of zero seven are our current indications about sixteen to seventeen percent of physicians participated in that first six month launch of the program some people have looked at that and said boy that's that's not very high number but a couple observations about that are worth noting one is when it was authorized it was only authorized for six months so if you're a physician and you're trying to decide whether to train staff and operate in this new program or do you make the investment if it's only for six months you might want to think twice about that so i think sixteen percent with that level of uncertainty was pretty good the second thing is physicians when it comes to these kind of programs sometimes are slow adopters to the program we have the participating physician program physician to be either participating or not participate in the in the medicare program and that has a differentiation and payment when that first started for this in participation was about twenty five percent and then over the grew to about ninety five percent so i think their early start of this program looks good in terms of the breakdown of the smaller physician offices i don't know if we have that numbers broken down that way we have more by specialties whether it was up to modest are others but in terms of practice size anecdotally the information i hear from our medical officers and c m s is that it looked like physicians across the spectrum both small and large participated and that seems to make sense because when you look at physician practices overall about fifty percent are physicians in practices of two or three year or less so i would think we would have had good representation by smaller responses many times will get witnesses of course and you are the messengers generally and you know what we do the messengers and sometimes a very careful in their responses and even with a live in another committee hearing with energy and commerce i just could not get him to answer whether he thought the g r was the way to go and i even had to transcribe so i could read it to all my physician groups back home he gave me a very alan greenspan  answer alan greenspan is infamous for actually remarking to a senator quote if you understood me i must have misspoken so but that's really what we've been receiving and i know it's the tail end of the physicians i think the consensus would be is that it's a pretty blunt instrument and that it is time to move on to find a better way to pay for and as we speak do you see that effort being undertaken either by people over at c m s i know we're trying to do certain things in congress i know dr burgess has his bill out there what do we have as we speak in a serious ongoing effort to find something in the way of a substitute i think the real good news here is that over the last two or three years there has been some great collaboration between c m s the physician community and i think congress to a large extent to really find a better way pay physicians to really think about paying for outcomes to pay for quality for pay for better safety of care instead of the volume of care that's out there right now so in that regard we've got some wonderful demonstrations underway that are showing some great promise at the chance for us to prove the concept through a demonstration i think there's a lot of good work in terms of collaboration and us with the physician consortium for development of measures so we can actually measure what's going on out there is working very well and then finally some real good work with  this program that mr shafiq mentioned in terms of really building the base to find a way for us to get that information from physicians so we can measure and know what the quality information is out there so some good start what do i wish we were further along than we are now absolutely but i think we've got a pretty good stake in the ground to get us going and coming to a new administration hoping that we're going to be much more aggressive and i do believe it really is the legislative imperative that congress leads the way i really believe that regardless of who wins the election is going to be there and hopefully we'll have people that are going to be sensitive to it in such i'm going to read from the member the memorandum prepared by staff the law specifies a formula for the annual update to the its spending is in excess of the target the future year is reduced the goal is to bring spending back in line i think that is the fundamental principle of the as g r is not reality based whether it's congress whether it's a president whatever we figure what we want to spend in a particular year and then we make thing sticks if we say we're only going to have ten dollars to reimburse physicians even though the cost of providing the service is fifteen dollars we are still going to do ten dollars and we may torture different numbers and formulas but i think that's why we're all in agreement so then we come over to your testimony and it says but in every year since two thousand and two congress is overridden the statutory cost growth controlled the sustainable growth rate the problem with this recent approach is that it runs up a tab that makes the next scheduled cut even larger and you know we've been addicted to that kind of behavior and it's really bad it is stopgap but i guess the message really is to c m s to the physician community and to congress is that indeed it is broken it is not working i've never had anyone really say that the s g r is the way to go now sir terry leavitt may have danced around it but i think in the final analysis he was talking about paper performance and how we do that we've heard from the governors of the states of minnesota and pennsylvania regarding their universal health coverage and how they pay for performance but then that opens up another can of worms so hope before we go there i'm going to be with them one last thought that i hope that you're very cognizant of and i think that you are everyone in the audience is whatever c m s says something is worth thank you madam chairman absolutely i would just say that all your points i don't think i would necessarily degree disagree with many of your observations made congressman and you know if you really think about the medicare program and the evolution that goes through when it started in one thousand nine hundred sixty five and then we paid physicians on this thing called customary prevailing and reasonable charges that were out there after about a decade and a half everybody realized that was very inflationary and very problematic and so in then came the rb r v s system the current payment system that we have that's been in place now fifteen almost twenty years and i think it's time to change to something else and the change that we're all talking about here is value based person and how we move in that direction the good news continues to be that the clabber ation between us and the physician community in the congress and others stakeholders on this is there but and it's working but it is slow work because you want to get it right as we go forward but you're right it needs to be done it's work worth doing but i think above all else i just leave you with this point is that in terms of getting answers from us at c m s as we move forward in this direction i think we have to have some guiding principles that drive us forward when i think we have to have investigative integrity and all that we do in driving forward in this change and i second and most is that we have to have transparency in all that we do not only with you all up here but with a physician communities and others because this kind of change i don't think you can order this kind of change on physicians and others i think it has to be they have to believe in it they have to help us develop it and have to be incentivized to drive a ford and that's where i think we'll get a success as we go forward important comments and we're talking about change and i really appreciated the last statement you made is that we go through this very laborious and difficult process that there has to be guiding principles and practices and i couldn't agree more about the transparency and the buy in factor from the physician community i want to represent a district in which i have a lot of understood i have understood communities in the urban part and i have big patches of rural communities that primarily rely on small practices for for their health delivery system and for their medicare services and and it's that access particularly primary care for the elderly is getting more and more difficult in the rule areas of my district but i want to ask you a question one of the things that i hear from those physicians of those small practices is the  card and and what c m s has suggested to these physician practices is why don't you call in to make that verification it's disruptive to the practice it's disruptive to the quality time that you need to spend with your patient and my question to you would be if c m s would oppose congressional intervention for lack of a better word to require one standard of m a card for for patient id cards we have if my understanding to our marketing guidelines some pretty good standardization right now in terms of id cards that are supposed to be provided to medicare beneficiaries furthermore the terms and conditions  and other aspects of the medicare advantage product need to be posted posted publicly on web sites for easy access by everyone but i'd like to go back and spend some more time with staff understanding the actual standardization as we have now and further needs that your constituents  exempt that my question is what c m s oppose congressional intervention to outlaw the use of all product clauses for medicare advantage products i would think in terms of the  aspects on that one is actually this morning we issued a new regulation to deal with marketing aspects of medicare advantage plans and so many of the issue that have been raised in the past in terms of marketing problems with with brokers and agents  we think we're we're getting a pretty good handle on that we've got some new information out there i think on the second issue that you raise here in terms of of the deeming requirements and and the operation of the plans particular the private fee for service plans i'd like to hear more information in terms of the problems that it's creating for individual providers because right now i think with again with our marketing standards that we have now with the terms and conditions that are posted that providers are able to access i would like to know what what other things that perhaps we can do administratively first before we turn to legislation so you will have an opportunity this afternoon because some of the witnesses that will be testifying will be discussing the same issue so for the really thank you for being here this morning thank you all very much and i w welcome and i really appreciate your cooperation and understanding by the fact that we spend so much time this morning trying to have five or seven votes on the house floor was home time we have you know members who manage more than thirteen thirteen thousand five hundred we're going to say sions and which almost two hundred seventy thousand physicians practice your welcome and you hop five minutes to make your percentage madam chair and members of the committee my name is known around earth and i am a practice administrator of a twenty six position orthopedic practice in fort wayne indiana our practice has twelve locations which serves patients and thirty counties from three states medicare regulations significantly impact physician practices and as the president of the indiana medical group management association i wanted to express my concerns on behalf of my national south asian thank you for having me here today i echo the concerns of my fellow panel members new medicare patients however we are considering significantly trimming back our acceptance of medicare advantage patients it's a ten point six percent cut or to take the take effect we would be forced to consider another operational change such as reducing the number of traditional medicare patients week so some of the practices in indiana are already managing the demand of medicare patients in their offices by keeping only a few appointments per day available to medicare patients therefore these double digit cuts clearly threaten high quality care to medicare beneficiaries my local experience is reflected in recent m g m a national research where more than eleven hundred group practices representing nearly twenty nine thousand physicians responded as a result of the six months financial uncertainty nearly twenty four percent of practices have began limiting new medicare patients and nearly fifty percent indicated in an additional ten point six percent cut will force them to stop accepting and or limiting the number of medicare beneficiaries their practices treats m g m a research also shows that more than half of responding practices are reducing administrative and clinical staff two thirds described how information technology and clinical equipment investments are also sacrificed or postponed indefinitely however medicare's challenges are not fully caused by the annual s g r struggle for the past two and a half years we've encountered continued and growing frustration associated with the medicare advantage program in two thousand five medicare advantage was three point six percent of my practice as medicare charges and has grown to twenty four percent in two thousand and seven our medicare advantage patients share our practices frustrations they don't know the rules practices like mine are bogged down trying to help patients understand their plans and navigate the many administrative complexities my practice has been forced to hire two full time staff just to deal with the avalanche of beneficiary questions and additional paper work associated with medicare advantage and even that is not enough m a has fielded countless medical practice inquiries and concerns regarding medicare advantage and has therefore developed four simple requests that if enacted would greatly improve the operational aspects associated with medicare advantage as well as improve provider and patient understanding about the program in recent m d m a research over fifty six percent of respondents said they could not accurately identify medicare advantage patients with ninety percent of respondents indicating that patient insurance cards provided ineffective identification because patients do not know what coverage they have i have had to direct my staff to contact medicare or the medicare advantage plan each time the medicare patient walks through the door this administrative burden could be avoided with the standardization of medicare advantage id cards if standardized cards were issued we could quickly identify the type of medicare advantage plan the patient is enrolled in and we could then know precisely where to build a claim and what contact information to use for further up these id cards should be required to contain a toll free number meant for providers to be able to get answers to questions and quickly check eligibility and or claim status just like traditional medicare our second request is the elimination of deeming in medicare advantage doing so would allow practices a fair opportunity to review negotiate and understand contracts with plans deeming allows a medicare advantage plan to consider a physician as accepting their contract if the patient presents in the and medicare advantage card prior to service often we are essentially forced to sign the last page of a contract without knowing what the rest of the lengthy and non negotiable contract says for example every day we treat arthritic patients who are driven to their appointment by family members that took time off work they present one of a hundred non standardized identification cards upon arrival at the front desk at that moment we must decide whether we will treat this patient it is cruel to the layer denied treatment because it's just impractical to review a contract while a patient is waiting services yet being denied the opportunity to review and negotiate the terms and conditions prior to rendering services is completely contrary to fair contract in principle our third request is the elimination of all products clauses in plain contract most states already outlaw these clauses in order to protect position practices from accepting all patients and all variations of insurance products offered by a given insure for any contract to be binding there must be a quid pro quo meaning both parties have received something from the other but this does not exist for medicare advantage plans and the physician if contracting by default occurs some states like indiana have addressed this practice but medicare advantage plans are exempt from the state laws we urge congress to prohibit the use of all products clauses in the medicare advantage program our final recommendation is that congress apply and in force of the time same timely payment provisions of medicare advantage that exist for traditional medicare traditional medicare does a great job paying promptly and accurately but my office as accounts receivable for medicare patients is fifty percent higher than it was in two thousand and five this is primarily due to medicare advantage we currently spend triple the work force to collect what's due from medicare advantage payers than what we used to collect from traditional medicare in following up on unpaid claims with traditional insurance payers we have the avenues available to us such as the department of insurance and federal agencies for issa plans with medicare advantage there is no comparable resource our region five office from c m s has heard plenty from from plenty of us and have offered somehow but it has been ineffective in causing any root change to the behavior of the payers applying the traditional medicare prompt payment lot to medicare advantage plans would be both logical and fair addressing our recommendations would greatly improve the medical communities perception and willingness to participate with medicare advantage plans therefore strengthening the program overall beneficiaries as well thank you for this opportunity and i'm happy to address your questions if you have any congressional district he lives in a level in ohio which is actually in jean schmidt's district he's close tom graduated with honors from northeastern university in boston massachusetts he's president and co owner of comprehensive physical therapy center which is an outpatient physical therapy provider located in suburban cincinnati tom also is currently vice president of the american physical therapy association private practice section thomas served as the reimbursement chairperson for the ohio chapter of the american physical therapy association some member of the physical therapy advisory committee to united health care and he's a representative for the american physical therapy association before payment policy organizations and committees and we welcome him and hear us here this morning thank you thank you chairwoman blast buzz ranking member shabbat and members of the house committee on small business thank you for the opportunity to address the house committee on small business and provide a small business owner and clinicians perspective on the pending cut to payments under the medicare physician fee schedule i am tired of the angelus a practicing physical therapist and co owner of a small physical therapist practice in the greater sense that the ohio area we currently employed twenty four individuals and three clinics and serve approximately one hundred eighty patients per week with musculoskeletal impairments our goal is to return these individuals to the highest level of function and productivity in their homes and their communities driving this payment environment is a challenge for small businesses in physical therapy the fish therapist small business climate in cincinnati has seen this firsthand in the past three years fourteen clinics have closed their office doors due to the negative pressure on payment my partner and i have personally reduced our salaries eliminated our advertising budget and seen significant increases in administrative and operating costs today i represent the american physical therapy association and their private practice section which advances small business ownership among physical therapist if congress does not act by july first two thousand and eight payments under the medicare physician fee schedule will be cut by ten point six percent this would begin a series of payment reductions under the fee schedule leading to an overall reduction in payment to care providers of forty percent by two thousand and sixteen a b t a supports efforts to avoid the ten point six percent cut in payments under the medicare physician fee schedule and to replace the flawed sustainable growth rate formula with a more accurate indicator of health care inflation payment cuts under the medicare physician fee schedule will have significant ramifications on the ability of physical therapist to serve individuals who have suffered from stroke had joint replacement chronic diseases that impair their ability to move wa and perform their daily tasks physical therapy continues to be a critical need for medicare beneficiaries a recent center for medicare and medicaid services study indicated that eight point five percent of medicare beneficiaries utilize outpatient physical therapy services resulting in three point nine million patients in two thousand and six the demand for high quality rehabilitation services by physical therapist will only increase as baby boomers age and people seek the services a physical therapist to keep active and productive the impact of the pending cuts on physical therapist small businesses can be summarized by three points first beginning july first in addition to a ten point six reduction in payment physical therapist will also be subject to a one thousand eight hundred ten dollar per beneficiary per year therapy cap on outpatient services this would limit patient access to needed physical therapy by not considering the patient's condition their diagnosis or other contributing factors this represents in essence upon a cut and would make the viability of physical therapist small business a significant challenge a b t a recommends the passage of the medicare access to rehabilitation services act h r seven forty eight legislation to repeal of the therapy caps second physical therapists in private practice have significant limitations on how patients may access their services and marketplace currently medicare requires that the patient be under the care of a physician as a prerequisite for payment of therapy services if the payment cuts go into effect and physician stop taking medicare patients than access to physical therapy services will be impacted as a ripple effect a p t advocates for the passage of the medicare patient access to physical therapist act h r fifteen fifty two as a strategy to improve patient access to physical therapists as physician practices struggle with the payment the incentive to develop additional sources of revenue increases this puts physical therapist small businesses at a competitive disadvantage since patients cannot directly choose their physical therapy provider and are often directed to clinics in which referral sources have financial interest a p t a advocates for stronger self referral provisions in federal law to ensure the integrity of the health care delivery service third physical therapists and small businesses are subject to burdensome administrative and regulatory requirements that add to the cost of providing health care these administrative burdens complicate physical therapist practice direct a physical therapist away from patient care and make it difficult to sustain physical therapist small business over the long term the compound in effect of payment cuts under the medicare physician fee schedule along with limitations on patient access a competitive marketplace and regulatory burdens makes it difficult to sustain physical therapy small businesses congress must move beyond the issue of temporary payment reprieves and look at the health of medicare physician fee schedule for the long term the health care delivery system needs physical therapist small businesses to meet patients rehabilitation needs and closing and the american physical therapy association and their private practice session want to thank the house committee on small business and its leadership for holding this hearing thank you thank you mr de angeles and it's my pleasure to introduce our next  seattle our school focuses on training primary care physicians for the northwest for alaska montana idaho washington and wyoming a c p is the largest medical specialty society is mentioned and about twenty percent of our a c p members are in solo practice and as i mentioned with the statistics nearly half of our members are in practices of five positions or fewer during my year as president a c p i've met with many of our members as i've traveled the country many of them are in businesses which are to breaking point due in large part to the problems with the medicare payment system just not keeping pace with practice expenses in fact i've become extremely concerned about doctors across the country particularly in smaller communities where the departure of a single physician because a doctor moved to town retires or dies and has no replacement creates a major community problem there's simply no elasticities in the system other than for a small town folks to drive farther and of course the whole community suffers when this occurs these practices are small businesses where much of their revenue is tired directly to medicare is flawed remember writes in formulas under the sustainable growth rate formulae application of this flawed system and its schedule put payment reductions over those last six years has created a genuine problem for physicians earlier this year the a c p surveyed its members to measure the impact of pending medicare payment cuts on their practices and on their patien although not designed as a scientific sample almost two thousand internist responded and provided a firsthand account of the effects of these cuts thirty percent of our survey respondents noted that they have already taken steps in their practice to anticipate the schedule medicare payment cuts in july one to two thousand and eight and january first two thousand and nine such as limiting the number of new medicare payments that the patients that they will accept eighty six percent of a c p respondents reported that they would be forced to make changes if congress does not avert the ten percent cuts scheduled for june july most commonly mentioned matter is to reduce the number of medicare paid patients they see a c p members have expressed heartfelt concern for the impact of these changes on their patients a texas internist told us the practice of medicine is a calling and as such my colleagues and i have endured far more unfair revenue cuts than most businesses would endure yet a medical practice is also a small business we are now at the point where further cuts are not survivable just like any small business our revenue has to exceed cost in order to survive despite everything that i have done to cut cost the margin of profit is now thin and the proposed greater than ten percent cuts will put us out of business the only option will be to downsize the practice and stop seeing medicare patients i would hate to do this but it will be the only option i have  congress does not reverse the proposed cuts as an educator i have also encountered hundreds of young people our students who are excited about the challenges and opportunities of becoming a patient's personal physician however when i when it comes to choosing a career path very few see a future in primary care and being this kind of a doctor the numbers are startling in two thousand and six only twenty six percent of third year internal medicine residents plan to provide practice general internal medicine down from fifty four percent only eight years earlier only thirteen percent of first year internal medicine residents plan to go into primary care the percentage of medical school seniors choosing general internal medicine has dropped from twelve percent in one thousand nine hundred nine to four percent in two thousand and four a c p survey ask if medicare payments are an important factor in medical students selection of a specialty sixty three percent responded that issue is extremely or very important that's a resident at case western reserve in cleveland commented when i entered medical school i always plan to become a general internist in primary care seeing the current deteriorating funding environment has cemented my in my mind not to go into primary care has conducted its survey in a number of other ways and a key feature has the excel rated retirement of older physicians with a high percentage expressing an interest in retiring very soon in fact if payment system isn't changed the college is very interested in the patient centered medical home concept which holds great promise for a cheesing better outcomes for patients but centrally lowering and rigid cost and reducing complications  avoiding hospitalization we also believe it will attract new physicians to general medicine and family medicine the key specialties in deficit we see urgent need to address this problem for many reasons and i'm pleased that this committee is interested in this problem and i was addressing it today thank you the opportunity to be here today and i'll simply echo the statements of the other presenters today that there is no question that the s g r is broken and they were in dire straits we're really grateful to have this opportunity to present before you because i example of a small business person i'm a general surgeon i'm in the town of around sixty thousand dollars seven of us in town that general surgery call and important for the members to understand that we all are in our own businesses we have to hire employees we have to buy from other small businesses in our community and so what happens to us affects all of the small businesses and vice versa what effects small businesses our community affects us now it's interesting that the college of surgeons is composed of many different surgical i'm refined in constrain my comments to general surgery which is about forty percent of all of our membership it turns out that of the general shorter's around seventy percent are in private practice so it's a high percentage of those for small business people and of those around forty percent or so derive their income from medicare so medicare is one of our larger payers and therefore what happens to medicare is very very important the average general surgeon has in a practice around forty five people has around fifteen employees and they have a payroll a hundred thirty thousand so it's it's like a regular business and part of our concern is is that we don't know when to pin the pony the next pick at we can't make our budget we can't project our expenses not knowing what was going to happen to the  now the other thing that kind of sets of searches apart from other physicians to some extent is the fact that we're paid on a global payment scale we're paid it ninety days global payment for most of our major surgical procedures and major surgical procedures really have not risen much in the last five to ten years worth about a three percent growth rate but our payment is a lump sum payment for everything we deliver in ninety days now for many different reasons payment being one of them we're running out of general surgeons in the general surgeon as you very well may know is the surgeon this in charge in your hospital your local hospital for emergency surgery in trauma surgery there are only a thousand general surgeons that come out of residency every year and of those general surgeons only around three hundred when you look at the big numbers hers i had a study at just this year in october of zero six there are only twenty one thousand active practicing general surgeons in america now that's a small number and when you put on top of that the drop in the number of surgeons we project is really going to become critical to the local hospitals for trauma care in emerging here and small business people though however the general surgeon has also an effect on the local hospital if as we heard if a surgeon tars and a physician retires oftentimes we can't find replacements to fill in our slot for a general surgeon if they retire or the hospital has roughly eighteen months if that's the only journalist surgeon to replace that surgeon or the hospital will dramatically reduce its services or have to close that has an impact not just on the local physician practice but also the the small business practices that rely upon that hospital we've seen a drop in our physicians to go in the private practice that are in office based practice eighteen percent in the last five years so it's from ninety five to two thousand and five forty seven north carolina counties experienced a decline in the number of general surgeons and for completely lost all journalists or coverage i was intrigued by that so i looked at the data from arkansas and between ninety seven  thousand and four twelve arkansas counties experiences same decline we have twenty one counties that have the general surgeon and of the seven counties that lost general surgeons two of the hospitals closed in five of the hospitals had to decrease their services dramatically so this this has an impact not just on the surface but on the community itself are some proposal in and one of the things we're trying to discuss with others is we we and the american osteopathic social action have a an alternative proposal for the as for the s g r which is broken and that's the service category growth rate and that's a proposal to divide the service we have in the six unique service categories not by a surgical or medical specialties but by the top a practice or service that they are prevented these care and primary care other of they wish management services major procedures which involves what we do minor procedures imaging services and then diagnostic tests etc we feel  that this will allow congress and the administration to better control the management of those individual services is much like operating with a scalpel stev abroad actually now we just have a large x to to perform surgery with because one cut takes care of everyone we propose having a much more refined solution to that so in conclusion i think we can propose that the current s g r fix itself these be fixed immediately we re with everyone here practice of medicine what do you believe are the problems if there is any problem with and the right and what alternate these assumptions do you believe they sho the productivity adjustment that is put in the medical economic and which suggests that if you have an inflation and inflation adjusted increase then physicians and others will compensate for that by doing more procedures and so your account for that by an adjustment we believe that that is not the case and we also believe that if that's going to be a part of it ought to be applied to everyone else  time this time that inflation adjustment that just is only applied to a physician practices in physician payment so we believe that in a comprehensive look at the emmys to see if there's some other things that need to be measured in essence makes a lot of college of surgeons has been working or not out there or not to make on this and forgot calculating medicare updates can you talk to us anything more about how it differs from some of the approaches care on the being no i'll do my best to you know it's a very technical issue and i really would defer to more people than me but basically the concept would be that we would divide the the large spectrum of services provided into discrete categories of services delivered by whatever specialists it is and each one of those congress administration would have the capacity to adjust the amount of money that's put in that bucket to spend in that given year and if the need arises f for the patients or medical home or for more primary care payments congress would have that ability to do that on the other hand if there's an ovary lose actual services and it was the wisdom that those payments should be reduced but allow you a much finer that might be based on on specialty our services as you've just heard from the surgeons are maybe even based on geography i guess our concern at the a m a is that that having had a global s which clearly has not worked has not been able to distinguish between good growth and bad growth as you've heard is really is a meat axe where surgical scalpel is needed we would have some concerns and think that to look at in essence having many s g r as which one might characterize this as we would need careful study to be sure it didn't just compound the problem and we believe that the critical thing is to move away from the system which and we also need to be looking at accountability and quality and performance and the kinds of things that you did here mr can talk about and has been working with c m s on thank changes and in particular the relationship between hospitals doctors and pharmaceuticals have changed enormously and it would really be much more important to study the global cost of health and then the partitioning of the funds to economic environment when you see the more difficult and costly to get a loan in your opinion will these costs affect the ability of practices to purchase needed health information technology and medical equipment absolutely and i believe it already has i mean we really haven't had a raise in the last seven years so we've been magine working for seven years with never a pay increase but only your expenses going up and so there's absolutely no reason to believe that they that they haven't already had an effect there are many people who are still struggling to try to find creative ways to make purchases of this kind of equipment so it is happening but just not at the rate that you know the nation would like to move to  emphasize that i am and solo practice of challenge around medicine and i can tell you that based on seventy five percent of my practice is medicare so it is actually a challenge for me to replace existing equipment in the we believe that there need to be incentives you know one of the realities is at this point only eleven percent of the benefits of going to help the information technology actually accrue to the provider the other seventy nine percent go to peers and asking congress to consider looking at the end of kickback laws and trust laws that might be able to be tweaked so that physicians can enter into relationships with with mentioned that twenty four percent of your patients are advantage is that correct twenty four percent of our medicare patients are now medicare advantage ok and do you is the treatment that they receive any different from a person  under regular medicare versus a person that might have some sort of private health care versus is there anybody the still pay sort out their own pocket in your practice or are they all have one of those coverages we do have an amish community around us they pay cash and so yes we do have self pay patients and if you are uninsured so the question would be how how is the care you know you know our mind when they get back to see the doctor there's no change there's no directive to to not see a patient in a certain manner or to care for them in any way differently and as a business person do you have any preference amongst the four different categories that we talked about well  i certainly would like to see an insured patient who i know the rules rather than an insured patients i don't know the rules because this patient may have to be directed to a particular hospital the patient may have to have certain services done before they will be approved for surgery so there could be a variety of reasons why i need to have information prior to but currently the way our practice operates the physician would probably know what kind of insurance the person has so that he might for instance well i see that you have to be done at this particular hospital so you know that's that's i go there on wednesdays that kind of thing but other than that we do not we do not do anything differently we have a few instances to where we have to get prior permission from a patient to do services on medicare medicare advantage patients they have to sign a release very rare but occasional and so we have to be cognizant of that thank you dr wilson i think you had mentioned the eleventh hour intervention and going back to the question that i had asked in the previous panel about how disruptive is it how inconvenient is it that congress doesn't act so we don't tell you ahead of time what the rules are going to be when you're going to get the money how much it's going to be how how disruptive is that when you're practicing medicine well  hope something will happen in time that debate changed clearly small businesses cannot plan for the future unless they have some way of estimating what their income is going to be so if your estimate of what the income is going to be  what's certain is that there could be a ten percent cut you can't plan for that future you're only planning for survival so to thank that wind can add new technology in the way of health of motion technology or other medical technology which same challenges that other small businesses do even outside the medical profession is that accurate you would also in the other challenges that you face they would include things like energy that other businesses would face as well is that correct i think i think all the practices have to bear the burden in the brunt of any inflationary increases from their share pliers and that this goes without saying another thing that we've not talked about today but it's certainly a very true phenomenon is the increase in health insurance premiums that the small businesses have to shoulder it's where health care providers but we have no control over the cost of health insurance which is going up and it's hard to get so that's another inflationary cost and that if we can buy those who are not well we don't know we don't know what what the next six months is going to hold so those sort of things are real life examples of how is becoming more and more difficult to practice medicine we it's hard to practice medicine surgery but now we have to worry about the business aspect of it and then just as more to the problem thank you and then for all the doctors does it continue to be a problem or something that you have in your mind the potential of being  having a lawsuit filed against the challenges one face and sometimes frivolous suits but nonetheless you still have to defend them is that still an issue that resonates that you think that should be dealt with state level or at the the rises have tapered in the last year but they have stopped rising as fast as they are unconscious of all levels so that if you're on a miami florida and paying two hundred forty seven thousand dollars everyone was reduced somewhat over the last few years and capital gains taxes were reduced and those types of things those those tax cuts were not permanent unfortunately because we didn't have votes in the senate to make them permanent so that they're going to go back up in a couple years unless congress does something to make those tax cuts permanent is that a is that a concern to the members of the panel or do you want have your taxes go up  is going to increase our expenses for for the small physical therapist practice has the potential to be extremely detrimental because we're literally right now working out in a survival mode  an example dr maybury just brought up that his health insurance goes up every year i just got my renewal notice for our small company and this year it goes up june they're proposing forty nine point five percent increase in my premiums  i don't know how that's justified but i know it's something that we cannot afford and so we are in a situation where we really live paycheck to paycheck in small business and so anything that's going to increase expenses anywhere we're not going to be able to make it quite frankly thank you dr dale comment because i think doctors are interested both in the in the cost and then the revenue side of government but i would say that  doctors are good citizens they pay their taxes and they pay them as happily as anyone else and i think that in terms of paying for medicare that we've been happy participants on both sides in talking to physicians they appreciate the value of medicare to the public but also to themselves thank you very much i thank the entire panel on your back my time mr gonzales thank you very much madam chair and again thank you for your testimony today and i also join my colleagues  expressing regrets that it's been such a delay but it's just been a tough week first and foremost i think everyone agrees that the s g r is in fact broken for whatever reason maybe it is not such a bad vehicle our manner in which to arrive but obviously the elements the factors and everything else maybe we're not getting the right information one two we're also working within fiscal constraints we're going to make it work whether we have the right information or not and that's the scary thought going to let the ten percent cut go into effect but is it going to be a six month six look this is an election year you know dump it on the new administration and see what happens and every we've been doing this since two thousand  and to be honest with you in the final analysis i think the health care providers are just happy that the cuts were in fact rated but we still don't fix the underlying problem which is never good and we've gone over the consequences of that but you heard mr cohen say something to the effect that there is a collaboration with the medical community on going and that was his testimony so my question all the way down the line because each of you represent an organization and association is your voice being heard what form does it take i'm really starting to wonder when i talk to my different whether it's the texas medical association my local medical society the different specialist  associations i don't get the message that there's a huge collaborative going on so you know i'll start with the first witnesses reimers i guess i will first of all say from an administrative standpoint getting the job done paying when we send in the claim you know we submit a bill they pay us traditional medicare is doing a very good job as opposed to a number of years ago where there were all kinds of administrative struggles and timeliness of payment was a severe issue i do not feel that c m s has done enough to oversee advantage payers behavior after the claim is submitted they're working pretty hard to try to straighten out beneficiary issues but i do not feel that they've done much to support physicians and to that  end not to my knowledge and i've tried to ask a lot of people there is no apparent method and i'm paid claim their claim that's not paid correctly if the advantage payer sends you a ten dollar check for something that should be a hundred there is no mandated way that a deems provider can make that advantage pay or review that claim and resubmit and possibly pay correctly and sometimes well and sometimes well thank you i would say c m s is doing a great  in this and i will i will defer some to our national organization ask them to follow up with you since i'm not on the inside day to day with the association however from the discussions that i have had my understanding is there is dialogue there and fairly consistent dialogue so i see that as a positive however i cannot state specifically that how well the voices being heard by be happy to have somebody follow up with you on that dr wilson along with all the special side is since two thousand the physician consulting for performance improvement which has developed now in excess of two hundred thirteen performance measures that is physicians deciding how physicians autum measure their consortium performance matches so we believe that is a positive where using real science the physicians have adopted so we have been very pleased we do believe that our voice is being heard the other side of the coin does have to do with th today and that's the s g r and we have felt for a long time that the administration had some options and we suggested some along the way that they might have been more helpful in addressing the problem of the cuts there may the organization of medical services which as i mentioned may save costs provide more patient satisfaction and also make the field of being a generalist more attractive we'd like to urge congress to enact legislation  testing of this idea there's a limited demonstration project that's been funded but it hasn't gotten started and i guess our basic feeling it's been awfully slow in getting started the other two things i briefly mention is we've testified before before congress about relative affected most of treatments and tests and we think the government c m s should be investing more in looking at the relative value of things that we pay for and second we have an initiat also to look at the cost benefit of things we pay for and we need to be bold more imaginative and more critical and put more effort into really analyzing what we're doing thank you dr matrix thank you i think i would echo what was said the three things i'd like to talk about that the college of surgeons been very engaged with and in with both administration as well as the other societies has been the search for quality you know if you're going to give us a dollar to deliver  then we owe it to you to show that we're delivering the care and that's what all of us have said the college has a national surgical quality improvement project which actually measures surgical outcomes in hospitals and that's a very important we think risk a justified  program and we're trying to spread that throughout the hospitals the others the surgical quality elements that comes up with new measures to measure the actual quality of surgery this being delivered are you getting a good operation complications r what are you doing to prevent problems those things are very important i think the third thing in this probably the most important as far as the dollar bank is we would like to see the agency asked the question of the what i would call the tough questions does an eighty year old man who has pancreatitis pancreatic cancer do they really need aggressive chemotherapy when their life expectancy is short anyway if they do need that what sort of aggressive thirty do they need the outcomes affect this is very critical that's where we're going to tell the difference between money that's wasted and money this will invest in a patient and those tough issues those tough questions that's what we need to be asking all how we're going to spend our money and can we spend it well and real quick  just kind of a final thought the chairwoman will have these early breakfast like eight in the morning and we have these roundtable discussions and we've had i'm with of course health care providers and it's been very interesting i think one of the most interesting aspects is that we've had individuals that are representative of either your associations organizations at the table and they've been able to identify specific individuals within the c m s who are very responsive and i would say that you all need to start looking at that and saying ok who does listen to us but this is the next administration is probably going to be looking for some guidance and from the different professional organizations as to who gets the promotion who remains and so on that we're going to have to have someone that's incredibly sensitive and is to be listening to you you have to be very organized in your approach because the bureaucracy has a way of just either waiting you out or where in you out and we have to fight that but i can assure you that we are very very vested in the small business aspect and you most of the practitioners are small business men and women thank you very much information technology quality improvement outcomes measurement in medicare what do you believe the challenges will be for small practices attempting to integrate this in the shit they have into their practice i think the first challenge is any technological requirements that would require an investment up front we would like to right now be moving towards electronic medical records and be able to capture some data that way but quite honestly we just can't do that the expense is too high and with the uncertainty of where we're going we're hesitant to take on any more debt load and move forward  in that area so i see that that would be probably the biggest limitation for a practice like ours would be the upfront expense of what we would have to do there i think that there might be some ways to capture certain data through billing mechanisms and things of that nature that we already do and that's where i think getting everybody to the table trying to figure out how we do that would be critic and sorting through that thank you i would  initially say first of all the upfront cost but once you get past that you do have with so many businesses involved whether it be hospitals doctors physical therapists audiologist you know the list goes on and on you're going to have  great need to figure out which pieces are discrete data your benchmarking and what makes good quality especially with an elderly population who by definition are going to decline so that i would say that there would be some need to the process to measure is going to be a lengthy one and maybe just taking certain measures as an p q are i is a good start but i see that the definition of each discrete data field may have all a lengthy two page definition to it so i think that defining each element you're trying to measure would be an issue thank you and anyone else will lead to com well again i want to thank all of you you know this committee and especially in the sense that i participate every week with the leadership the democratic leadership voice the concerns of the small business community when it comes to physicians formula and we hopefully get a resolution soon