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21–365 2016

THE IMPLEMENTATION OF THE MEDICARE 

ACCESS & CHIP REAUTHORIZATION ACT 

OF 2015 (MACRA) 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

MAY 11, 2016 

Serial No. 114–HL07 

Printed for the use of the Committee on Ways and Means 

( 


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COMMITTEE ON WAYS AND MEANS 

KEVIN BRADY, Texas, Chairman 

SAM JOHNSON, Texas 

DEVIN NUNES, California 

PATRICK J. TIBERI, Ohio 

DAVID G. REICHERT, Washington 

CHARLES W. BOUSTANY, JR., Louisiana 

PETER J. ROSKAM, Illinois 

TOM PRICE, Georgia 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

LYNN JENKINS, Kansas 

ERIK PAULSEN, Minnesota 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

TOM REED, New York 

TODD YOUNG, Indiana 

MIKE KELLY, Pennsylvania 

JIM RENACCI, Ohio 

PAT MEEHAN, Pennsylvania 

KRISTI NOEM, South Dakota 

GEORGE HOLDING, North Carolina 

JASON SMITH, Missouri 

ROBERT J. DOLD, Illinois 

TOM RICE, South Carolina 

SANDER M. LEVIN, Michigan 

CHARLES B. RANGEL, New York 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL, JR., New Jersey 

JOSEPH CROWLEY, New York 

DANNY DAVIS, Illinois 

LINDA SA ́ NCHEZ, California 

DAVID STEWART, Staff Director 

NICK GWYN, Minority Chief of Staff 

SUBCOMMITTEE ON HEALTH 

PATRICK J. TIBERI, Ohio, Chairman 

SAM JOHNSON, Texas 

DEVIN NUNES, California 

PETER J. ROSKAM, Illinois 

TOM PRICE, Georgia 

VERN BUCHANAN, Florida 

ADRIAN SMITH, Nebraska 

LYNN JENKINS, Kansas 

KENNY MARCHANT, Texas 

DIANE BLACK, Tennessee 

ERIK PAULSEN, Minnesota 

JIM MCDERMOTT, Washington 

MIKE THOMPSON, California 

RON KIND, Wisconsin 

EARL BLUMENAUER, Oregon 

BILL PASCRELL, JR., New Jersey 

DANNY DAVIS, Illinois 

JOHN LEWIS, Georgia 


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C O N T E N T S 

Page 

Advisory of May 11, 2016 announcing the hearing .............................................. 2 

WITNESS 

Andrew Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services ......................................................................................................................... 5

QUESTIONS FOR THE RECORD 

Questions from Representative George Holding of North Carolina to Andrew 

Slavitt .................................................................................................................... 43 

Questions from Representative Tom Price of Georgia to Andrew Slavitt ........... 44 

SUBMISSIONS FOR THE RECORD 

The Impact of IRS Activities on At Risk Citizens ................................................. 58 

American Society of Clinical Oncology (ASCO) ..................................................... 60 

Institute for Child Success (i(cs)) ........................................................................... 68 


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THE IMPLEMENTATION OF THE MEDICARE 

ACCESS & CHIP REAUTHORIZATION ACT 

OF 2015 (MACRA) 

WEDNESDAY, MAY 11, 2016 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON WAYS AND MEANS, SUBCOMMITTEE ON HEALTH, Washington, DC. 

The Subcommittee met, pursuant to call, at 2:05 p.m., in Room 

1100, Longworth House Office Building, Hon. Pat Tiberi [Chairman 

of the Subcommittee] presiding. 

[The advisory announcing the hearing follows:] 


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ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON HEALTH 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–3943 

Wednesday, May 4, 2016 

No. HL–07 

Chairman Tiberi Announces Health Subcommittee 

Hearing on the Implementation of the Medicare 

Access & CHIP Reauthorization Act 

of 2015 (MACRA) 

House Ways and Means Health Subcommittee Chairman Pat Tiberi (R–OH) today 

announced that the Subcommittee will hold a hearing entitled ‘‘The Implementation 

of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).’’ The hearing will take place on Wednesday, May 11, 2016, in Room 1100 of the Longworth House Office Building, beginning at 2:00 p.m. 

Oral testimony at this hearing will be from the invited witnesses only. However, 

any individual or organization may submit a written statement for consideration by 

the Committee and for inclusion in the printed record of the hearing. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit written comments for the hearing record must follow the appropriate link on the hearing page 

of the Committee website and complete the informational forms. From the Committee homepage, http://waysandmeans.house.gov, select ‘‘Hearings.’’ Select the hearing for which you would like to make a submission, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, submit all requested information. ATTACH your submission as a 

Word document, in compliance with the formatting requirements listed below, by 

the close of business on Wednesday, May 25, 2016. For questions, or if you encounter technical problems, please call (202) 225–3943 or (202) 225–3625. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the Committee by a witness, any materials submitted for the printed record, and any written comments in response to a request for 

written comments must conform to the guidelines listed below. Any submission not in compliance with these guidelines will not be printed, but will be maintained in the Committee files 

for review and use by the Committee. 

1. All submissions and supplementary materials must be submitted in a single document via 

email, provided in Word format and must not exceed a total of 10 pages. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official 

hearing record. 

2. All submissions must include a list of all clients, persons and/or organizations on whose 

behalf the witness appears. The name, company, address, telephone, and fax numbers of each 

witness must be included in the body of the email. Please exclude any personal identifiable information in the attached submission. 

3. Failure to follow the formatting requirements may result in the exclusion of a submission. 

All submissions for the record are final. 


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The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TDD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://www.waysandmeans.house.gov

f 

/. 

Chairman TIBERI. The Subcommittee will come to order. Good 

afternoon everybody. So we are going to begin. I am really excited 

to finally be having this hearing. 

When I came to Congress back in 2001, the sustainable growth 

rate, or SGR as we all know it by, a provision in the Balanced 

Budget Act of 1997, was in the process of being implemented, and 

under this payment formula, any yearly increase in per beneficiary 

spending that exceeded growth in GDP could result in a negative 

adjustment for physician payment in Medicare. 

Dr. Price was really well aware of that. Clearly, this policy or the 

math didn’t work, and for the next 15 years we had almost yearly 

struggles over what was aptly named the ‘‘doc fix.’’ Seventeen of 

these doc fixes later takes us to last March when we came together 

in a bipartisan fashion with stakeholder input and CMS technical 

support to pass the Medicare Access and CHIP Reauthorization Act 

of 2015, or now commonly known as MACRA. With nearly 400 

votes in the House, this legislation finally put an end to the sustainable growth rate so that doctors could focus on patient care and 

not worry about unpredictable payments. 

We have called this hearing today to take our first look at the 

regulations released by CMS on April 27. We will look closely at 

how these regulations match up with congressional intent and 

what our Members and CMS are hearing from stakeholders as they 

digest 950 plus pages of regulations. 

That is the scope of the hearing, to discuss the implementation 

of this truly historic legislative feat, and there is a lot in the proposed rule to discuss. So I know that on a bipartisan basis we are 

going to dive in, in a deep way. 

Furthermore, I would like to take a moment to encourage Members of both sides of the aisle, as you hear from stakeholders and 

constituents regarding concerns or thoughts about the proposed 

rule, please bring them to the attention of the bipartisan Committee staff so that we can continue to do robust oversight and 

keep CMS up to date on the information as they formulate their 

final regulation. 

The passage of MACRA last year confirmed our commitment on 

both sides of the aisle to keep Medicare strong for America’s seniors. This is particularly important to me as well as many of you, 

especially after we just celebrated Mother’s Day as both my parents, back in my district in Ohio, depend on this important Medicare program. 

By replacing the way that physicians are paid and consolidating 

the separate quality measurement systems, we have taken a great 

step toward the ultimate goal of fully-integrated value-based care 


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through the incentivization of high-quality care. Now our role, as 

Congress, is to provide oversight, and in conjunction with CMS, to 

provide education on how this new law will work for the various 

types of clinicians and provider groups. 

We need to answer how this rule will affect individual and small 

group providers versus larger groups. How will this rule affect specialty groups versus primary care physicians? How will the timing 

work for implementation under some potentially tight timelines? 

These are questions that I hope to get clarity on today in going forward through the implementation process. 

As we move forward with implementation, I want to make sure 

that we, as Congress, recognize some very important facts regarding the law that we passed. The merit based incentive payment 

system, or MIPS is, and was, created as a budget neutral program. 

High-quality value-based care will take effort. 

As I said before, such efforts must be recognized within the environmental and timing factors based in reality. And additionally, 

the thresholds for providers to qualify as advanced alternative payment models are high and are set in statute. Working on a bipartisan basis with stakeholders from every corner of our country in 

an open dialogue, with cooperation from CMS, will allow us to follow MACRA into the next generation of value-based health care. 

Now we can go to work. With that, I would like to yield to the 

distinguished Ranking Member, Dr. McDermott, for the purposes of 

an opening statement. 

Mr. MCDERMOTT. Thank you, Mr. Tiberi. 

When Medicare was put in place some 50 years ago, a critical decision was made by the medical association in order to have them 

join in the effort, and they demanded that they be paid their usual 

and customary fees, and we, on this Committee, have been, since 

that time, trying to get back the keys to the Treasury. This is another effort here. 

Now, the proposal by MACRA, or the MACRA rule from CMS is 

really as a result of our efforts, as Mr. Tiberi says, of 15 years of 

realizing what we put in place didn’t work. It took us 15 years to 

figure out that we have to try to do something different. 

Now, I hope this is the beginning of a constructive bipartisan 

conversation about how to advance our shared goal of controlling 

costs and improving the delivery of health care in the country. 

Passing MACRA was a tremendous bipartisan accomplishment in 

that it put an end to a cycle of dysfunction. We had the same thing 

happen every year. We are going to have a 20 percent cut in doctor’s pay, so there would be a big rush around here and we would 

put a patch on it. And then we go on for another year, and next 

year it will be a 24 percent cut in doctors pay, and we put a patch 

on it. We did that again and again. 

For years we lurched from crisis to crisis. And to avoid what 

were draconian cuts in the physician’s payment, we ended up by 

spending more on those temporary delays than it would have cost 

to do away with the SGR in the beginning. 

But last year, we put an end to this cycle once and for all by 

passing MACRA. I was trying to step forward, as MACRA is much 

more than just simple repeal of SGR. It is also the most significant 

payment reform the Medicare program has seen in years. 


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Thanks to MACRA, we have set Medicare on a more sustainable 

course that will allow us to pay for volume in health care—or excuse me, value in health care, rather than volume. The law modernizes and streamlines physician’s payment. Instead of a patchwork of incentives and alternative payment models, it consolidates 

various programs into a single framework, it will allow flexibility 

for providers, it will allow them to practice medicine independently 

while still holding them accountable for providing high-value care. 

These are complicated issues, and we are still in the early stages 

of digesting this proposed rule. It is big enough. It will take awhile. 

But what we have seen so far has been encouraging. The Administration has worked diligently to implement the law as intended 

through a process that is responsive to the needs of the public. 

The proposed rule is consistent with the goals of MACRA. It provides flexibility to participate either in the merit-based incentive 

payment program, or alternative payment methods that reward 

high-value care. This will make sure providers do not end up in a 

one-size-fits-all approach that doesn’t make sense to them or their 

patients. It is the product of an open and transparent process that 

began months ago through active outreach, consideration of extensive comments, and public workshops with stakeholders. The agency has heard from a range of viewpoints, and the proposal reflects 

careful consideration of that input. 

I am confident the Administration will continue to be responsive 

to the needs of the public as it develops the final rule. This is an 

ongoing conversation. We still have much more to learn as we work 

toward our shared goal of making the implementation of this landmark law a success. 

Getting the people covered by health care is one thing. Controlling the cost is another thing, and this is about controlling the cost, 

and I don’t believe we have our arms around it yet, but we are in 

the process, and that is why we welcome you here, Mr. Slavitt, to 

make this presentation. Thank you. 

Chairman TIBERI. Thank you, Dr. McDermott. Without objection, other Members’ opening statements will be made part of the 

record. 

Today’s witness panel includes just one expert, and we are lucky 

to have him, Andy Slavitt, Acting Administrator at the Centers for 

Medicare & Medicaid Services, who, along with his colleagues, have 

the daunting task of implementing this very important law. 

On a personal note, thank you for having me at your office yesterday. It was nice to get to know you and members of your team, 

and I look forward to continuing dialogue in the future. 

With that, Mr. Slavitt, please proceed with your testimony, and 

we appreciate you being here today. 

STATEMENT OF ANDREW SLAVITT, ACTING ADMINISTRATOR, 

CENTERS FOR MEDICARE & MEDICAID SERVICES (WASHINGTON, D.C.) 

Mr. SLAVITT. Thank you. Thank you, Chairman Tiberi, Ranking 

Member McDermott, Members of the Subcommittee, and thank you 

for the opportunity to discuss CMS’ work to implement the Medicare Access and CHIP Reauthorization Act of 2015. 


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We greatly appreciate your leadership in passing this important 

law, which gives us the unique opportunity to move away from the 

annual uncertainty created by the sustainable growth rate to a new 

system that promotes quality, coordinated care for patients, and 

sets the Medicare program on a more sustainable path. Our number one priority is patient care. And thanks to Congress, MACRA 

streamlined the patchwork of programs that currently measure 

value and quality, into a single framework called the ‘‘Quality Payment Program’’ where every physician and clinician has the opportunity to be paid more for providing better care for their patients. 

In recognition of the diversity of physician practices, Congress 

created two paths. The first allows physicians and other clinicians 

a new flexibility to participate in a single simplified program with 

lower reporting burden and new flexibility in delivering quality 

care. 

The second path recognizes those physicians and clinicians who 

choose to take a further step toward care coordination by participating in more advanced models like medical homes. Our goal is 

to make both of these paths flexible, transparent, and simple so 

physicians can focus on patient care, not reporting or scorekeeping. 

We have approached this implementation with the belief that 

physicians know best how to provide high-quality care to our beneficiaries, and we have taken an unprecedented effort to draft a proposal that is based directly on input from those on the frontline of 

care delivery. We have reached out and listened to over 6,000 

stakeholders, including State medical societies, physician groups, 

and patient groups to understand how the changes we are proposing may positively impact care and how to avoid unintended 

consequences. 

The feedback we received shaped our proposal in important 

ways, and the dialogue is continuing. Based on what we learned, 

our approach to implementation has been guided by three principles. 

First, patients are and must remain the key focus. Financial incentives should work in the background to support physician and 

clinician efforts to provide the highest quality care and create incentives to more coordinated care. 

Second, we are focused on adopting approaches that can be driven at the practice level, not one-size-fits-all from Washington. It 

will be important to allow physicians to define the measures of care 

most fitting with their patients. 

Third, we must aim for simplicity in everything we do. Physician 

practices are already busy, and we are seeking every opportunity 

possible to minimize distractions from patient care by reducing, 

automating, and streamlining existing programs. Among the many 

places that we seek feedback during the comment period, this is 

among the most important as the burdens on small and rural practices, in particular, have increased over the last several years. 

One of the important opportunities will be for physicians to define and propose new payment models so that we can create an 

array of customized approaches that reflects the diversity of care 

across the country, and particularly as it relates to the various specialties that provide care. 


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Congress had the foresight to create a formal voice for physicians 

through the Physician-Focused Payment Model Technical Advisory 

Committee. I had the opportunity to meet with them last week and 

can tell you that they are very eager to move forward with their 

important work, and we are eager to work with them. 

With all the work that went into this proposal, it is critical that 

we receive direct feedback from physicians and other stakeholders 

and are undertaking significant outreach efforts. Our proposed rule 

is the first step in the process, and we look forward to receiving 

and reviewing comments to refine and improve our approach. 

In the month of May alone, we have 35 scheduled events and listening sessions to hear from a wide range of stakeholders, and this 

outreach will remain an important part of our work. I personally 

have been meeting regularly with physician groups, including 

smaller and rural practices, and have spoken to thousands of physicians in different parts of the country about their work, the opportunities and challenges they face, and what this proposal means 

for them and their patients. 

Throughout this, I have appreciated the open dialogue with this 

Subcommittee and the larger Committee, and it is clear to me that 

we share the goals of creating a more sustainable system with 

smarter spending that keeps people healthier. 

We are striving to do just that in the implementation of MACRA, 

but it will take work and broad participation to get it right. I look 

forward to hearing your further thoughts on this implementation 

and to answering your questions. Thank you. 

[The prepared statement of Mr. Slavitt follows:] 


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Chairman TIBERI. Thank you, Mr. Slavitt. As you know, in my 

district, I represent urban, suburban, rural, and most of the concerns I have heard with respect to MACRA and the future implementation of MACRA is from small and rural providers’ practices. 

So the proposed regulation assigns three levels of risk required 

for entities participating in the APMs, the alternative payment 

models. And what I have not seen are any tiers or variabilities in 

the amount of risk for participation between an individual and 

small group clinician and large group clinicians. 

Have you heard concern from providers about this? 

Mr. SLAVITT. Thank you for the question. I think the topic of 

particularly small practices and making sure that they can succeed 

is of utmost importance, and our data shows that physicians that 

are in small and solo practices, so long as they report, can do just 

as well as physicians in larger size practices. 

So we know, however, that there is a burden on us to make the 

reporting as easy as possible. We also know there are a number of 

other steps that we need to be looking for, and looking out for, to 

make sure we make things as easy as possible and accommodate 

smaller practices. 

So importantly, we are looking for additional steps and ideas as 

people review the rule, but I will say that we are focusing on technical assistance, providing access through medical home models, 

opportunities to report in groups, and using a reporting process 

that automatically feeds data, reduces the number of measures, 

and overall lowers the burden for small practices. 

Chairman TIBERI. So in a followup to that, in reading through 

the regulation, there are several areas that seem to allow a little 

more flexibility for individual and small group practices. Can you 

outline some of the major differences in reporting for individual 

and small group practices versus the larger groups that could 

maybe ease the burden or send the message to the smaller groups 

that there is sensitivity there? 

Mr. SLAVITT. Sure. Absolutely. First of all, at the request of the 

physician—we met with a lot of physicians and physician groups 

and small practices in this process. One of their key requests was 

that if they are already participating in something like a clinical 

registry or some other way of getting data across that may be an 

accountable care organization or clinical registry, that we use that 

information rather than requiring them to send it again, and our 

proposal does indeed allow multiple ways for us to get information. 

Second, we are required to measure the cost of care, and we are 

going to be able to do that automatically by getting a claims fee, 

so it is going to require physicians to send us no information whatsoever. And then there are a number of areas where they will simply need to attest to whether they are doing a certain activity, 

which we think will reduce the burden, and we are looking more 

broadly at the overall experience for physicians. Small physicians 

can report in groups in many categories where they hadn’t been 

able to before, and then finally, I would say, there are a large number of physicians who won’t have to report at all because they will 

be underneath their minimum threshold. Congress put forward 

that if physicians don’t see enough Medicare patients or meet the 


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minimum threshold through Medicare, they don’t have to report at 

all. 

So all of those things, I think, are there. And again, we also look 

for additional steps, if there are some, that we can take. 

Chairman TIBERI. Just a final thought, and I don’t mean to put 

you on the spot on this, but do you think there is any more that 

we can do, those of us on this side of the dais, and you and your 

team at CMS, to ensure that, as we lay the foundation for MACRA 

going forward and there is buy-in, complete buy-in from the physician community, that the system is not built with an inherent fairness or fairness issues—again, going back to the rural provider or 

the two-person provider group that has a bunch of angst right 

now—— 

Mr. SLAVITT. Right. 

Chairman TIBERI [continuing]. As this has begun to unfold. Is 

there anymore that we can do, or you can do, or we can work together on? 

Mr. SLAVITT. Yeah. I think it has to be a vital continuous effort. 

Last week I met with small physician practices from southern Arkansas, southern Oregon, and New Jersey. We had a meeting on 

Friday with Rural Health Association at their annual meeting. We 

went out to Kansas City last week to meet with the Family Practice Association, and we do hear a lot from small physicians who 

are concerned, and I think they are particularly concerned if people 

in Washington are making centralized decisions that are going to 

impact their quality of care. 

And what they tell us over and over again, and we need to keep 

talking to them and getting more feedback, is give us the freedom 

to take care of these patients. We know how to do it, let us define 

quality, let us select the measures that are right for our practice, 

give us more flexibility, and don’t make us focus on reporting. Let 

us focus on patient care. And it is really critical, I think, as we 

work together and as you hear input, that you get this to us and 

that we hold ourselves very much to that standard that physicians 

across the country are holding us to. 

Chairman TIBERI. Thank you, sir. With that, I recognize Dr. 

McDermott for 5 minutes. 

Mr. MCDERMOTT. Thank you. One of the issues that the questions Mr. Tiberi is raising about small practices sort of leads me 

to the question of consolidation and driving doctors together in 

larger and larger groups. The question then comes to my mind— 

I practiced both as an individual, and in the military, and in a 

group practice, so I have been in all sorts of forums. One of the 

things that strikes me that is going to be difficult to deal with here 

is the whole question of what is the best care. 

If you have a large organization and they have an MRI and they 

don’t want to use it, or they want to use it, they can crank a lot 

of people through an MRI for everything, or they can say don’t use 

an MRI, and there will be patients out there who do not benefit 

from what they could find. I can give you an example of a young 

woman, 34 years old who had pain in her back, and was told there 

was—you know, you are riding a bicycle, and there is a lot of reasons why, you know, you are young, and blah, blah, blah. 


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At 35, they did an MRI and found a tumor in her spine. Now, 

if they had done that, they would have found it 5 years earlier, but 

the organization was encouraging people not to use. So how are we 

going to make our judgment about whether we have quality of care, 

if the major factor is going to be money? I mean, what is built into 

this to actually look at the quality of care? 

Mr. SLAVITT. Yeah. So I think at the heart of the question, the 

most important thing above all else is making sure patients get 

high-quality care, and we do believe that if patients are getting 

high-quality care, that is going to lead to better cost control because if someone gets the right surgery, they won’t need to have 

a second surgery. 

Likewise, quality is also defined as making sure the care is coordinated, so if somebody needs to have a followup visit or has a 

prescription or something with an instruction, that they understand what that is, it is explained to them and that the system 

works and supports them. So our job here is to enforce that, number one. 

Number two, I think our job isn’t to define quality here ourselves 

as much as it is to take the best standards of care that the specialists and the physicians around the country have defined as quality 

and make sure that we keep up with that and that we keep those 

measures as the things that physicians decide, as a group, that 

they should be measured on, and those are the things—and then 

third, as I said earlier, that at the practice—things actually differ 

at the practice level. 

And we believe the practice is, by and large, are the people that 

know best for what is right with their patients, and that the dialogue between the patient and the physician—so nothing we are 

doing should be seen to be interfering with that in any way. And 

in fact, we ought to be reinforcing those things, and I think 

MACRA gives us the opportunity to say if you are delivering a better quality of care outcome for your patient, you ought to be rewarded for that. 

Mr. MCDERMOTT. You are suggesting the whole question of evidence-based medicine, that is, I mean, I have been to the doctor recently, and they send out, from the University of Washington, a 

sheet to me, and it says did you have good care. Well, was he polite, was he nicely dressed, and blah, blah, blah, down at the bottom, were you satisfied with your care? 

Now, for some people, if they don’t get a prescription or they 

don’t get an X-ray or they don’t get a blood test or they don’t get 

something, they haven’t had—the doctor hasn’t done anything. 

Mr. SLAVITT. Right. 

Mr. MCDERMOTT. So how do you measure then the patient who 

says, well, I wasn’t satisfied because I went away and I still ain’t 

got—my sinuses are a mess and he didn’t give me antibiotics. How 

do you deal with that issue in the quality of care? 

Mr. SLAVITT. Sure. I think one of the nicest things is—I will 

give you an example. I was sitting down with some physicians that 

are practicing medicine in southern rural Arkansas, I referred to 

them recently. They are in one of these models, a medical home 

model, where they have a per member, per month payment they 

get in order to coordinate the care, and they have hired care coordiVerDate Sep 11 2014 14:14 Oct 20, 2016 Jkt 021365 PO 00000 Frm 00026 Fmt 6633 Sfmt 6602 I:\WAYS\WAYSPS\21365\21365.XXX 21365

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nators, and what they told me was, the physician I was talking to 

told me, he said, now I actually can get paid to practice medicine 

the way that I am supposed to practice medicine instead of practicing medicine the right way and getting paid on something completely different. 

So I think the more we evolve our healthcare system to a way 

that reinforces what physicians know are the right things to do in 

delivering quality of care to patients, the better off we are going 

to be, as opposed to a system where if you don’t make a cut in 

someone’s skin or give them a prescription or something that they 

leave the office with, that is not success. 

Mr. MCDERMOTT. I have a medical home at the University of 

Washington. Thank you. 

Chairman TIBERI. Thank you, Dr. McDermott. That was really 

good. We agree on something. 

Mr. Slavitt, thank you so much. You know, I have 12 different 

questions I could ask you on 12 different topics, and my mom has 

one that she shared with me last night she wanted me to ask you. 

But it doesn’t have to do with MACRA, so that is for another day, 

and I would like to remind all Members to try to keep the topic 

to this important law that we passed. 

With that, Mr. Johnson is recognized for 5 minutes. 

Mr. JOHNSON. Thank you, Mr. Chairman. 

Mr. Slavitt, welcome. You have said that CMS is working to regain the hearts and minds of physicians through implementation of 

MACRA, and that is great because many physicians in solo and 

small practices have really struggled to stay afloat in recent years. 

And while there are a lot of good things in the proposed rule, I 

have one issue I would like to raise with you. I am concerned by 

the estimates in table 64 where CMS projects the greatest negative 

impact on payments to practices with 9 or fewer doctors and the 

least harm to large systems with 100 or more docs. If CMS is trying to win back the hearts and minds of physicians, this proposal 

falls short since it will continue to push physicians out of their solo 

or small practices. 

Can you tell me specifically what CMS is doing to ensure that 

solo practitioners and small groups can succeed under the MIPS 

and participate in alternative payment models by 2019? 

Mr. SLAVITT. Thank you. Thank you, Congressman Johnson, for 

the question, and I really would actually welcome the opportunity 

to address this table, and for anyone who hasn’t seen the table, the 

table is designed to estimate what the impact of these regulations 

could be on practices of various sizes. 

And the first thing I want to make very clear is that the question 

of making sure that small groups and solo practitioners can be successful is of utmost importance, and I would also indicate that despite what that table shows, our data shows that physicians who 

are in small and solo practices can do just as well and actually do 

just as well as physicians that are in practices that are larger than 

that. 

Now, the reason that table looks the way it does is for one very 

simple and important reason. It accounts for the fact that in 2014, 

when the table the data uses, most physicians in small and solo 


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practices did not even report on their quality, and this is important 

for a couple of reasons. 

First of all, I should say that in 2015 and subsequent years, the 

reporting went up, so at best, this table would be very, very conservative, and of course, as I explained to Chairman Tiberi, reporting is going to get far easier going forward. 

But it does point to a couple of things that I think we would be 

wise to pay attention to. One, making sure that it is as easy as possible for physicians to report. One of the reasons why we don’t have 

the hearts and minds of physicians is because there is just too 

much paperwork in health care. 

Mr. JOHNSON. I would agree. 

Mr. SLAVITT. They need to be practicing medicine, not doing paperwork. So there has been a tremendous amount of effort so far, 

and this is just a proposal. So this next period of time for comments is a time when we are hoping people can give us even further ideas and further ways that we can reduce the administrative 

and reporting burden. But to be very clear, there is absolutely 

every opportunity, and in fact, an equal opportunity for small and 

solo practices to be successful. 

Mr. JOHNSON. Well, thank you. Maybe we better indoctrinate 

the nurses, too. Don’t they do most of that? 

I thank you, Mr. Chairman. I yield back my time. 

Chairman TIBERI. Thank you, Mr. Johnson. 

Mr. Kind is recognized for 5 minutes. 

Mr. KIND. Thank you, Mr. Chairman. Thank you, Mr. Slavitt, 

for your testimony here today. Needless to say, I think Congress, 

in passing MACRA, gave you a huge undertaking, and now with 

a 900-page rule, I think it is pretty obvious that we are going to 

need to keep the lines of communication open, and hopefully your 

outreach with the stakeholder groups will continue as it has been, 

with not just physician but patient feedback as well. 

I know many Members of this Committee, myself included, have 

been pushing hard to move to a more integrated coordinated 

healthcare delivery system. I come from a region of the country in 

Wisconsin that established models of care, and has been pushing 

aggressively in this direction for quite some time. And then ultimately, you know, alternative payment methods so we get the 

quality, value-based, outcome-based reimbursements. And again, 

that is kind of the directive that MACRA gave you. 

But also a lot of my providers were early stage first generation 

ACO models. My question is, what more can be done in order to 

provide an on-ramp for advanced APM payments to those early 

stage ACOs, or are they going to have to just leapfrog and go on 

to Gen 2, Gen 3, Gen 4? 

Mr. SLAVITT. So you are raising a very important question, 

which is where physicians have an opportunity—as we mentioned, 

all physicians in every program will have the opportunity to get rewarded for quality care, but where physicians have an opportunity 

to and have had the opportunity over the last several years, to join 

with other physicians in these more coordinated care models, the 

medical home would be one example, we think those are a good 

idea. We think they are a good idea if they are right for the physician, if the physician thinks they make sense for their patients, 


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and of course, it creates an opportunity in its own right to earn 

more. 

What MACRA does is it gives physicians an even additional opportunity, an opportunity to earn 5 percent additional bonus on top 

of what they may already be earning in these advanced models. So 

the question is: What is the requirement to get access to that 5 percent bonus? And the legislation puts forward a number of requirements, and the requirement really, in a nutshell, if I were going 

to simplify it, is that there has to be a higher degree of shared accountability from the physician, and that shared accountability is 

shared accountability for the outcome to the patient and a minimal 

sharing of the costs with the Medicare program itself. 

So in other words, in order to qualify for this 5 percent bonus, 

I think the words that are in the legislation are there has to be 

a more than nominal risk. 

So our job in putting this regulation together is to put the definition around what is that nominal risk. We have tried to do that in 

as consistent a way as possible and as simple a way as possible, 

but really it is one of the areas where we really are inviting feedback. And then all of our models, whatever model we are in, will 

have to qualify based upon that definition. 

And so even if a physician is in a model that doesn’t qualify because there is not as much nominal risk, there is still great opportunities, and there is still opportunities for them to grow into other 

models. 

Mr. KIND. Well, finally, you know, the great cost driver in our 

society, and it is true at the Federal level at the budget, at State 

and local, for families and businesses alike, is rising healthcare 

costs. So with the direction this rule is taking, can we sit here with 

reasonable confidence that this may ultimately lead to some cost 

savings but without jeopardizing the outcome or quality of care 

that our patients are receiving? Or is this going to turn into a Lake 

Wobegon type of situation where everyone is above average, everyone is qualifying for bonus payments, and there is no real cost savings at the end of the day? 

Mr. SLAVITT. Right. Well, I think, first of all, we all are striving 

for a higher quality healthcare system. We all want our money 

spent more wisely, and we don’t want to do it in a way that people 

feel like they are getting—skimping on their care. We have 10,000 

new seniors every day in America, and our jobs are to be able to 

figure out how to take care of them better for less money. And that 

means being able to take care of them in lower cost settings, more 

comfortable settings like their homes rather than in institutions 

like hospitals, and so those types of incentives are vital to this program. 

Within the regulation, there are—the pool balances out, and so 

we are going to have to allocate money and have upward and 

downward adjustments as part of this program in order to be able 

to meet the sustainability test you talked about. That is nothing 

new. There are upward and downward adjustments in programs 

today. What is new is that this will be a simpler more aligned program that is easier to measure and keep track of. 

Mr. KIND. Great. Thank you. Thank you, Mr. Chairman. 

Chairman TIBERI. Mr. Roskam is recognized for 5 minutes. 


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Mr. ROSKAM. Thank you, Mr. Chairman. Mr. Chairman, I have 

an observation, a point, and a nudge. 

My observation is this: There is a level of anxiety that is out 

there in our public life today because people look at Congress and 

they say nothing is happening. And yet here we have this issue 

where both sides of the aisle, the White House, everybody came together, wrestled a very complicated issue to the ground, came up 

with a solution, and it doesn’t involve snarling at one another on 

television, it doesn’t involve, you know, a hyperbole and so forth, 

but there was this very serious effort, and we are on the verge of, 

I think, some good things. 

So just a little shout out, and that is, three cheers for something 

getting done, and I think there is an encouraging element to that. 

My point is that debate matters. I would argue that one of the 

reasons that we were able to have that discussion, when Speaker 

Boehner and leader Pelosi were able to come together, and the two 

of them really drove the discussion, it was because it had been well 

wrestled through in the United States over the past several years 

that we need to do something on Medicare. And both sides have 

different views of the world and so forth, but it had become normalized in that sense that these things had to change. 

So debate does matter, and I think we are better off if our debate 

doesn’t involve snarling at one another, and it is two various 

points, but debate matters because debate is a prelude to action. 

Margaret Thatcher said: First you win the debate, then you win 

the vote. 

Okay. Now here is the nudge, and this is the nudge for you, Mr. 

Slavitt. One of the things that I think you and I have talked about 

offline, and you have alluded to some of this, too, a minute ago, 

there is this tension that is out there, and there is a tension that 

manifests—and let me just tell you a quick story. 

I served in the State legislature, and we had some education 

testing issues that came before us, and you know how this works. 

There is always a new test, there is always a new standard, so I 

called a friend of mine, who is an old friend from high school, who 

is a high school administrator, and I said: Give me the straight 

scoop on these tests. 

And he said: Peter, look, will you just pick a test and stick with 

it and not change it every 4 years? He goes: We are happy to be 

accountable, but stick with the test, stick with the program. And 

that deeply resonated with me. 

So the tension is that I think healthcare providers want a standard, they want something that is predictable, but now, also, the 

tension is they don’t want something that is declarative and dispositive and can never be revisited because that is big and that is 

overwhelming and that is what SGR had—that is what we had to 

do for, you know, the doc fix for all those years. That was declarative. It was an overcharacterization, and it failed. And the proof 

that it failed was you had to kick—we all had to kick the can down 

the road. 

So my nudge is this: As you are going through and you are figuring this out—and I really appreciate the disposition and the attitude and the open rule time that you have now and the comments 

that you are taking in, if you could really be mindful of those 


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smaller practices that Mr. Johnson mentioned, the point that Mr. 

McDermott made, and that is, how is it that a physician that is 

stewarding antibiotics correctly or not giving in to patient pressure 

for a prescription, how is that physician protected? Also, I hadn’t 

thought about it until Mr. Kind mentioned it, are the bonus payments a new floor, and does the average become the expectation? 

So, I am here, and I think that the Chairman has set the great 

tone here, and that is for us to listen and to learn, but as you are 

navigating through those natural tensions of having something 

that can be predictable but also maintaining that level of flexibility 

where it can be revisited and changed, I think is the best of both 

worlds. 

And with that, you don’t need to respond. I’ll yield back. Thank 

you. 

Chairman TIBERI. If you would like to respond, you may. It is 

up to you. 

Mr. SLAVITT. We had this conversation, including a little bit, 

yesterday. I think this idea of making sure that people don’t feel 

like the game is changing on them, made porous, is critical. So 

there is enough in this legislation that allows us to tell folks going 

in, hey, here is how it works, in advance. I think there is nothing 

more frustrating than being told after you took the test how it is 

being graded. 

And then I think you make an important point as well, which is 

how do you trade off making sure you are predictable, with staying 

current with the state of the art of the state of medicine, and what 

physicians are saying that they want, and I think we have a process for that, we take comment on that process, we think it is an 

effective process, but it is also important that physicians have the 

flexibility to navigate the process, particularly at different times in 

their practice. 

Chairman TIBERI. Thank you. Mr. Thompson is recognized for 

5 minutes. 

Mr. THOMPSON. Thank you, Mr. Chairman, for having the 

hearing today. Thank you, sir, for being here. I am sorry I had to 

step out, so I hope I am not going to be repetitive here. 

But we are all very, very interested, I think you can tell by the 

tone of all the questions, that this law works. We have a very vested interest in that, not only as a Committee of jurisdiction, but also 

these are the people, providers, and patients that we represent at 

home, and we want to make sure that it works. 

And so to that end, I would like to hear what the Administration 

is doing to help providers get ready ahead of the 2017 start date, 

and what would you recommend providers be doing to get ready, 

and is there anything that we, as Members of Congress, should be 

doing to help facilitate this transition? 

Mr. SLAVITT. Yeah. Thank you. So I guess maybe I will start 

to direct that question as if what I would say to a physician who 

was wondering what does this all mean, and it is a conversation 

that I get to have frequently because I have been having a lot of 

conversations with physicians, and I think there are probably 5 

things I would say that I would keep in mind as a physician or 

from, I think, our perspective. 


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Number one and most importantly, keep focusing on your patients and on patient care. Don’t worry about the scorekeeping. It 

will be our job to put this forward in a way where it becomes easier, and indeed, it will be easier and more streamlined than the 

processes that people have to go through today, so that is the good 

news, and that is the first thing. 

The second thing is, we have to continue to talk to people and 

educate people as there are opportunities. As the Chairman’s question implied earlier, because physicians will have the opportunity 

to decide which measures and which ways the measuring quality 

they want to be measured on, at some point they will be able to 

think about what those things are and they will be able to put 

those in motion, and that is really one of the important early 

things. 

I think if there are opportunities to participate in these more advanced models, these care coordination models like medical homes, 

they should obviously consider those because there are some extra 

rewards for that, but it won’t be until the spring of 2018 that physicians would first need to report on MACRA. And so it is important that they not get too concerned about that. 

And then the final thing I would say, and I think what we are 

trying to encourage for everybody, is to provide us feedback. During 

this comment period, we really want physicians to be able to review this. We are setting up a number of sessions. I talked to 3,000 

physicians yesterday on a call. We do twice a week webinars to get 

your questions answered and then ask you to give us feedback on 

how you think this is going to affect your practice. 

Mr. THOMPSON. And as far as us being able to do anything to 

help facilitate the transition, any comments for the Committee? 

Mr. SLAVITT. I think the more listening sessions and open forums that there can be with physicians, and giving physicians an 

opportunity not just to hear what is in the rule but to tell us how 

it is going to impact them—I spoke with one of the Members of the 

Subcommittee who asked me to participate in one of those sessions 

with people in his district. I think we have a lot of the staff at CMS 

that are available to do phone calls and other things to reach out 

directly, so let us know what you are hearing from your constituents, and our job is to be responsive. 

Mr. THOMPSON. And so in my particular case, would you rather do a phone call to the Napa Valley or would you rather come 

out and do it in person? I yield back. 

Chairman TIBERI. Maybe a future Subcommittee hearing. 

Dr. Price is recognized for 5 minutes. 

Mr. PRICE. Thank you, Mr. Chairman, and thank you, Mr. 

Slavitt, for joining us today. I think, as has been said, I think we 

are moving in a better direction, but we still have a long way to 

go, and if we are going to make it so that physicians can once again 

be able to care for patients without an inordinate amount of influence or burden from outside, we have to continue to work through 

this, and I appreciate your willingness to do so. 

I have a couple of specific areas, and then I want to tick through. 

One is you have the moving from meaningful use to ACI, whatever we want to call it, we have the 365-day rule. In the past, it 

has always been a 90-day rule, which means that the practice has 


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to demonstrate that they comply for a 90-day continuous period 

within a 365-day period. 

It only makes sense, nobody is perfect every day, and if they are 

going to get dinged because they are not able to comply 1 day or 

2 days or 3 days, then we have simply got to move to a 90-day, and 

I hope that you are able to work in that direction. 

Mr. SLAVITT. So it is one of the key areas we are inviting comment right now during the comment period. 

Mr. PRICE. Good. So I invite comment as well from folks from 

whom I have heard. 

Mr. SLAVITT. Okay. 

Mr. PRICE. On the alternative payment models. You have a lot 

of folks out there, a lot of docs, guys, and gals who have already 

modified what they are doing. The bundled payment, BPCI programs, the future CJR program, and yet it appears that those programs, that CMS has pushed on docs, and encouraged docs, and 

incentivized docs, don’t even qualify for APMs. That doesn’t make 

any sense at all. 

So I hope you are looking at just grandfathering those or moving 

them in or allowing them to qualify as APMs. 

Mr. SLAVITT. So Congressman, one of the things that I think 

we have to do now that the law is being implemented is to go back 

and look at all of our models and see where we can make changes 

to them so that the participants in them can qualify. And I know 

that Dr. Conway is very much directing the team to look for ways 

to do that where possible. They have to meet—there are certain requirements that have to be met. 

An example would be what percentage of the patients I am seeing are part of this bundled payment, and so that is because that 

is in the statute and the law, we have to look at how we can modify 

these programs or work with you on what our flexibility is to be 

able to—— 

Mr. PRICE. I agree. If you expand the ability for them to use 

their entire practice instead of just Medicare, that oftentimes gets 

them to that point. 

Mr. SLAVITT. Right. 

Mr. PRICE. So I would urge you to look at that. 

Mr. SLAVITT. Okay. 

Mr. PRICE. Docs are really frustrated with things for which they 

are being held accountable that they have no control over. One of 

them is on the meaningful use, ACI issue, this data blocking that 

is occurring by the vendors. Docs don’t have any control over what 

the vendors do at all, so how we can have a system that actually 

punishes docs or potentially punishes docs because of what somebody else does that they don’t have any control over, again, that 

doesn’t make any sense at all, and they are pulling their hair out 

trying to comply with this, so if you can look at that, that would 

be appreciated as well. 

Mr. SLAVITT. Will do. 

Mr. PRICE. I want to touch on the nominal risk that you talked 

about. The nominal risk, as I understand it, is a minimum of 4 percent of total spending to be qualified under an APM. 

Mr. SLAVITT. That is correct. 


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Mr. PRICE. And as you know, the physicians control, I don’t 

know, pick your number, 14, 15, 16 percent of total spending. So 

4 percent of total spending is really a 25, 30 percent hit for the 

docs. So how can we have a system that punishes the people that 

are—where the rubber hits the road, trying to care for these patients, and again for which they have little control over? Shouldn’t 

that be 4 percent of the physician total reimbursement? 

Mr. SLAVITT. One of the areas where we are looking for feedback in the comment period is both what is nominal risk quantitatively? We have chosen a number that was consistent across the 

MIPS program, but that is just in the proposal. 

Mr. PRICE. Doesn’t that presume that the physician controls 

every dollar of spending? 

Mr. SLAVITT. And that is the second area where we seek feedback, which is, under what universe total cost of care, which of 

course the benefit of a total cost of care is a primary care physician 

has the opportunity to get rewarded for being able to keep the patient out of the hospital when they don’t belong there and so forth. 

Of course, as you point out, it is an area where we are looking for 

feedback and very much hearing that perspective. 

Mr. PRICE. A lot of those things are out of their control. 

Mr. SLAVITT. Sure. 

Mr. PRICE. We would like to believe that they control them, but 

in an ideal world, that might be nice, but a lot of those things are 

out of their control. 

I have a few seconds left, and I just want to point out, once 

again, the table that you identified, table 64, which by your own 

data, stipulates that 87 percent of solo practitioners are going to 

see a negative adjustment. This is your own data. Granted, it is 2 

years old, but it is going to be 2-year-old data that is going to reward them in 2019 based upon what happens in 2017, so I would 

urge you to relook at how you are adjusting that, and in realtime, 

providing an update. 

Mr. SLAVITT. Right. Right. And we are going to look in the final 

rule at having the most updated and most accurate information in 

that table. Again, while that table would not be good news for reality, I don’t believe it is reality, however I will say that the silver 

lining is I think drawing attention to the impact of this regulation 

on small and solo practices is a good thing, and so I think it is 

where we need to have dialogue, and so despite the fact that I don’t 

think that table represents the reality, I do think that the reality 

of how difficult it is to practice medicine in a small or solo practice 

is very real, and so we are looking for ways to make sure we make 

it better. 

Mr. PRICE. Great. Thank you very much. Thank you, Mr. Chairman. 

Chairman TIBERI. Thank you. I think you might be sensing a 

theme up here. 

Mr. Blumenauer, you are recognized for 5 minutes. 

Mr. BLUMENAUER. Thank you, Mr. Chairman. I appreciate the 

opportunity to have the conversation today. Mr. Administrator, I 

appreciate the approach that you folks have taken to help us turn 

the corner. 


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I personally have found the charade we went through for some 

17 years kind of embarrassing, dancing away from an event we 

know nobody had any expectation should happen. We were dealing 

with a budget fiction. 

I think the agreement that was struck is reasonable. There is 

still much value to be squeezed out of the system, but I appreciate 

the fact and some of the references from my friend, Dr. Price. 

We have people who are in the middle of practice patterns, limitations on data, and just a whole host of other changes taking 

place, and I appreciate the commitment to do so in a thoughtful 

and deliberate fashion. 

You have also heard another theme emerge that people are keenly interested in making sure that we make this transition to rewarding value over volume, and that we have had problems in the 

past with some things, theoretically. I mean, I have strongly supported Medicare Advantage, but at the same time, parts of the Affordable Care Act to try to coax more value out of it because, theoretically, it should enable us to deliver care more efficiently, and 

we continue to have a pretty significant premium. 

The compromise that was struck, and one that I thought was 

healthy, was to provide bonuses based on performance and try to 

deal with some of the areas where there is some decidedly, I don’t 

know if one wants to call them outliers, but there are some real 

performance problems being overcompensated, coming from one of 

those regions that we like to think that if everybody practiced medicine like they do in my congressional district, we wouldn’t have 

the funding problems that we have. 

You know, I am looking at charts like this that kind of display 

how it is supposed to work over time. I wonder if you can just give 

us a sense of where you think the pinch points are, where will 

some of the things that we need to be prepared to be able to work 

with you be, if there are further adjustments legislatively, if there 

are things that we need to do a better job of just being able to understand ourselves, to explain to our community at home, where 

are the pinch points you think we need to zero in on? 

Mr. SLAVITT. Thank you, Congressman Blumenauer. I think I 

point to a couple of areas that I think are really critical focus areas 

for us. One is the education and communication process, particularly with smaller practices and individual solo physicians. It is 

vital that we hear their feedback and understand what the impact 

of the decisions that we are making here today will be on their 

practices several years from now. So that education process, I 

think, means a couple of things. 

One is that we talk in plain English instead of acronyms, which 

we are quite guilty of here, I know, but we are trying very hard 

to do a better job with that. We have created simple fact sheets, 

and training sessions, and PowerPoints, and as many options as 

possible to do that, and to the extent that you can help us do that 

and tell us what you are hearing, that is going to be critical. 

The second thing that I think we will need to continue to hear 

from you all on, and I think the conversation with Congressman 

Price is apropos to this, is where there are places where you think 

there should be flexibility and how we should be exercising flexibility, whether it is with smaller practices or whether it is in how 


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we define the models that qualify for the 5 percent bonus, and in 

all of those areas, your feedback on our interpretations is critical 

because we really do want to get to the best answer. 

And I will tell you that we don’t have a monopoly on that. We 

want to do that through the dialogue and the debate that Congressman Roskam referred to, and we also are going to have to 

make this an ongoing commitment because we will have to look at 

this program at the end of its first year and understand what 

worked well and what didn’t and what can work better, and we 

can’t be afraid to call out the things that didn’t work as well and 

sit down together and try to figure out how to make those things 

better, whether it is with technical improvements or whether it is 

simply in how we are implementing things. 

Mr. BLUMENAUER. Mr. Chairman, I do appreciate the opportunity to get into something, which I hope we are able to periodically review and update. I appreciate that part of this is process 

and part of it is performance, and being able to strike that balance 

in a way that is protective of the people who depend on this service 

but also of the taxpayer, I think, is going to be a challenge for our 

friends at CMS and for the Committee, and I hope we can continue 

sort of zeroing in in that fashion. Thank you. 

Chairman TIBERI. Thank you. Well said. Mr. Smith of Nebraska 

is recognized for 5 minutes. 

Mr. SMITH OF NEBRASKA. Thank you, Mr. Chairman. Thank 

you, Administrator Slavitt, for being here today. I represent a very 

rural district, and some parts more rural than others, in fact. With 

75 counties touching six States, obviously, we are very spread out. 

We are the number one agricultural district in the Nation, very 

productive. Of the nearly 60 hospitals in my district, about 54 are 

designated as critical access, and that might be a single designation, but that is about 54 different types of expertise and providers, 

and I am actually inspired by the work that they do serving communities from smaller than 1,000 up to about 12,000 plus. Nonetheless, they have a very large task, and I guess so do you. 

Can you discuss the feedback you received from rural providers 

in response to the initial RFI and how you addressed that in producing the rule and then what rural providers and critical access 

hospitals can expect from this rule? 

Mr. SLAVITT. Yeah. Thank you, Congressman. And in your district, and I think throughout the country, you know, we face the 

challenge of not having enough physicians, in many cases enough 

specialties, and there are many districts around the country where 

there are, you know, only one or two providers in certain specialties. So we cannot allow the sideshow that goes along with the 

practice of medicine to make the practice of medicine less fulfilling 

and less rewarding. 

So as it relates to the small physician practices, the medical 

home models that many of them are participating in, we have had 

really terrific feedback from, and I think what I hear from small 

physicians is: give us the opportunity, find ways for us to have the 

opportunity to participate in some of these same opportunities, the 

models that people do in urban settings and make them work for 

us. So can you make changes to them that can work for us? That 

is, I think, one of the things we—— 


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And then on critical access hospitals. Obviously, for us, you 

know, so many of our Medicare beneficiaries get taken care of and 

get treated and rely on those critical access hospitals, and the economics of health care in rural America is different than it is in 

other places. And that is both a short-term issue that we have regulations, as you know, to set and deal with, but it is also a longer 

term question around how those hospitals are structured, what 

they provide, and how we support them in the appropriate way. 

Mr. SMITH OF NEBRASKA. Okay. In your response to the 

Chairman, you had mentioned a reporting exemption for small providers. At the same time I have heard questions from those who 

fall below the reporting threshold who would like to be able to report data. Will they have that opportunity? 

Mr. SLAVITT. So it is interesting you say that. I had that feedback last night when—in talking to a specialty society who said we 

want our specialty to be more engaged in the practice of medicine 

with seniors. And so even our physicians, who are only seeing 

small amounts, want to do that. 

I will tell you I heard feedback in both directions so that I think 

our job will be, over the comment period, to take all that in and 

figure out how to do the best job accommodating the most types of 

practices as possible. 

Mr. SMITH OF NEBRASKA. Okay. Well, I appreciate that. I 

know that the providers I talked to are constantly not just saying 

what the problem is but providing solutions and innovations, and 

I would hope that we can empower providers to care for their patients without the government getting in the way or messing things 

up. 

Thank you, Mr. Chairman. I yield back. 

Chairman TIBERI. Thank you. The former mayor of Paterson, 

New Jersey, Mr. Pascrell, is recognized for 5 minutes. 

Mr. PASCRELL. Thank you very much, Mr. Chairman. 

Administrator Slavitt, under your leadership, CMS has stressed 

the importance of better data to improve quality, to improve outcomes, and has made great strides in making that data available. 

MACRA included a provision that allows innovators to use QE 

data, to help us make smarter decisions. Do you agree that the 

medical devices used in care—and I will focus in on that—particularly for the most common Medicare procedure, joint replacements, 

play a role in healthcare quality and outcomes? 

Medicare has no information on the medical devices implanted in 

Medicare beneficiaries. I think we should let that settle in for a few 

seconds. Extremely problematic, I think, from an oversight perspective, and most importantly, from a safety perspective. You and I 

have had discussions, there is a history here that we need to address. 

So shouldn’t this information be made available? 

Mr. SLAVITT. Yeah. 

Mr. PASCRELL. Administrator. 

Mr. SLAVITT. Thank you, Congressman. 

So the question you raise is really one of—should there be, and 

how should we capture, a device identifier in a unique way on 

every device, and I think that is the goal. It is a goal that we share. 

It is a goal that the FDA shares. And it is critical for post-market 


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surveillance to be able to understand the safety of how these devices work. 

So there are several, I think, critical things that we can do, and 

are doing, and are trying to do to make this possible. So despite 

our enthusiasm for this—and this is an issue that has long preceded me. As you know, it has been an issue for quite some time— 

there are a number of parties who have a say in the matter of how 

this happens. 

I think as a first step, we are moving forward with the incorporation of a unique device identifier into electronic health records. I 

think this is a strong step, particularly considering the dramatic 

growth in electronic health records. But I know that there is also 

an interest on claim forms that there is a way for providers who 

provide care to indicate the device identifier on the claim form. We 

think that also has merit, particularly from a research perspective. 

I think there are a couple of issues to making that a reality: One 

is the Committee that essentially designs the claim form, which is 

made up of a wide group of participants and hospitals and physician groups; second, is making sure that if we at CMS are given 

the charge to do this that we can fund it and have the funds to 

do it operationally; and then third, there will be an education and 

training process because the history is that physicians don’t automatically put the information they need to down on a form unless 

it is critical to them getting paid. 

So I think we need to work through all of these issues with you. 

We have pledged to do this with your office, and we are working 

closely with the FDA to find the best path forward. 

Mr. PASCRELL. I think you have used the best word, ‘‘critical.’’ 

But if we don’t do it this time, then we have to wait another 15 

years before we change those forms, and our seniors will not be 

well served. This is important. I have been frustrated with CMS’ 

resistance to what I believe is a very important priority, particularly of safety, including the unique device identifiers on health insurance claims. 

In order for the UDI to be added to the claims form as part of 

the next update, it would go into effect, I think, in 2021. That is 

the soonest. We need to act now, and I think—I can’t stress 

enough, Mr. Chairman, we are talking about the safety of the people who use these devices, and we all want to be on the same page. 

This is, I think, a good time for us to address this issue. 

A number of cases, a number of anecdotal stories about not only 

seniors, by the way, but—we talked about seniors here because we 

are talking about Medicare—people that have had the problems, 

and we need to address that in order to improve safety. Everybody 

on this Committee talks about it, and I believe them and their 

hearts. Here is a chance for us to do something about it. 

But I want to thank you, Mr. Slavitt. You have done a great job 

and thank you for putting up with us, but we are not going away. 

Thank you. 

Mr. SLAVITT. Thank you, Congressman. 

Chairman TIBERI. Thank you, Mr. Pascrell. 

Ms. Jenkins is recognized for 5 minutes. 

Ms. JENKINS. Thank you, Mr. Chairman. 

Thank you, Mr. Administrator, for joining us today. 


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Medicare obviously plays an important role for many Kansans. It 

is the largest payer for medical services in America, a lifesaving 

benefit for many people. Last year, over 485,000 Kansans had 

health coverage from Medicare. We were pleased MACRA passed 

last year in a bipartisan manner. With the passage of MACRA we 

repealed SGR and instead put in place what will hopefully lead to 

a better reimbursement system for physicians. 

Mr. Slavitt, the relationship between a physician and a beneficiary cannot be underscored in importance, and I believe this is 

especially true when talking about seniors. With the moves that 

MACRA makes toward higher-value care centered on the quality of 

care administered by clinicians, it is ever important to ensure that 

we encourage greater and greater communication around decisionmaking between the doctors and their patients. So as MACRA’s 

implementation continues over the next several years, do you 

see room to begin including patient activation measures, placing 

greater responsibility on this relationship with the hopeful result 

of shared responsibility over healthcare maintenance and thus furthering the quality of care? 

Mr. SLAVITT. Yes. Thank you, Congresswoman, for that. I think 

that is a really important question, and I think there is an opportunity over the next several years to begin to incorporate those engagement measures in. 

There are a few things that are in the current proposal that I 

would point to that take steps in that direction: One is there is a 

practice improvement focus opportunity on the creation of a joint 

care plan between a patient and a physician; second, in the advancing care information area, there are opportunities that focus on 

measures around how patients and physicians are communicating 

using technology and making sure that information is being made 

available to patients electronically and through other means. 

But I think this is, as you point out, a ripe opportunity and a 

brand new area of focus for more patient engagement. We have 

been meeting with a number of patient groups as we have been 

putting this work together, and that is an important area of feedback for us. 

Ms. JENKINS. All right. Thank you, Mr. Chairman. I yield back. 

Chairman TIBERI. Thank you. 

Mr. Davis is recognized for 5 minutes. 

Mr. DAVIS. Thank you very much, Mr. Chairman. 

Let me welcome you, Mr. Slavitt. I know that you have spent 

considerable growing-up time in Evanston, Illinois, which isn’t very 

far from my district. And I also know that your mother lives in my 

district, and I am pleased to tell you that I have not had any real 

complaints from her, and so that makes me feel good. 

Mr. SLAVITT. That makes one of us. 

Mr. DAVIS. But let me compliment you on your work. Medicine 

is a very complex environment, and there is tremendous complexity. And I also want to thank your staff. I have 24 hospitals 

in my district, four large medical schools, a number of research institutions, and a very activated citizenry. So we get lots of inquiries, lots of calls for assistance, a lot of calls for clarification. And 

so we spend considerable time not pestering but certainly inquiring 


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of your staff, and I want to thank them for the kinds of sensitivities they have displayed. 

I also have a very active medical community, physicians associations and organizations. Just last week I had a meeting with the 

Chicago Medical Society. But I have heard concerns that under the 

proposed rule that we are talking about, only a limited number of 

physicians will meet the alternative payment model, or APM, criteria to earn the payment bonus. 

By your own estimation, you have indicated that there may be 

only 30,000 to 90,000 physicians who meet these terms, which is 

a tiny fraction of the total Medicare-eligible doctors in the country, 

and I am certain that we will hear some more from these physician 

groups. They would like to know what could make it—or how likely 

is it that anything will make it easier for there to be more pathways to qualify for the APM bonus payments? 

And how can CMS improve the opportunities for our physicians 

to meet the advanced APM criteria, and achieve the incentive to 

drive better care that Congress intended? 

And would you consider additional pathways that qualify as advanced APMs to provide assistance for our physicians who wish to 

enter the current model? 

Mr. SLAVITT. Thank you, Congressman. And my mother made 

me promise to tell you that she was a teacher at Howe and working with Principal Pat Tyco (ph), she knows you well and so she 

made sure I said this publicly. So I have delivered that for my 

mother. 

Mr. DAVIS. Thank you. 

Mr. SLAVITT. And your question is an important question because all physicians who participate in the Medicare program are 

going to have a significant opportunity to get rewarded and get 

paid for providing quality medicine, which is exactly what we hear 

from physicians that they want. Some physicians will have the opportunity to go further, and I think the law allows those physicians 

to get a 5 percent bonus if they participate in these advanced payment models. 

So our goal is not just to make the core program good but to create as many opportunities for physicians as possible to move into 

these programs, and we can do that in a number of ways. One of 

the important ways to do that is to simply create more models and 

more opportunities. We also have to make it easy for people to 

move back and forth if they choose to between programs, and I 

think that is one of the things that we are striving to achieve. 

And then, as we talked about earlier with Dr. Price, we also have 

to look at—are there ways we can take existing models and make 

them compliant with this new law? So we are going to work on all 

three of those avenues because it is a goal for any physician that 

wants to move to one of these advanced APM or care coordination 

models that they have the opportunity to do so. 

Mr. DAVIS. Thank you very much. 

Thank you, Mr. Chairman. I yield back. 

Chairman TIBERI. Former Mayor Marchant of Texas is recognized for 5 minutes. 

Mr. MARCHANT. Thank you, Mr. Chairman. 


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Mr. Slavitt, does the CMS have the resources to approve and implement the new alternative payment model proposals in a timely 

manner? 

Mr. SLAVITT. Yes. Thank you. 

I believe the question is can we implement new models in a 

timely manner, and one of the things that we have to do—and the 

answer is yes, we can. We need to, in concert with the committee 

that was set up by the Congress, the PTAC, we need to receive proposals from physicians because physicians can generate their own 

proposals for models and quality and then work with them to, as 

rapidly as possible, test them and put them into action. 

It is one of the things that we have had the opportunity to work 

on over the last 6 or 7 years through the innovation center. It is 

something that we have gotten better and better at, and we are 

eager to get going with this Committee to get as many models in 

as possible so that we can get more and more models approved. 

And I had a chance to speak with that committee and speak in 

front of that committee to try to encourage more model development. 

Mr. MARCHANT. And there is a deadline period, so you are confident that you can get all that done by the deadline? 

Mr. SLAVITT. Well, fortunately, this is something that will be 

ongoing, so as soon as we get models in we can get them tested. 

But this committee, I believe, will be standing for a number of 

years. I am not sure if I know the exact number of years, but it 

will be ongoing because physicians will be able to continue to develop new models. 

Mr. MARCHANT. So the transition in governments that is coming up won’t have any affect on this process? 

Mr. SLAVITT. No. The staff at CMS will work with the new secretary, whoever that is, and continue moving that forward very 

much with that, and I think there is—as I have heard today and 

as I think we continue to hear—there is strong bipartisan commitment and a strong commitment to this program in moving this forward, so I don’t see any concerns at this point. 

Mr. MARCHANT. And just some input in my district, I hear 

from two different groups, and this is concerning the new program 

where you basically are—let’s say, a knee replacement or a hip replacement, you are basically going to fund a lump sum for that. I 

am hearing from seniors who think that the doctors and hospitals 

are going to cut corners so that they will make the most amount 

of profit and just hurry them through the system. And then I am 

hearing from the doctors and the hospitals who are afraid that they 

are not going to get enough money to take the kind of care of their 

patients that they need to take care of them. 

So I guess you have created a pretty positive—these two tensions 

that are working out there, could you just make a comment about 

that? 

Mr. SLAVITT. Sure. I think what you are referring to is a new 

type of payment approach, new for Medicare but it has been ongoing in health care for a long time, called the bundled payment. 

Mr. MARCHANT. Yeah. 

Mr. SLAVITT. And really the idea behind the bundled payment 

is so that people—everyone who is involved in the patient care, 


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whether it is before they would have a surgery, the surgeon, the 

anesthesiologist, but also the people that take care of the patient 

afterwards, have an alignment to get on the same page to provide 

a high-quality outcome and to do it as a team. 

And so it is relatively new to Medicare. We have had good experience and good feedback so far. But as with anything new, we continue to look for feedback, for data, for our experiences, and in particular, if there are beneficiaries in your district or hospitals or 

physicians in your district that have experience with the program, 

we would love to get feedback for them from you or your staff. 

Mr. MARCHANT. Well, the group that I hear from the most is 

the in-home healthcare people, who feel like they are kind of at the 

tail end of the process and that they may be the ones—and they 

feel like they are the most cost effective of all, yet they feel like 

at the end of that process there may be some shortchanging going 

on. 

Mr. SLAVITT. Thank you. 

Mr. MARCHANT. Okay. Thank you. 

Chairman TIBERI. Thank you. 

Mr. Lewis is recognized for 5 minutes. 

Mr. LEWIS. Thank you very much, Mr. Chairman, for holding 

this hearing today. 

Mr. Administrator, thank you for being with us. Thank you for 

all your great and good work. 

Can you talk more about what people on Medicare might experience as a result of this change of payment policy, how smaller provider groups would be impacted and the doctors who need help to 

get up to speed? 

Mr. SLAVITT. Thank you. 

I think the most important thing that we have an opportunity to 

focus on here is patient care and improving patient care. And I 

think the ways to do so are severalfold: First, is this new legislation allows us to pay physicians more for providing higher-quality 

care, and the objective is to do this in a way which allows the physician to define what they believe to be the highest quality care 

from a menu of options and reward them for achieving those benchmarks. And I think physicians have been asking for that in one 

form or another for quite some time. 

Second, though, it is important to do that in a way that frees up 

physicians to actually practice medicine instead of just keeping 

score. And too many programs result in a lot of paperwork and a 

lot of scorekeeping and a lot of reporting, and we need to minimize 

that by simplifying wherever possible. 

The role of small physician practices, which you also mentioned, 

is critical here. And as we mentioned earlier, we believe that small, 

solo, and solo practitioners have every opportunity to be just as 

successful as larger size practices, and our data suggests that that 

indeed happens so long as the smaller practices report. So that 

means we need to minimize paperwork. 

We have also put in place some accommodations for smaller practices, including some technical assistance, some additional models, 

and ways that they can get excluded from reporting if their volumes are too low. 

Mr. LEWIS. Thank you. 


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Furthermore, Mr. Administrator, this is a very large regulation, 

over 900 pages. It is pretty big. It is a lot to digest, a lot to understand. If you had to tell your doctor the highlights of these 

changes, what would you tell her, what would your doctor need to 

know to maximize benefits and avoid payment cuts? 

Mr. SLAVITT. Great. That is a great question, and it may be one 

of the most important things that I can communicate today. 

First of all, it is key focusing on patient care. There is nothing 

in here that should distract anybody from patient care, and, in fact, 

it will make it easier by streamlining a patchwork of programs that 

are already out there today into something simpler. So that is first. 

Second is they will have the opportunity to select goals that they 

believe are right for their practice and right for their patient population, and at some point in time they will have an opportunity to 

do that. 

Third, I think, would be that over time there will be opportunities for them to participate in more advanced models, like the 

kinds you asked me about earlier. 

Fourth, is they don’t need to really worry about reporting anything until spring of 2018, and we will make it clear what needs 

to be done well before then. 

And then finally, the last thing, and this is more my asking of 

them, is to provide feedback to this rule, whether it is through the 

medical society they belong to, the State medical society, or directly 

to us. We really need line physicians who are practicing medicine 

every day to give us their feedback on what works about this rule 

and what might be the unintended consequences. 

Mr. LEWIS. Thank you very much. And again, I appreciate your 

effort, your great and good work, and thank you for being willing 

to serve. 

Mr. SLAVITT. Thank you. 

Mr. LEWIS. Mr. Chairman, I yield back. 

Chairman TIBERI. Thank you, Mr. Lewis. 

Mr. Paulsen is recognized for 5 minutes. 

Mr. PAULSEN. Thank you, Mr. Chairman. 

And Mr. Slavitt, it is great to see you here today—welcome— 

rather than on an airplane going back and forth to Minnesota. 

As has already been said, you know, last year both sides took 

very historic action to move forward to finally get rid of the flawed 

Medicare payment formula based on the SGR and we wonder if we 

are going to fix it every 6 months or every year. And like any law, 

passage is just the first step, right? It is the implementation that 

has to be carried out and followed through, making sure it is done 

correctly so that we are achieving the intended results. 

I just want to thank you at the outset for working with physicians, working with patients, having that connecting dialogue with 

all the appropriate stakeholders, including Members of the Committee, to make sure that we are implementing it in the correct 

fashion. 

I do want to continue on the comment theme and just mention 

at the outset that it is important to know that I continue to hear 

from folks back in Minnesota as well that aren’t in large, integrated practices, solo practices, small group practices, et cetera, 

that do have that concern. And as you mentioned, you want to 


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make sure that they have every opportunity to participate. And I 

think they want that reassurance and we just kind of need to keep 

monitoring that going forward. I thank you for that. 

Let me ask you this question: I have also heard from a lot of physicians and doctors in Minnesota about the meaningful-use program for electronic healthcare records and how it doesn’t do a very 

good job of taking into account the way physicians treat patients 

and use their electronic healthcare records. Is this rule the sameold, same-old, or do you make real changes in how you are going 

to be encouraging doctors now to actually use their electronic 

healthcare records? 

Mr. SLAVITT. Thank you, Congressman. And I would agree that 

our district practices some of the best medicine. 

The meaningful-use program is something that we took an extremely hard look at. We took a step back, because the meaningfuluse program actually is responsible for helping to make technology 

pervasive in medicine, and that is a very good thing. If we look 

back 5 or 6 years ago, most physician offices, most hospitals didn’t 

have adequate information technology. Today, by and large, 97 percent of hospitals, 70 percent of physician practices have technology. 

But as we look at how to go forward, we spend a lot of time talking to physicians and hearing exactly what you said, Congressman, 

which is that the meaningful-use program was focusing on making 

sure they were using their computers and not focusing on taking 

care of patients. 

We also heard that physicians want their technology to be more 

connected. They want to be able to get information back and forth 

from other physicians when they refer patients or from hospitals, 

and they are also frustrated that there isn’t enough connectivity 

and the data doesn’t flow as easily as it should. 

And so we have been asked to focus on it, and I believe have focused on, in this rule, changing the program so it becomes much 

more flexible, moves the focus to the patient and away from the 

use of the technology, focuses on the interaction and communication, and allowing the free flow of data to move back and forth. 

And those are the areas that we emphasize we look forward to 

comments on during the comment period about whether or not we 

have done that well. 

Mr. PAULSEN. Does it seem like the proposed rule, replacing 

meaningful-use with this new category, advancing care information, right, we have all these different acronyms, but accounting for 

25 percent of a physician’s performance score in the first year, is 

that going to essentially be interoperability now for electronic 

healthcare information for venders, for hospitals, for all the different actors and players, physicians and other providers? Is that 

the intent that this information is going to be that widely shared, 

that readily available, not just being on the computer but actually 

using information? 

Mr. SLAVITT. Right. That is the intent. I would say everybody 

has a job to do in that regard. If any of us here could wave our 

magic wand and make the healthcare system more interoperable, 

I think we would do it. But this really requires vendors to share 

data to publish to what they call open APIs, to not practice what 

we talk about is data blocking, which the Congress has expressly 


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asked that vendors not do, and physicians, to a large extent are 

really a victim of what the technology allows. 

They all want to share data. I have not met a physician who 

when they refer a patient doesn’t want to know what happened to 

that patient and get that back electronically. But it is the technology that really needs to do that job. We think in the EHR certification that just came out and in a number of the other activities, we think vendors are going to move in that direction. They 

need to move in that direction. 

Mr. PAULSEN. Thank you, Mr. Chairman. I appreciate it. I yield 

back. 

Chairman TIBERI. Thank you, Mr. Paulsen. 

Thank you, Mr. Slavitt. 

One comment related to that is—we can discuss this more—as 

you develop a final rule and the performance period begins on January of 2017, vendors are going to have a limited time to reconcile 

with this new rule and then physicians are going to have to digest 

the new rule. So, you know, I hope that, again, particularly for the 

small group rural markets, I hope that you will work with us to 

make sure that that implementation is done smoothly. 

And related to that, I don’t know if you think you have some authority in this area, but the gap of time between performance period and then the payment here for physicians is 2 years, yet the 

clinician reporting period is a shorter period of time. Do you think 

CMS has the ability, the rulemaking, the authority to change that 

a little bit? 

Mr. SLAVITT. Yep. So one of the things that we do see comment 

on are the proposed measurement periods and payment periods. 

What I will say is a couple things: One is, we have two feedback 

periods built in so that—one in the middle of 2017 and one in the 

middle of 2018, to provide information back to physicians. So there 

is a more current feedback loop. 

The second thing I would say is because we have focused so 

much on reducing burden and reducing the number of measures 

and so forth, that is—we have had some feedback that people want 

to make sure that that starts as early as possible. We have had 

other feedback, of course, which tells us make sure we have enough 

time, make sure we have enough time to do the things we need to 

do, make sure we don’t get penalized unnecessarily because we 

didn’t have enough time. 

And to your earlier question, Mr. Chairman, if people will begin 

on the older technology and move to the newer technology, they 

will not get penalized for that. So we are making those accommodations. But of course, the purpose of the comment period is for people to tell us what are the things we missed, what are the things 

that could have an impact on someone’s practice or on their patients that we didn’t think of. 

And that is one of the reasons why, if there is an important message today to get out, it is to please engage in the rule and give 

us the feedback that we need to hear. 

Chairman TIBERI. Well, I can’t thank you enough for coming 

today. As you can tell, in a bipartisan way, Members have a lot of 

interest in this and not just at the Subcommittee level but the 

Committee as a whole, as well as the Congress. 


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And we really appreciate you taking the time and look forward 

to working with you and your team as you continue to develop this 

and ultimately put it into practice the way that we all intended it 

to be. And I appreciate the fact that you were so kind yesterday 

as well. 

I look forward to working with you. Hopefully we have treated 

you nice enough that you will come back, as we have this bipartisan concern about the way this unfolds. 

So as a reminder, any Member wishing to submit a question for 

the record will have 14 days to do so. If any Members submit questions after the hearing, I ask that the witnesses respond in writing 

in a timely manner. 

With that, again, thank you and this Subcommittee is adjourned. 

[Whereupon, at 3:36 p.m., the Subcommittee was adjourned.] 

[Questions for the Record follow:] 


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dkrause on DSKHT7XVN1PROD with LOCATORS21365A.039
70 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.040
71 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.041
72 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.042
73 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.043
74 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.044
75 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.045
76 


dkrause on DSKHT7XVN1PROD with LOCATORS21365A.046
77 

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dkrause on DSKHT7XVN1PROD with LOCATORS21365A.047