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MEDICARE ACCESS AND CHIP REAUTHORIZATION 

ACT OF 2015: EXAMINING PHYSICIAN EFFORTS 

TO PREPARE FOR MEDICARE PAYMENT REFORMS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

SECOND SESSION 

APRIL 19, 2016 

Serial No. 114–137 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

DORIS O. MATSUI, California 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 2 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 3 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 5 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 7 

Prepared statement .......................................................................................... 7 

WITNESSES

Robert McLean, M.D., Member, Board of Regents, and Chair, Medical Practice and Quality Committee, American College of Physicians ......................... 9 

Prepared statement .......................................................................................... 12 

Answers to submitted questions ...................................................................... 140 

Robert Wergin, M.D., Board Chair, American Academy of Family Physicians .. 36 

Prepared statement .......................................................................................... 38 

Answers to submitted questions ...................................................................... 150 

Barbara L. McAneny, M.D., Immediate Past Chair, Board of Trustees, American Medical Association ...................................................................................... 44 

Prepared statement .......................................................................................... 46 

Answers to submitted questions ...................................................................... 159 

Jeffrey Bailet, M.D., Co-President, Aurora Health Care Medical Group ............ 53 

Prepared statement .......................................................................................... 55 

Answers to submitted questions ...................................................................... 166 

SUBMITTED MATERIAL

Statement of the American College of Cardiology, April 19, 2016, submitted 

by Mr. Pitts ........................................................................................................... 86 

Statement of the American College of Surgeons by David Hoyt, Executive 

Director, April 19, 2016, submitted by Mr. Pitts ............................................... 88 

Statement of the Alliance of Specialty Medicine, April 19, 2016, submitted 

by Mr. Pitts ........................................................................................................... 97 

Statement of the American Society of Clinical Oncology by Julie Vose, President, April 19, 2016, submitted by Mr. Pitts ..................................................... 101 

Letter of April 19, 2016, from the Advanced Practice Registered Nursing 

Organization to Mr. Pitts and Mr. Green, submitted by Mr. Pitts .................. 106 

Letter of April 15, 2016, from Johan S. Bakken, President, Infectious Diseases 

Society of America, to Mr. Pitts and Mr. Green, submitted by Mr. Pitts ....... 112 

Letter of November 17, 2015, from Halee Fischer-Wright, President and Chief 

Executive Officer, Medical Group Management Association, to Andrew 

Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, submitted by Mr. Pitts ............. 118 

Statement of the Medical Group Management Association, April 18, 2016, 

submitted by Mr. Pitts ......................................................................................... 136 

(1) 

MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT OF 2015: EXAMINING PHYSICIAN 

EFFORTS TO PREPARE FOR MEDICARE PAYMENT REFORMS 

TUESDAY, APRIL 19, 2016 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON HEALTH, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:14 a.m., in room 

2322 Rayburn House Office Building, Hon. Joseph R. Pitts (chairman of the subcommittee) presiding. 

Members present: Representatives Pitts, Guthrie, Shimkus, Burgess, Bilirakis, Long, Ellmers, Bucshon, Brooks, Green, Castor, 

Sarbanes, Matsui, Schrader, Kennedy, Ca ́ rdenas, and Pallone (ex 

officio). 

Staff present: Gary Andres, Staff Director; Rebecca Card, Assistant Press Secretary; James Paluskiewicz, Professional Staff Member, Health; Graham Pittman, Legislative Clerk; Jennifer Sherman, Press Secretary; Heidi Stirrup, Policy Coordinator, Health; 

Kyle Fischer, Democratic Health Fellow; Tiffany Guarascio, Democratic Deputy Staff Director and Chief Health Advisor; Samantha 

Satchell, Democratic Policy Analyst; Andrew Souvall, Democratic 

Director of Communications, Outreach, and Member Services; and 

Arielle Woronoff, Democratic Health Counsel. 

Mr. PITTS. The time of 10:15 having arrived, the subcommittee 

will come to order. The Chair will recognize himself for an opening 

statement. 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Today’s hearing is a sequel to our Health Subcommittee’s earlier 

review of the implementation progress of the Medicare payment reforms as included in the Medicare Access and CHIP Reauthorization Act of 2015—MACRA—which repealed the sustainable growth 

rate and replaced it with new payment models and other reforms. 

Through a variety of incentives, MACRA encourages physicians 

to engage in activities to improve quality, patient experience and 

outcomes and reduce costs. 

Prior to MACRA, physicians not only faced the threat of 

unsustainable cuts from the SGR, but a series of well-meaning but 

2 

uncoordinated requirements stacked on top of each other from a variety of reporting requirements. 

MACRA seeks to consolidate, streamline and integrate these efforts into a single program. However, rather than wait until CMS 

issues a proposed rule on how they plan to implement these incentives and program changes, there are steps every practitioner can 

be taking right now. 

Physicians should be thinking about ways they can modernize 

their practices and participate in current programs to act as a 

springboard for their preparation for MACRA. 

Provider organizations should be developing measures to aid 

their members and help MACRA’s goal of creating meaningful 

measurements that every provider feels are relevant to them. 

Physicians should also start evaluating options available to 

them, whether the Merit-based Incentive Payment System— 

MIPS—or the Alternative Payment Methods—APMs—is right for 

them both for tomorrow and where they want to direct their practice in the future. 

Our hearing today will examine options for ensuring the smoothest transition for our providers, based on what we know today. We 

expect to hear today from our witnesses who come from diverse 

backgrounds and training and practice from all over the country in 

rural and urban settings. 

Each are practicing physicians in different arrangements and all 

have worked with their organizations to provide tools and best 

practices that other physicians can utilize and learn from to be better positioned to succeed under MACRA. 

By the conclusion of today’s hearing, our Health Subcommittee 

will have held two oversight hearings on the implementation of 

MACRA prior to the issuance of CMS’ proposed rule. 

As we have demonstrated in our commitment so far, the Energy 

and Commerce Committee will continue to be vigilant in our bipartisan oversight to ensure MACRA is a success and this will certainly not be our last hearing on the matter. 

[The prepared statement of Mr. Pitts follows:] 

PREPARED STATEMENT OF HON. JOSEPH R. PITTS

Today’s hearing is a sequel to our Health Subcommittee’s earlier review of the implementation progress of the Medicare payment reforms as included in the Medicare 

Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustained Growth Rate (SGR) and replaced it with new payment models and other reforms. 

Through a variety of incentives, MACRA encourages physicians to engage in activities to improve quality, patient experience and outcomes and reduce costs. 

Prior to MACRA, physicians not only faced the threat of unsustainable cuts from 

the SGR, but a series of well-meaning but uncoordinated requirements stacked on 

top of each other from a variety of reporting requirements. MACRA seeks to consolidate, streamline and integrate these efforts into a single program. 

However, rather than wait until CMS issues a proposed rule on how they plan 

to implement these incentives and program changes, there are steps every practitioner can be taking right now. 

Physicians should be thinking about ways they can modernize their practices and 

participate in current programs to act as a springboard for their preparation for 

MACRA. 

Provider organizations should be developing measures to aid their members and 

help MACRA’s goal of creating meaningful measurements that every provider feels 

are relevant to them. 

3 

Physicians should also start evaluating options available to them—whether the 

Merit-based Incentive Payment System (MIPS) or Alternative Payment Methods 

(APMs), is right for them both for tomorrow and where they want to direct their 

practice in the future. 

Our hearing today will examine options for ensuring the smoothest transition for 

our providers based on what we know today. 

We expect to hear today from our witnesses who come from diverse backgrounds 

and training and practice from all over the country in rural and urban settings. 

Each are practicing physicians, in different arrangements and all have worked with 

their organizations to provide tools and best practices that other physicians can utilize and learn from to be better positioned to succeed under MACRA. 

By the conclusion of today’s hearing, our Health Subcommittee will have held two 

oversight hearings on the implementation of MACRA prior to the issuance of CMS’ 

proposed rule. 

As we have demonstrated in our commitment so far, the Energy and Commerce 

Committee will continue to be vigilant in our bipartisan oversight to ensure MACRA 

is a success. This will certainly not be our last hearing on the matter. 

Mr. PITTS. My time is expired. I now yield to the ranking member, Mr. Green, 5 minutes for his opening statement. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, and I thank our witnesses for being here today and I want to thank you for this—the 

hearing, the second part of our subcommittee’s hearing on the implementation of MACRA. 

As we know, the Medicare Access and CHIP Reauthorization Act, 

or MACRA, was signed into law a little over 1 year ago. This landmark legislation repealed the flawed sustainable growth rate, the 

SGR, formulated to provide long-term stability to the Medicare 

physician fee schedule and reward value over volume. 

It was critically important that Congress pass and the CMS institute a reasonable responsible payment policy for physicians and 

Incentivize quality care that spends our dollars wisely. 

Now that the historic achievement of finally repealing and replacing the SGR has been made, staunch oversight over the implementation of MACRA is critical. 

This will ensure that we do not make the same mistakes of the 

past. To do so, we need a system that’s set up that’s fair, smart 

and sophisticated enough to meet the unique challenges of a variety of providers participating in the Medicare system and their patients. 

The physician stakeholder community provided extensive feedback during the development of MACRA and publicly supported 

and voted the bill through the passage into law. 

Like all of us, the provider community appreciates this important 

step toward a more rational payment system and share a sense of 

ownership over it. 

I want to thank the stakeholders who continue to work with this 

subcommittee and CMS to ensure that the legislation works for the 

spectrum of providers and their Medicare patients. 

The emphasis on quality and value that underpins MACRA is 

consistent with the broader mission that Congress and the administration have engaged in over the last decade beginning with the 

Affordable Care Act. 

As we know, MACRA provides stable updates for 5 years and ensures no changes are made to the current payment system for 4 

4 

years. In 2018 it establishes a streamlined improvement incentive 

payment program that will focus the fee for service system on providing quality and value. 

The incentive payment program refer erred to as Merit-based Incentive Payment System, or MIPS, consolidates the three existing 

incentive programs continuing to focus on quality, resource use and 

a meaningful electronic health record use. 

But unlike the past, it does this in a cohesive program that 

avoids redundancies. MACRA also provides another route to 

incentivize the movement away from volume-based payments by 

giving financial bonuses to providers who participate in alternative 

payment models, or APMs. 

APMs hold great promise but their viability and effectiveness requires sophisticated construction and implementation. 

I look forward to hearing from our witnesses about their vision 

for the APMs, specifically how the model will be designed so that 

they are relevant to different specialties, different sizes of practice 

and in line with State-based initiatives and private insurance models. 

APM should prioritize measures on outcome, patient experience, 

care coordination and measures of appropriate use of services. They 

should also take into account gaps in quality measurements and 

applicability of such measures across the various healthcare settings. 

It is the intent of Congress that specific quality metrics used will 

be tailored to different provider specialties and each eligible professional will receive a composite quality score. 

The challenges with constructing a system that fully accounts for 

the variabilities in providers and the type of care they’re trained 

to provide and the patient mix as well as how to meaningfully 

evaluate quality are significant. 

But I believe it can be accomplished. To do so, the Centers for 

Medicare and Medicaid, CMS, has initiated a rule making process. 

A rule is imminent. I know everyone in this room is looking forward to its release by CMS. 

When the rule is announced I’m confident we’ll see additional 

stakeholder engagement, collaboration, continuation of the transparent and public process throughout the course of implementation. 

MIPs and the opportunity to participate in APMs is just around 

the corner. Now it’s time to start preparing. I look forward to hearing from our panel on how they’re instructing their peers to begin 

to prepare for transition. 

This subcommittee will continue to exercise oversight over 

MACRA implementation, not just today but throughout the rule 

making process. 

And again, Mr. Chairman, I thank you for calling the hearing 

and a follow-up and I hope we’ll have other ones as we go along. 

Again, we don’t want to repeat the problems of 1997. 

I yield back. 

Mr. PITTS. The Chair thanks the gentleman. Now, filling in for 

the chair of the committee, Dr. Burgess, 5 minutes for opening 

statement. 

5 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. Thank you, Mr. Chairman, and thank you, Ranking Member Green, for reminding me why I wake up in a cold 

sweat at 4:00 o’clock every morning. The word is that the next part 

of this act does not go as well as the first part. 

But last week we had the 1-year anniversary of the passage of 

H.R. 2. Big deal. And this—now we’re all reflecting on the historic 

accomplishment of permanently and forever repealing the sustainable growth rate formula. And just take—worthwhile to take a moment to acknowledge. 

It could not have come to pass without the commitment of the 

medical community and the leadership of the Energy and Commerce Committee on both sides of the dais. 

The hard work is far from over, however, and we’ve entered into 

what I like to consider a 5-year cessation of hostilities between the 

Congress, the agency, and doctors, and we need to make certain, 

as Ranking Member Green pointed out, that we get it right during 

this interval. 

So we are now having our second hearing on the implementation 

phase of the Medicare Access and CHIP Reauthorization Act and 

I’m glad that this committee does remain dedicated to ensuring 

that we get this next phase of payment reform right. 

In the act, we sought to put power back in the hands of those 

who actually provide the care so the doctors, not agencies, will help 

shape Government care payments systems of the future. 

And I am encouraged that when CMS began the process of implementation of this reform it began with a request for information 

and I was even more encouraged by the response from doctors. 

We had 560-odd responses to that request for information. It is 

important to note that doctors actively engaging in the regulatory 

process can’t just be at the beginning. 

We’ve got to see this through, and certainly the societies have 

some obligation to help doctors actually prepare for the implementation of this. 

Medicare participation should never subject doctors to the things 

that we’ve—we want our doctors to take care of our Medicare patients. 

Some would argue that Congress shouldn’t even be in the business but we are and we’ve been there for 50 years. We might as 

well do it right if we’re going to do it and part of doing it right is 

we shouldn’t punish doctors. 

But right now, doctors have to do this—all of these different 

quality incentive programs. The piecemeal initiatives have undermined their ability to focus on quality. 

So to resolve that problem, the MACRA requires CMS—all these 

acronyms—MACRA requires CMS to streamline the current programs into a single value-based payment structure. 

This is called the Merit-based Incentive Payment System and the 

system is designed to incentivize quality whether a doctor is an 

independent in rural practice or in a large integrated healthcare 

system, and that was an extremely important part of just getting 

H.R. 2 done. 

6 

We had to allow for success in whatever practice or arrangement 

a doctor was in. We had to meet them where they were. 

Now, this transition is not going to happen overnight and I am 

certain that—what I am certain of right now is that no doctor is 

going to face the double digit cuts that they were facing under the 

SGR. But really, truly, we don’t want our doctors to wait until 2019 

to begin to take action. 

Congress currently is universally condemned for being dysfunctional, ineffective. Not a headline there to the guys writing for the 

press. I know that. 

But when you stop and think about what we accomplished with 

the overwhelmingly bipartisan passage of H.R. 2, and I would note 

I went to all the celebratory things down at the White House where 

the president took credit for it. But, honestly, it wasn’t the president’s deal. It was the committee’s deal and we brought the other 

committees of jurisdiction, both the House and Senate, along with 

us and it was truly that bipartisan effort. 

Henry Waxman was my co-sponsor on H.R. 2. I mean, that’s phenomenal in and of itself when you think of it. 

But it isn’t just—and when you look at some of the successes and 

failures of major healthcare policy that have come through Congress in the past it’s also—you know, they always say the devil’s 

in the details. 

So this is where the devil’s in the details and we’ve got to get 

this—we’ve got to get this right. 

It took two decades to replace the SGR because it was hard to 

do and it required a certain commitment and a certain suspension 

of hostilities between Republicans and Democrats on the dais. But 

we did it because it was the right thing to do, and we’re going to 

be called upon to do that again in the future. 

I don’t know what form that will take but in other healthcare 

policy that certainly we could—people would do well to follow the 

template that we provided in the Energy and Commerce Committee. 

The policies outlined in H.R. 2 are the result of an open and 

transparent process which sought input and participation from 

every doctor, patient, member of Congress, administrative agency 

and anyone else who professed an interest. 

We’re at this critical juncture in physician payment reform and 

we’ll only get it right if implementation follows that same open, 

transparent and bipartisan structure that we use to get this to the 

president’s desk. 

I want to thank all of our witnesses for being here today. I sincerely appreciate the efforts of all of the provider groups to help us 

in going forward. 

I look forward to your testimony today and look forward to the 

next in what will be a series of hearings, Mr. Chairman. I’ll yield 

back. 

Mr. PITTS. The Chair thanks the gentleman. 

The ranking member wants to say something. 

Mr. GREEN. Chairman, I just want to thank my colleague from 

north Texas. But, you know, I felt the same way about the President because he got the Affordable Care Act called Obamacare and 

7 

all he had to do is sign his name to it. We had to do the legwork. 

So I understand how you feel. 

Mr. BURGESS. Some of us did not do that legwork, nor did we 

vote for it, nor will we ever, Mr. Green. So if you want me to refer 

to that as Greencare in the future, I’ll be glad to do that. 

Mr. GREEN. All right. 

Mr. BURGESS. I will be honored to do that because I said that. 

Mr. PITTS. OK. The Chair now recognizes the ranking member 

of the full committee, Mr. Pallone, 5 minutes for opening statement. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. 

I think this is an important hearing and I thank the witnesses 

for being here today. 

We’re meeting to continue our discussion on one of the great bipartisan success stories of this committee, the Medicare Access and 

CHIP Reauthorization Act, or MACRA. 

Our panel of witnesses practice in a variety of settings across the 

country and represent diverse expertise and training. They each 

have the unique perspective to share with us regarding the implementation of MACRA. 

The law put in place a dual track system for providers instead 

of the patchwork of quality reporting systems that providers currently use. They will instead use the Merit-based Incentive Payment System, or MIPS, and MIPS will streamline quality reporting 

for providers and incentivize high-quality efficient care. 

Providers are most enthused to use alternative payment models, 

or APMs, which have also proven to increase quality and lower 

costs. 

Today we’ll discuss the steps all providers can take to modernize 

their practices, provide higher quality care for their patients and 

successfully transition to the new payment models established by 

MACRA, and this will be our second hearing on MACRA implementation. I’m pleased this committee is performing such thoughtful 

oversight. 

While we know that MACRA is already showing promising results, these hearings are necessary to ensure that the law reaches 

its full potential and I look forward to discussing the tools and best 

practices physicians can employ to help make MACRA work effectively for all. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Good morning. Thank you, Mr. Chairman, for holding this important hearing, and 

thank you to the witnesses for being here today. 

We’re meeting to continue our discussion on one of the great bipartisan success 

stories of this committee, the Medicare Access and CHIP Reauthorization Act of 

2015, or MACRA. Our panel of witnesses practice in a variety of settings across the 

country and represent diverse expertise and training. They each have a unique perspective to share with us regarding the implementation of MACRA. 

The law put in place a dual track system for providers. Instead of the patchwork 

of quality reporting systems that providers currently use, they will instead use the 

8 

Merit-Based Incentive Payment System or MIPS. MIPS will streamline quality reporting for providers and incentivize high-quality efficient care. Providers can also 

choose to use Alternative Payment Models or A–P-Ms, which have proven to increase quality and lower costs. 

Today we will discuss the steps all providers can take to modernize their practices, provide higher quality care for their patients, and successfully transition to 

the new payment models established by MACRA. 

This will be our second hearing on MACRA implementation and I’m pleased that 

this committee is performing such thoughtful oversight. While we know that 

MACRA is already showing promising results, these hearings are necessary to ensure that the law reaches its full potential. I look forward to discussing the tools 

and best practices physicians can employ to help make MACRA work effectively for 

all. Thank you. 

Mr. PALLONE. So I just want to yield the remainder of my time 

to Congresswoman Matsui from California. 

Ms. MATSUI. Thank you for yielding. 

Thank you, Mr. Chairman, for holding this second hearing on 

MACRA. Last year, we joined together in overhauling the broken 

SGR system, replacing it with one that incentivizes quality over 

quantity of care, rewards efficiency and encourages the use of 

breakthrough technologies that will provide more people access to 

health care across this country. 

I am looking forward to discussing ways we can advance the 

transitions that are already happening and will accelerate with 

MACRA. 

Today, we are joined by physicians who offer important perspectives and best practices for ensuring that delivery systems continue 

to make inroads in providing high-quality efficient health care to 

patients. 

One of the ways I believe that we can expand access to care and 

improve outcomes is through the incorporation of telemedicine and 

to this new value-based system. 

Through telemedicine we truly have the opportunity to better engage patients and their families, improve care coordination with 

loved ones and maximize efficiency of resources. 

As we make inroads into this health system transformation, I 

look forward to working with you and hearing your perspectives on 

these important issues. Thank you and I yield back. 

Mr. PITTS. The Chair thanks the gentlelady. As usual, all the 

members’ written opening statements will be made a part of the 

record. I’d like to submit the following documents for the record: 

statements from the American College of Cardiology, the American 

College of Surgeons, the Alliance of Specialty Medicine, the American Society of Clinical Oncology, the Advanced Practice Registered 

Nursing Organizations, the Infectious Diseases Society of America, 

and comments and a statement from the Medical Group Management Association. 

Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. PITTS. We have one panel today. I’ll introduce them in the 

order of their presentations. 

First, Dr. Robert McLean, MD, FACP member of the Board of 

Regents, chair of the Medical Practice in Quality Committee, American College of Physicians; then Dr. Robert Wergin, MD, FAAFP, 

board chair of the American Academy of Family Physicians; Dr. 

Barbara McAneny, MD, immediate past chair of the American 

9 

Medical Association, and finally, Dr. Jeffery Bailet, MD, MSPH, 

FACS, executive vice president of the Aurora Health Care, co-president of the Aurora Health Care Medical Group. 

Thank you for coming today. Your written testimony will be 

made a part of the record. You’ll be each given 5 minutes to summarize your testimony. 

And so we’ll begin by recognizing Dr. McLean for 5 minutes for 

his summary. 

STATEMENTS OF ROBERT MCLEAN, M.D., MEMBER, BOARD OF 

REGENTS, AND CHAIR, MEDICAL PRACTICE AND QUALITY 

COMMITTEE, AMERICAN COLLEGE OF PHYSICIANS; ROBERT 

WERGIN, M.D., BOARD CHAIR, AMERICAN ACADEMY OF FAMILY PHYSICIANS; BARBARA L. MCANENY, M.D., IMMEDIATE 

PAST CHAIR, BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION; JEFFREY BAILET, M.D., CO–PRESIDENT, AURORA 

HEALTH CARE MEDICAL GROUP 

STATEMENT OF ROBERT MCLEAN 

Dr. MCLEAN. Thank you. 

My name is Robert McLean. I am pleased to share with you the 

perspectives of the American College of Physicians on the key 

issues we believe should be addressed in the implementation of 

MACRA and what we are doing to prepare our members to be successful under it. 

On behalf of the college, I wish to express our appreciation to 

Chairman Pitts and Ranking Member Green for convening this 

hearing. 

I’m a member of the college’s Board of Regents and chair of its 

medical practice and quality committee. ACP is the Nation’s largest 

medical specialty organization representing 143,000 internal medicine physicians and medical student members. 

In addition to teaching medical students, residents and fellows 

Yale, I’m also a full time practicing physician who sees over 80 patients per week as part of the Northeast Medical Group of the Yale 

New Haven health system. 

We sometimes forget even though it has been only a year what 

has been achieved by repealing the SGR and replacing it with 

MACRA. 

For years, many looking to improve our healthcare system have 

embraced the laudatory goals of the triple aim—improve the patient experience of care, improve the health of populations and reduce per capita healthcare costs. 

However, when I would mention this to my colleagues in practice 

I frequently received glazed looks and given their list of real world 

concerns such as I’m struggling with my electronic health record— 

I am overwhelmed with these regulations—I’m given data on clinical metrics and do not know what to do with it—my patients are 

unhappy because I am taking visit time away from them to deal 

with all of these hassles, and before MACRA repealed the SGR, 

they would then add and I have to worry every year that my Medicare fees will be cut up to 20 percent or more due to some crazy 

formula. In that environment, can anyone wonder why there is 

such concern about physician burnout? 

10 

Since MACRA became law, though, I can truly tell my colleagues 

that there is reason for hope. I tell them that the MACRA law will 

align and simplify some of the measures and reporting. It will truly 

reward those who have made investments in advanced practice 

structures like the patient-centered medical homes and will eliminate the yearly financial anxiety created by the dreaded SGR. Then 

those glazed and frustrated looks change dramatically. 

With surprise, I’m then asked, you mean that this law really 

does things that will simplify our lives and practice and allow us 

to focus more on delivering high-quality care to our patients, and 

I tell them yes. 

One way that MACRA does this is by giving physicians more 

control over our Medicare payments. As you’re aware, the SGR resulted in ever physician’s conversion factor being cut by the same 

scheduled amount no matter how cost effective they were or the 

quality of care they provided the patients. 

MACRA fundamentally changes this because the annual adjustment in each physician’s conversion factor starting in 2019 will be 

based on each physician’s own contribution to improving quality 

and providing care more effectively, giving physicians more control 

over their annual payments while benefitting patients with better 

outcomes. I truly believe that MACRA can be a shot in the arm to 

combat burnout if it is rolled out as Congress intended. 

To this end, the college has provided CMS with our views on the 

priorities it must address as MACRA is implemented. There are 

three in particular that I’d like to highlight. 

Number one, CMS must improve the measures to be used in the 

quality performance category of MIPS and established less burdensome reporting as Congress clearly intended when it harmonized 

existing Medicare quality reporting programs into MIPS. 

Number two, ACP is very pleased that MACRA supports patientcentered medical homes through both the MIPS program and as an 

alternative payment model and has urged CMS to create multiple 

realistic ways for medical homes to obtain certification. 

We are encouraged by CMS’ announcement just last week of the 

Comprehensive Primary Care Plus program, a multipayer patientcentered medical home initiative which potentially could enable 

participating practices to qualify for higher payments under 

MACRA. 

And number three, CMS should promote innovation by employing a very broad definition of entities that should be considered eligible APMs as well as create pathways for multiple physician-focused APMs to be accepted. 

It isn’t just up to CMS to ensure that MACRA is implemented 

successfully. Professional associations including the ACP must do 

our part. Our educational efforts include online resources, guides, 

presentations, articles in our publications and practical tools, all 

designed to help our members prepare for MACRA. This includes 

MACRA-specific sessions at our annual scientific meeting to be 

held here in Washington, DC, just two weeks from now. 

One thing I would like to highlight is the ACP practice advisor, 

an online interactive tool that offers practices the ability to conduct 

significant evidence-based quality improvement based on the most 

up to date clinical guidelines, improve performance on clinical qualVerDate Mar 15 2010 11:14 Sep 14, 2016 Jkt 037690 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X137MACRAPHREPASKOK080316\114X137MACRAPREPPDFM
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ity measures, implement the principles in the medical home model 

and improve the overall management of their practice. 

While the practice advisor serves to facilitate practice transformation independent of any given payment model, it is particularly relevant to preparing physicians to be successful under 

MACRA. 

Thank you for giving the ACP the opportunity today to share our 

perspective on what CMS needs to do to ensure that MACRA is implemented as Congress intended and on what we are doing to help 

our members be prepared to succeed under this landmark law. 

Thank you. 

[The prepared statement of Dr. McLean follows:] 

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Mr. PITTS. The Chair thanks the gentleman. Thank you for your 

testimony. 

We’re still having trouble with the mics. So Dr. Wergin, make 

sure you pull that close to you and make sure the mic is on. 

The Chair now recognizes Dr. Wergin, 5 minutes for an opening 

statement. 

STATEMENT OF ROBERT WERGIN 

Dr. WERGIN. Chairman Pitts, Ranking Member Green and members of the subcommittee, thank you for this opportunity to address 

you this morning. 

My name is Dr. Robert Wergin. I chair the American Academy 

of Family Physicians board of directors. The AAFP is an organization of 120,000 members. I am pleased to be asked to speak about 

Medicare Access and CHIP Reauthorization Act implementation. 

First of all, I want to thank all of you for your effective bipartisan leadership in repealing the much-despised Medicare SGR and 

putting into place payment reforms that clearly emphasize valuebased health care. 

More importantly, thank you for putting together legislation that 

will make a real and positive different in the lives of your constituents. 

MACRA implementation will be a major shift in Medicare in a 

very short period of time. These changes, as dramatic as they may 

be in the coming years, are consistent with the key principles of 

practice transformation that the AAFP has supported for over a 

decade. 

For example, almost 10 years ago the AAFP, along with four 

major primary care organizations developed the joint principles for 

the patients that are in a medical home that promotes coordinated 

care, quality and safety and patient access. 

Consistent with those principle we believe that the practice 

transformation necessary to make MACRA successful will mean 

better care for patients, better professional experiences for our physicians and better control of healthcare costs. 

We hope it will also bring back the joy of the practice of medicine 

to our members. As I travel from State to State meeting with 

AAFP chapters I hear a lot of anxiety related to MACRA, particularly for my colleagues in rural and underserved areas. 

I challenge my colleagues to be optimistic. MACRA reform will 

not be easy but it’s much better than what physicians faced before 

the law was enacted. Instead, I urge them to take advantage of the 

AAFP resources they can utilize to begin transforming their practices now. 

The AAFP believes MACRA is by intent and design a law aimed 

at transforming our healthcare delivery system into one that is 

based on a strong foundation of primary care. 

As I fully explained in my written testimony, the whole person 

and complex care that primary care physicians provide helps improve patients’ outcomes and constrain overall healthcare costs, 

which are also consistent with the law’s intention. 

Also, the alternative payment models will improve how 

healthcare systems value primary care and the services that are 

fundamental to disease prevention, chronic care management and 

37 

population health—all areas of health care that a fee for service 

system cannot adequately address. 

Although MACRA is among the most significant reforms to occur 

in decades, many of our members may not be aware of the upcoming changes or do not know their level of readiness for MACRA implementation. 

As a result of that, the AAFP has launched a comprehensive 

multiyear member education and communications effort designed 

to simplify this transition. 

Called MACRA Ready, the effort will include a variety of tactics 

designed to get the word out to our members starting with a dedicated content page on afp.org. 

One of the best primers is an article in the April/March issue of 

Family Practice Management. Other MACRA content already 

available to AAFP members are MACRA 101, frequently asked 

questions, MACRA time line, AAFP news articles, MACRA readiness assessment tool and a MIPS APM calculator and decision tree 

tool as well. 

The AAFP is dedicating considerable time and thought into preparing our members for MACRA and that is reflected in our wealth 

of available resources. The AAFP is also supporting MACRA implementation by advising CMS about the agency, how the agency 

might handle many features of the new law which are fully outlined in my written statement. They include but are not limited to 

the critical importance of an interoperable electronic health record. 

The AAFP has also shared recommendations regarding the importance of issuing regulations that are less cumbersome and more 

user friendly for physicians. 

Ultimately, we believe these concerns could be address as the 

process moves forward and we truly believe that the vision for 

practice transformation, better patient care, lowering costs and return to the love of the practice of medicine is achievable. 

Once again, I want to thank you for your kind invitation to speak 

about MACRA and its implementation. I look forward to answering 

your questions. 

[The prepared statement of Dr. Wergin follows:] 

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Mr. PITTS. The Chair thanks the gentleman. 

Now recognizes Dr. McAneny, 5 minutes for her opening statement. 

STATEMENT OF BARBARA L. MCANENY 

Dr. MCANENY. Good morning. I’m Dr. Barbara McAneny, a hematologist oncologist from New Mexico and immediate past chair 

of the American Medical Association board of trustees. 

Thank you for inviting us to this hearing on MACRA focusing on 

physician efforts to prepare for Medicare payment reform. 

As background, my practice is the New Mexico Cancer Center, 

which provides multidisciplinary outpatient cancer care at multiple 

sites including under served rural areas. 

As a practicing physician, I felt the burden of a broken SGR payment system for many years. With half of my patients covered by 

Medicare, the threat of significant payment cuts was very real and 

jeopardized the viability of my practice every year. 

How could I justify hiring people to provide patient education 

and care coordination when I would have to lay them off if Medicare cuts went through? 

How could I continue to provide services in our most under 

served area, my Gallup clinic, if the Medicare cuts meant that I 

couldn’t make payroll? 

The passage of MACRA now provides physicians with the opportunity to focus on our patients by creating a single performance reporting program, known as MIPS. The law gives us the opportunity 

to streamline measures, reduce reporting burden and create flexibility to encourage physicians in every specialty to participate and 

improve care. 

MACRA also promotes innovation by encouraging new alternative payment models. APMs can be tailored to specific patient 

populations to drive care improvement, leverage technology and 

promote new treatments. 

Importantly, the law acknowledges physician leadership is needed in developing APMs which not only promotes participation but 

protects patients and can drive down costs. 

To ensure physicians can take advantages of these MACRA improvements, the AMA is providing information and resources to 

physicians. We know that physicians are in many different stages 

of readiness for MACRA and few have detailed knowledge of the 

law’s requirements. 

The AMA is eager to work with CMS so that together we can 

teach all physicians how to avoid the penalties that could threaten 

the existence of their practices, especially those working in medically under served areas who lack the resources of larger more affluent areas. 

To improve outreach, the AMA has created numerous free online 

tools and resources to guide physicians. This includes basic information for those with little understanding of MACRA. 

The AMA had also created CME training modules that can provide assistance on key issues for MACRAs such as EHR implementation and team-based care. 

We are also helping physicians decide what path, either MIPS or 

APMs, is right for them by creating a payment evaluator tool to asVerDate Mar 15 2010 11:14 Sep 14, 2016 Jkt 037690 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X137MACRAPHREPASKOK080316\114X137MACRAPREPPDFM
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sess their practice. For those interested in moving to alternative 

payment models, the AMA has created this guide on physician-focused APMs. 

This tool walks through seven different models describing the 

components and benefits of each including examples on how the 

model could be implemented. 

My own experience with APMs have shown that when physicians 

have the opportunity to innovate, these models can be successful. 

In 2012, I received a CMMI grant to replicate across the country 

how my practice was providing cancer patients with better care at 

a lower cost. 

By implementing a medical home model, we were able to cut hospitalizations in half. This is a model for chronic care management. 

CMS must now implement MACRA to ensure that the law successfully achieves the goals intended by Congress. Knowing that 

the devil can be in the details, the AMA has provided CMS with 

guidance from physicians to inform its proposed rule. 

We have convened specialty and State societies to build consensus and have created a MACRA task for as well as two work 

groups, one on MIPS and another on APMs, to examine specific 

issues related to our program. 

In addition to our comment letters and responses to RFIs we’ve 

also held listening sessions for CMS and other stakeholders to inform MACRA implementation. 

In conclusion, we are hoping the forthcoming regulations from 

CMS will promote the smooth and successful implementation of 

MACRA by consolidating and improving current reporting programs, providing broad opportunities for participation in the APMs, 

addressing current concerns with methodologies of performance 

measurement and providing physician practices with CMS data 

needed to evaluate the models. 

MACRA provides the opportunity to help every physician in 

every practice setting make the changes that provide meaningful 

improvements in the care they give to the patients they serve. 

We thank the subcommittee for your continued efforts on this 

issue and look forward to working with you to ensure a successful 

start to MACRA. 

[The prepared statement of Dr. McAneny follows:] 

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Mr. PITTS. The Chair thanks the gentlelady and now recognizes 

Dr. Bailet, 5 minutes for his opening statement. 

STATEMENT OF JEFFREY BAILET 

Dr. BAILET. Chairman Pitts, Ranking Member Green, and distinguished members of the Energy and Commerce Subcommittee on 

Health, thank you for the opportunity to testify on behalf of Aurora 

Health Care, the largest private employer and the largest integrated healthcare delivery system in the State of Wisconsin. 

I am Dr. Jeffery Bailet, co-president of Aurora Health Care Medical Group and one of the largest multispecialty medical groups in 

the Nation. 

As an otolaryngologist head and neck surgeon and medical group 

co-president, I am responsible for co-leading 2,600 physicians and 

advanced practice clinicians who provide care to 1.3 million unique 

patients. 

Aurora’s diverse delivery system includes several rural community hospitals, urban hospitals, a psychiatric hospital as well as 

Aurora St. Luke’s Medical Center, the State of Wisconsin’s largest 

hospital. 

Thank you for extending this opportunity to speak on behalf of 

MACRA. I am pleased to be a leader of this transition not only as 

a medical group physician leader but also as co-chair of the physician-focused Payment-Model Technical Advisory Committee, or 

PTAC. 

I applaud Congress, particularly this committee, for incorporating the PTAC in MACRA as an advisory panel to consider 

physicians and other stakeholders’ proposals for new models of 

high value care. 

I am also fortunate to serve as chair-elect of the American Medical Group Association representing medical groups and health systems including some of the Nation’s largest most prestigious integrated delivery systems. 

I am pleased when standing in front of the physicians I support 

or speaking with physicians across the country that there’s no 

longer debate about the need to transition to value-based care delivery. 

Shifting the culture of the healthcare community to the importance of value is a huge accomplishment and our patients across 

the country will benefit. It is equally important, however, that regulators appreciate the need to proceed cautiously during this transition. 

Many physicians are in various stages of readiness for a valuebased payment system. There is and will continue to be a significant learning curve as providers begin to take on financial risk. 

When implementing the regulations for MACRA’s payment systems, CMS should recognize that the healthcare system will need 

time to adapt and learn how to function in this new payment environment. Providing an incremental approach that includes flexibility and rational exposure for financial risk will be vital in ensuring a successful transition to value-based payment. 

Congressional oversight of this process is needed and welcomed. 

Physicians, whether they are in small group practices, larger multispecialty medical groups or high-performing integrated delivery 

54 

systems must make significant investments to succeed in a riskbased environment. 

For example, Aurora launched a predictive analytic pilot focusing 

on preventing hospital admissions and readmissions. Using a predictive analytic tool, Aurora was able to stratify a population of 

heart failure patients who had an 80 percent or higher likelihood 

of needing to be hospitalized as a result of their disease. 

We then redesigned our care approach using health coaches, frequent proactive outreach and engaged patients to take active ownership of their treatment and health status. This effort helped Aurora reduce our congestive heart failure-related admissions by 60 

percent. 

To help solo and small group practices participate, Aurora is developing clinically integrated networks across our geographic area. 

For example, we helped found About Health, a clinically integrated 

network that enhances clinical quality, increases efficiency and improves customer experiences, providing access to care for about 94 

percent of Wisconsin’s population. 

About Health is an example of how partnerships in Wisconsin between integrated delivery systems and small group practices can 

create a culture of learning and fostering of best practices to improve quality of care and reduce costs. This effort also helps small 

groups and solo practices that wish to maintain their independence 

the ability to do so. 

It is vital that CMS continues to engage the stakeholder community. The healthcare provider community is eager to share its insights with CMS and to date CMS is making a sincere effort to engage. 

I encourage CMS to build upon these efforts as value-based parameters are being clearly defined. MACRA represents a realistic 

opportunity for healthcare providers to improve the quality of care 

while reducing healthcare spending. 

High-quality patient outcomes is paramount and the continuous 

improvement initiatives and redesigned infrastructure we have implemented at Aurora can serve as a guide to other providers. 

Also, Aurora seeks out better, more effective ways to deliver care 

from our colleagues around the country. Moving forward, Aurora is 

prepared to fully participate in the development of new risk-based 

payment models that have the potential to improve patient care 

and bend the cost curve. 

Thank you. 

[The prepared statement of Dr. Bailet follows:] 

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Mr. PITTS. The Chair thanks the gentleman. Thanks to each of 

you for your opening statements. We’ll now begin questioning. I’ll 

recognize myself for 5 minutes for that purpose. 

I’d like to begin with the APMs and then go to MIPS and we only 

have 5 minutes so we’ll just go down the line. Dr. McLean, what 

can physicians do right now to position themselves to succeed 

under an APM? 

Dr. MCLEAN. Well, I think an APM is a larger entity. For either 

of the two, let me say, to start off I think physicians need to realize 

that they need to have a good electronic records system. 

Most of what we’re dealing with now is really dealing with lots 

of data and a lot of physicians and smaller practices have not had 

to do that. 

They’ve had to start to if they’ve been keeping up with PQRS 

and some of those things, but you may know that PQRS I think 

recently showed that something like 50 percent of physicians in the 

country didn’t even report. 

It just wasn’t worth the effort to them. They’d rather take the 

financial hit than kind of put the systems in place to do so. Now 

with some of these things I think there’s a lot more motivation for 

physicians and physician groups to actually do that. 

So the first thing they need to do is make sure they have an electronic records system that’s able to do a lot of the things that are 

required here and simplistically. 

Mr. PITTS. All right. That’s good. 

Dr. Wergin, what can physicians do right now to position themselves to succeed in MIPS? 

Dr. WERGIN. They can go to our Web site and look at the resources we have. 

But for a starting point is recognize quality measures we hope 

that can be standardized and the collaborative quality measures 

will be measured and report to PQRS. You need to be a meaningful 

use provider of electronic health records, which can be challenging. 

In my own practice, I made it on the 90th day in the last few 

hours. I had to call two patients to call me with a question, which 

was hard because I practice in a Mennonite community who don’t 

have TVs or radios and they don’t have computers. So I had to find 

some non-Mennonites. 

You need to do that, and we recommend to our members to move 

towards the patient-centered medical home. In the MIPS or eventually an alternative payment model we feel that’s where you need 

to move. 

Even under MIPS on the fourth criteria you’ll get full credit for 

that, and we believe that’s a better delivery of care. 

Mr. PITTS. Thank you. 

Dr. McAneny, as you may know, this is our second oversight 

hearing on MACRA even before the proposed rule and this committee will continue to be vigilant in our bipartisan oversight to ensure that MACRA is a success. 

Can you speak from both your organization’s perspective and 

that of a physician of why oversight is important and the message 

you believe it sends to the physician community? 

Dr. MCANENY. Thank you, Mr. Chairman, for that question. I 

think it’s a very important one. The change in the opinions from 

63 

CMS that we are now going to have a partnership with physicians 

to move forward in creating alternative payment mechanisms is 

probably the most important change that we’ve seen for a while. 

As a practicing physician now I have the opportunity to have 

Medicare payment reflect what I actually do for my patients to free 

me from the face to face required encounters and let me actually 

create a system that will manage patients more effectively provides 

an incredible opportunity. 

From the AMA standpoint, we are working very hard to continue 

to work with CMS. We have provided information at their request 

for information. We’ve had listening sessions with CMS. 

We continue to convene specialty societies from all around the 

country to be able to work with their own specialty to try to create 

alternative payment methodologies that will work in that specific 

specialty and we recognize that in different communities with different needs and different levels of resources it will take a different 

method to provide these alternative payments for them. 

So we really have worked a lot with our physician guide to alternative payments, with our Web site offerings, our Steps Forward 

program to teach physicians what they need to know right now as 

they prepare and we very much look forward to seeing the proposed rule. 

Mr. PITTS. Before I go to Dr. Bailet, how would you characterize 

the general physician’s knowledge on the repeal of SGR and the 

passage of MACRA? 

Dr. MCANENY. Well, I think the general physician is thrilled to 

have the SGR repealed and to have that taken out from the sword 

that’s hanging over our heads. 

The average physician has—well, there’s a huge variation in the 

amount of information about MACRA. People know that it’s there 

but they don’t quite know how it’s going to apply to them yet. So 

all of the specialty societies have their work cut out for them. 

Mr. PITTS. Thank you. Thank you. 

Dr. Bailet, you note the importance of engaging with the specialist community in the development of APMs. Can you elaborate 

on where you see growth potential in the future for specialists playing a bigger role in new care delivery models? 

Dr. BAILET. Yes. Specialty care, being a specialist myself, they 

have a lot of influence on some of the care that’s delivered that has 

a higher price tag and the specialists that I talk to around the 

country are very actively engaged in trying to influence efficiencies 

and care delivery and they’re very sensitive and aware of the treatments that they’re offering and the cost associated with them. 

Again, it’s a learning curve so the physicians are becoming more 

familiar with the costs and essentially the end product of the care 

they deliver and it is a partnership. It is no longer silos of primary 

care and silos of specialty care. 

In order for us to be effective and efficient we need to work together as a team and it’s not just physicians, it’s also advanced 

practice clinicians. It’s nursing. It’s your care team. That is the 

only way we’re going to maximize the potential of the health system and deliver the care the patients deserve at the expense and 

cost that is rational that will carry us forward. 

Mr. PITTS. Thank you. My time has expired. 

64 

The Chair recognizes Mr. Green, 5 minutes for questions. 

Mr. GREEN. Thank you, Mr. Chairman. 

Again, I want to thank our panel and you each represent different specialties and I just want to appreciate you taking your 

time and away from your practice. 

My question of each—what are you instructing your members to 

do to prepare for the transition whether under MIPS, fee for service or the alternative payment methods? 

Dr. McLean. 

Dr. MCLEAN. Well, I think the testimony gets into a little more 

detail but as other organizations the ACP has been working very 

hard to put resources together that are available online as well as 

in multiple publications. 

The ACP has worked for years on trying to help internal medicine and its subspecialty practices kind of do the right thing 

through the practice organization. So for a number of years, there’s 

been stuff on their Web site and resources about becoming a patient-centered medical home and on how to pick out health records 

something called EHR partners. So there are resources available to 

try to make it easier for physicians to go through some decision 

making on some of those things. 

As we now have MIPS and APMs we’re taking some of those resources that were already there and developing them into something that’s really germane to what we’re talking about now so the 

physicians can have help making the decision. You know, do I—am 

I in an organization that’s going to qualify as an APM or do I need 

to kind of go the MIPS path because that’s kind of one major fork 

in the road that people or that physicians will need to decide. 

Mr. GREEN. Thank you. 

Dr. Wergin. 

Dr. WERGIN. Well, I think it’s—I hope this is on—I think it’s a 

challenge for our diverse group. We go from rural communities like 

mine of 2,000 people up to large healthcare systems. So we have 

to go where our members are. 

But I think in the long run it still comes down to comprehensive 

coordinated care. That’s what we can provide to an APM. When I 

go out to States, I am kind of amazed. A lot of people have heard 

of MACRA but not a lot of details. So we try to begin the education. 

They’re holding back. 

We said now is the time to act and move forward to, you know, 

to being the transformation of your practices to prepare for 

MACRA. 

So we have tools on our Web sites. When I’m there talking to 

them for the smaller practice virtual groups or the TPNs or some 

of the assist granted money that that way can do it to band together and create the infrastructure to keep them alive. 

They’re important and when they complain I said, do you want 

to go back to 20 percent cut. In my practice, it’s 35 percent Medicare. It would have probably been the end of my practice. I couldn’t 

boutique it. They’re my neighbors. 

I can’t say I can’t see Medicare anymore. Couldn’t anyway from 

a business plan. So we want to prepare all our members in whatever form their practices take and give them the resource to prepare for it. 

65 

Mr. GREEN. Dr. McAneny. 

Dr. MCANENY. Thank you very much. 

Again, we start out with the idea that we need to have a tool and 

we’ve created one that will help physicians try to learn whether 

they’re better off in MIPS or in MACRA or in the alternative payment model of MACRA. 

We also are working very hard to make EMRs—electronic health 

records—into the functionality that they need to have. 

One of the very important things that all practices are going to 

need is to be able to have the date both their own internal data 

and claims data back from Medicare so that we know how we’re 

doing. And it doesn’t help us at all if we get data six months or 

a year later. How can you change when that happens? You’ve already lost a year. 

So we’re trying to work with CMS to modify the electronic health 

records meaningful use processes so that those become tools that 

really help us as we engage in patients and not just data collection 

instruments and we will continue to work, as the others have mentioned, with educating our members as to what their options are, 

how to get prepared for this, how they can look at creating quality 

measures. 

The other thing that’s very important that I think the AMA is 

doing is working with multiple specialty societies to create quality 

measures that are not only good measures but are actually useful 

as they work to transform their own practices. 

Mr. GREEN. OK. I only have a few seconds left. 

Dr. Bailet, I was just wondering—you know, Congress subjected 

physicians for 18 years to the SGR and uncertainty. Electronic 

medical records is such a vital part of what we’re doing. 

Your accountable care organization, Aurora, is redesigning several approaches to patient care, especially in the area of heart failure and COPD. Can you describe these and also if you’re suggesting in your practice and your other physicians anything different than what the other specialties make? 

Dr. BAILET. Well, I’m answering the question from the perspective of a medical group leader and I will say that there is anxiety 

amongst the physicians that I support mostly from not knowing exactly what the rules are going to be, how this is going to play 

through their practice at the individual level and it behooves us as 

leaders to support them and to help them understand that we’re 

here—we’re here for that support and unburdening their practice. 

I want to be clear: The electronic health record is the foundation, 

but it is nowhere going to get us where we need to be if we cannot 

take the data, analyze it and reflect it back to the practice in ways 

that are actionable, that are actually going to impact patient care, 

then it will just be noise that’s out there and the physicians will 

get continually frustrated and they won’t be able to do what they 

need to do for their patients. 

So we have to develop a culture of learning, a culture of continuous improvement and to maximize the data in a way, as I said, 

that it becomes actionable at the patient level. And that is not a 

small initiative and undertaking. I want to be clear that yes, you 

can buy an electronic health record, yes, you can deploy it and yes, 

you can teach your physicians and clinicians to use it. But until 

66 

you develop the infrastructure that can analyze it, compartmentalize it, can stratify your patients where you’re going to need to 

deploy your resources in the most critical areas, you’re not going 

to be able to provide the kind of care at the cost that is going to 

make this successful. 

So I just want to caution that it’s going to take time build all 

that infrastructure in and my concern, and maybe that’s too strong 

a word, but my cautions is that we cannot move too quickly. 

I know there’s a pressing urgency to move forward and I respect 

that. But I also think if we go too fast and we strip out the physicians who are already struggling with burnout—one of my colleagues mentioned that today—this could tip things out of balance 

and that would take something as wonderful as MACRA and essentially harm its ability and its effectiveness and I really don’t want 

that to happen. 

Mr. GREEN. Thank you, Mr. Chairman. Thank you. 

Mr. PITTS. Chair thanks the gentleman. I now recognize Dr. Burgess, 5 minutes for questions. 

Mr. BURGESS. Thank you, Mr. Chairman, and I hope our friends 

at the press table were paying attention to that discussion of Dr. 

McAneny and Dr. Bailet—that you all—I mean, that was some of 

the most optimistic forward-looking stuff that I’ve heard. The ability to use predictive analytics, the ability to use data in real time, 

not 2 years later—this is what doctors want to do and the thing 

that used to bug me about pay for performances I never drove to 

work in the morning saying, boy, I hope I’m average today. 

No, you go to work every day and do your best work and you’re 

talking about why don’t we make things so that they can provide 

doctors the platform to do their best work and that’s enormously 

optimistic. 

Dr. Bailet, I’m like you. I mean, I get to go talk to doctor groups 

all over the country. I recognize that most of the people in the room 

are my age or older and most of them, if they’re not burned out, 

they’re very close and by the time I finish my talk about what 

we’re going to do in their practices they’re checking their retirement plan to see how—you know, how many more days they have 

to work, not how many more years. 

So this is important. We all recognize we have a personpower 

problem—manpower, womanpower problem in health care, especially in our physicians and we run the risk of making it worse. 

And this is one of the things that was so important to me when 

we tried to reform this. 

I think, Dr. Wergin, you said—you used the phrase it takes the 

joy out of practice, and I’ve used that phrase on the floor of the 

House. Nothing pulls the joy out of the practice of medicine like realizing your Congress is going to whack you off at the knees December 31st every year for, what was it, 17 years. 

I mean, that is—that is a joy-killing exercise if there ever was 

one. So, again, this is an optimistic hearing today and it’s forwardlooking hearing and I’m grateful for that. 

Dr. McLean, on the—on this wonderful brochure that—is this 

yours or is it Dr. Wergin’s? Dr. Wergin. And, you know, unfortunately we don’t have this where everyone can see it. But, you 

know, if you just run through your physician payment time line 

67 

that you’ve got over there on the—on the right hand side, OK, the 

doctor says, I’m just not going to do a darn thing—I’m sick of Congress, I’m sick of rules, I’m sick of CMS—I’m not going to do a darn 

thing. 

Well, actually you might wake up in 2019 and realize oh my 

gosh, I got a 4 percent ding. Now, you didn’t get a 27 percent ding 

so that’s an important point right there but you got a 4 percent 

ding and you could have gotten a 4 percent bump if you’d just done 

a little. 

So the important thing—the message here is for those people 

who are so frustrated they will not lift a finger until 2019 and then 

they look across the hall and say well, that guy got a 4 percent 

bump and I got a 4 percent ding—what do I have to do so I’m in 

the bump and not the ding group, you can actually start catching 

up then. 

And the folks at Legislative Council and Congressional Research 

Service and CMS referred to this as everybody gets an A. Well, it’s 

not quite that simple but we wanted it to be simple and we wanted 

there—and I think I certainly recognize that there was so much 

frustration out there that, OK, you come at me with a hundred new 

PLAs—that’s three-letter acronyms—I’m not—I’m not there. I’m 

not going to participate. 

In fact, I’m going to retire—I’m getting out. But if they don’t get 

out and they look around in 2019 I can go from the ding to the 

bump group and it is not that hard. Many of the things I’m already 

doing. 

I might already be emailing a patient. I might already be involved—engaged in performance practice enhancement activities 

and so be eligible for that. 

So thank you for making that kind of—I think it’s just critical 

that doctors do understand that yes, a lot of this stuff is really 

hard in the healthcare policy but some of it’s not and some of it 

makes sense. 

Your Mennonite stuff doesn’t make sense with a meaningful use 

but some of it makes sense. I will also confess to you I used to consider myself basically a medical home for my patients when I was 

in practice and I was the medical home until the wizards at CMS 

with administrative pricing decided I wasn’t worth it and didn’t 

pay me for it anymore. 

So I ran for Congress and that medical home is now abandoned. 

But it is that concept—let’s do the things for people that actually 

facilitate what we need done. 

And Dr. McAneny, you talked about physician leadership and, 

you know, that is so critical and this leadership has to come from 

within medicine itself. It’s not going to come from a consultant. It’s 

certainly not going to come from CMS. God knows it’s not coming 

from the Congress. 

It’s got to come from inside medicine itself. So think you for your 

efforts in making certain that your constituent members understand that and I’ll leave my last second for you to respond to that 

if you’d like. 

Dr. MCANENY. If I may, Mr. Chairman. 

Mr. PITTS. You may proceed. 

68 

Dr. MCANENY. The point that you made about we want everybody to get an A is the most important point because we can’t afford to leave any physicians behind when we are facing a physician 

shortage. We need to find a path forward for everyone and we need 

to understand that we’re not going to get it right with the first set 

of regulations. 

But we need to make this a rapid-learning process where physicians can try something, not be penalized for it but to have CMS 

as a partner with all of the specialty societies they work with to 

be able to move forward and come up with something that better 

serves the patients of the country. 

Mr. BURGESS. Great. Leave no doc behind, Mr. Chairman. 

Mr. PITTS. The Chair thanks the gentleman and now recognizes 

the gentlelady from Florida, Ms. Castor, 5 minutes for questions. 

Ms. CASTOR. Thank you, Mr. Chairman, and thank you all very 

much for being here today. It’s great to hear from folks on the front 

lines who are taking care of our families and neighbors back home. 

You all sound like many of the doctors and physicians that I 

interact with back home in the Tampa Bay area. They really are 

enthused about the opportunities of practicing medicine and focusing on value over volume but are a little bit concerned about the 

transition ahead. So we’re really going to need your help and advice as we go along. 

First of all, for all of you just a quick answer. Is CMS being 

proactive with you? Are they open to your comments? I know it’s 

still fairly early in this. Are they—and do you believe they have the 

expertise to work with you to develop these alternative payment 

methods? 

Dr. MCLEAN. So thank you. Yes, absolutely. I think that from the 

get-go since they rolled out the first, I guess, RFI last fall and the 

ACP—at least I can speak for them—sent in I think 40 pages of 

comments and question/answers and received tremendous feedback 

on that. There’s been an ongoing dialogue between our organization 

and people at CMS, and then with the second round of questions 

in the last month or two. So as with everyone else, we’re clearly 

very anxious to see what the final rules are going to be because I’m 

sure it’s not going to be perfect. 

Nothing ever is. But I think that thus far CMS has proven to be 

a very willing participant in conversations as is willing to listen 

and that’s critical. 

Ms. CASTOR. Do you all agree with that? 

Dr. WERGIN. Yes. 

Ms. CASTOR. OK. Great. 

Dr. WERGIN. I would say the same, and our response is we feel 

like they’re listening and we respond and try to be very specific 

and positive in what we would suggest and a key thing is keep it 

simple and reduce our administrative burden. 

Ms. CASTOR. And Dr. McAneny, you—in your testimony you raise 

some points. The population all across the country is not the same 

and you talked about how these alternative payment methods and 

MIPS are going to have to be tailored for populations. 

How do you think that’s going to work in areas of great health 

disparities? How do we ensure that doctors are available to take on 

those complex cases that are going to be especially difficult? You 

69 

wouldn’t want medical professionals to be—to have a disincentive 

for taking care of those populations. 

Dr. MCANENY. Well, I think that’s very important to avoid any 

of the disincentives. We need to make sure that as we do quality 

measures or performance measures that they are very useful for 

each individual practice. 

Making a physician take time away from the patients they serve 

to answer questions and fill out data fields that have nothing to do 

with what they do all day takes away a valuable resource of physician time. 

What we are trying to do at the AMA is to make sure that we 

have a variety of tools and recognize that this is going to have to 

come from the bottom up with CMS and Congress as a partnership 

rather than as a punitive entity so that when a physician says this 

would be what would benefit my patients we’re hoping that when 

the proposed rule comes out there will be enough flexibility in that 

to allow the creativity of physicians to be tested and, if it doesn’t 

work—and not all the models will work—we need to have the ability then to go back and change things without imposing penalties 

that threaten the existence, particularly of those rural practices 

and under served areas who are often hanging on by their fingernails now. 

Ms. CASTOR. I agree, and I think we’re going to have to be especially mindful. 

Dr. McLean, we have a very serious issue with graduate medical 

education and this arbitrary cap, I think, after the SGR the Congress, with all of your help, we have got to tackle this doctor shortage and focus on GME as well. But setting that aside, are we training the doctors of tomorrow to be ready for this kind of practice? 

Maybe we have been all along and then the SGR and volume 

over value took its toll but what do you see as the future of medical—— 

Dr. MCLEAN. Interesting question. I think in the last several 

years when you look at where graduating medical students go into 

residency there has been an uptick in primary care in medical 

fields. 

Until that time I think some of the finances of medical school 

debt and what potentially am I going to go into as a practice situation—am I going to—you know, my income is going to be related 

to what debt I have to pay was a big issue for I think a lot of physicians and helped drive physicians away from some of the primary 

care specialties which tend to be lower paying in aggregate. 

I think that the SGR being removed takes that cloud away somewhat. Is it going to drive, you know, a real difference I don’t know 

yet. At the same time, I think people who go into medical care now 

are going into it really for the right reasons. 

They know that it’s a complex field and it’s remarkably complex 

and they want to take care of patients, and in some cases I think 

there’s much more education on systems and big data and how do 

you fix populations. Population health is really a new concept in 

the last 5 or 10 years and I think there’s a bit more education 

about it at medical schools. So I think that they have a better 

sense of what they’re going to need to deal with going forward. 

Ms. CASTOR. Thank you very much. 

70 

Mr. PITTS. The gentlelady’s time has expired. The Chair now recognizes the vice chair of the subcommittee, Mr. Guthrie, 5 minutes 

for questions. 

Mr. GUTHRIE. Thank you. Thank you all for being here, and I 

met with a group—a physician group yesterday and they were asking a lot of questions about alternative payment models and so 

forth, and my point to them was if—you know, if a few dozen people or so sit in Washington, DC in a room and design all of this 

it’s not going to be successful. It’s got to be from physicians up— 

from practitioners moving up so that we can take it into account. 

So this panel is important and I appreciate the opportunity to 

have you guys before us and eagerly look for your input as we 

move forward because that’s how it’s going to work. 

But we’re also eagerly awaiting the proposed rule but I want to 

know about the proposed rule what are you guys most excited 

about? I’ll just open it to the panel. I’ll start to my left and start 

with Dr. McLean. What are you the most excited about by the opportunities that MACRA offers? 

Dr. MCLEAN. You know, I think to echo what Dr. Bailet said, I 

think the idea that we can take a lot of data that’s been floating 

around out there that we’ve been collecting in many ways and actually make it actionable incentivize is extremely exciting. 

There’s a lot of information on clinical guidelines that come out 

of there. Sometimes they changed from week to week, depending 

upon the topic and the organization that puts it out there. 

But physicians are confused—do I need to follow this or not. But 

clinical guidelines are a part of clinical practice. There are clinical 

measures that have been out there. 

Some are good, some are bad. How do we use them? If those kind 

of elements of clinical practice and trying to improve how well we 

can deliver high-quality care can be systematically kind of put into 

a situation where doctors are incentivized to use this data well. 

The electronic records that to some extent are almost a necessity 

are configured to use those elements well we can make a part of 

daily flow—work flow—and patients’ care will be better and more 

reliable and safer and physicians will be happier because they’re 

not checking off all these boxes just because CMS told them to. 

There’s actually a rhyme behind the reason and it’s been missing 

that up until now, I think. 

Mr. GUTHRIE. OK. Do you want to add? That was a pretty comprehensive answer but we’ll—go ahead, I’ll let you guys—— 

Dr. WERGIN. I would just say personally and for my members 

we’re excited about the opportunity to value primary care appropriately which hasn’t always been done and it was mentioned we 

need more primary care family physicians across this country in 

any setting—urban, rural, under served—and that’s an opportunity 

that finally moved us up to the plate. We’re excited about transforming our practices to patient-centered medical homes whether 

they be in the MIPS or APM models because our studies show that 

the physicians are happier. 

They’re there to see patients, not click boxes, not try to meet all 

these arbitrary guidelines or requirements, and I think that’s what 

team-based patient-centered medical home can do. 

71 

So I think valuing primary care more appropriately will give us 

resources to think outside the box, not face to face care all the 

time—all the other parameters that we can use. So we’re excited 

about it. 

Dr. MCANENY. Thank you for that question. Personally what I’m 

most excited about is that a week and a half ago my practice was 

selected to participate in the oncology care model, which is one of 

the, hopefully, alternative payments and we’re one of ten practices 

in the country that’s certified as an oncology medical home. So I’m 

hoping that the proposed rule will come out and say yes, that is 

an alternative payment. 

I’m also very excited about the idea that electronic medical 

records will become interoperable so I can share data with other 

people who are taking care of my patients without having to fax 

records back and forth and to be able to use the alternative payment from the oncology care model to maybe be able to hire a social worker. 

I haven’t been able to afford a social worker. Or perhaps a dietician to help my patients or nurses to have more time to spend educating patients about their choices. 

So I think what I see in my own particular practice will translate 

very well across the country and the AMA is going to work very 

hard with all of the specialty societies to find models that can make 

them as excited about what they’re doing as I am about what I’m 

doing. 

Mr. GUTHRIE. OK. So let me ask another question. We’ll start 

with you, Dr. Bailet, and we’ll work back the other way this time. 

So when we passed MACRA we envisioned it as a means to provide greater flexibility for physicians and not impose new burdens. 

Can you speak to the current burdens associated with quality programs in your practices and how you believe MACRA can lower the 

administrative burden while focusing on quality? 

Dr. BAILET. I think my colleagues will agree there’s so much repetitive reporting, overlap, gaps. It’s incredibly burdensome on the 

reporting today and I’m hopeful that in—you know, hopeful that 

the legislation will address that going forward. 

I think that that’s one of the biggest pieces and also how we engage the physicians with the reporting. I mean, there is in my own 

practice to some degree there is—there are gaps and disconnects 

where the reporting is a little down field. 

It’s not direct line of sight. So physicians want to do the right 

thing and we have to provide the information to them in a way 

that allows them to make changes that are relevant in the moment. 

And I would say that our current system doesn’t allow us to do 

that. I know you changed your question but I had an answer. 

Mr. GUTHRIE. Go ahead. 

Dr. BAILET. But it’s 0K—— 

Mr. GUTHRIE. Yes, as long as the chair—— 

Mr. PITTS. Go ahead. 

Dr. BAILET. I think MACRA has the opportunity to unleash innovation. We are essentially going to transform the care delivery. 

This is a very single moment in time where we’re going to make 

an impact and rally physicians and clinicians around giving them 

72 

ways and tools to better manage their patients and provide and reflect back to them results that actually make a difference. 

And we need to create the aura of desirability at a national level 

where it becomes group agnostic. The best practices, once identified, need to get pushed out quickly and I think these incentives 

will help foster that. So that, to me, is one of the most exciting 

things about the position that we’re in now. 

Mr. GUTHRIE. Thank you. I do have more questions but I’m out 

of time so I’ll yield back. 

Mr. PITTS. The Chair thanks the gentleman and now recognized 

the gentleman, Dr. Schrader, 5 minutes for questions. 

Mr. SCHRADER. Thank you, Mr. Chairman. Interesting panel and 

interesting discussion. It is nice to hear a fairly upbeat panel in 

front of us these days and you’re at the ground zero for making this 

whole thing work and I guess our job is to hopefully help you that 

way. 

A question—doesn’t matter, Dr. Wergin, I guess—how to the incentives, in your opinion, on MIPS and the APMs align in terms 

of the dollar value? 

Dr. WERGIN. Well, I think one of the things we supplied to CMS 

is if you base your quality payments or your value-based payments 

on the old fee for service world, we were relatively under valued. 

So we hope that they won’t use those criteria—the complexity and 

intensity of visits we have. 

But in general, I think we’re not afraid to be—step forward and 

have that comprehensive coordinated care piece that we do and I’d 

be remiss if I didn’t mention quality measures. 

When I have diabetics come into my practice and say what 

should my numbers be, doctor, I have to ask them what insurance 

do you have because if you’re Blue Cross, it’s this—if it’s United 

Health Care, it’s that. 

Huge opportunity for MACRA to say these are evidence-based 

standardized guidelines. Then I know what the field is like and can 

get them there. 

Mr. SCHRADER. So who decides the quality measures that are— 

how much do the physicians or other medical providers play into 

that? 

Dr. WERGIN. Well, again, it goes back to the payers and I think 

CMS has had a collaborative group, said 21, not 165—that’s the 

other thing that can be great. 

Usually in my area with six or seven different plans, payers, it’s 

set by the payer and there is physician input in that but they vary 

slightly, each one. So you can be a prime five-star physician in one 

and a one-star bum in the other, just depending on where you’re 

at and how they set their parameters. 

Mr. SCHRADER. So Dr. McAneny, is there—is there a form right 

now for medical providers to share in ways to succeed under a 

MIPS or APM model? 

Dr. MCANENY. I don’t think we have a—set up a forum for that. 

But one of the things we’re trying to do both through our 

innovators committee and through the AMA network of physicians 

working with all the specialty societies is to try to do some rapid 

learning and bring some of those forward. 

73 

Mr. SCHRADER. I think it would be a good idea to make sure folks 

could share and, you know, hey, I’m on—I’m doing the MIPS thing 

and here’s how I succeed—here’s—I’m going APMs and here’s a 

way you could succeed there. 

You know, a lot of—to your guys’ points these are small business 

men and women just trying to, you know, keep their practice open 

in addition to practicing great medicine and so they’re going to 

need some help. Their practice managers, hopefully, would be able 

to access some of the—some of the data. 

Dr. Bailet, with regard to EHR, I mean, I hear a lot of conflicting 

things when I go back home from my medical community. It’s yes, 

it’s really good—we’re getting into that interoperability or geez, it’s 

terrible—I can’t get my lab report to speak to my physician office, 

you know, and my—I come from Oregon. 

In my State it’s all pretty much Epic and so I’m totally confused 

as to if we’re winning or losing on the EHR front. And then to your 

comment, you know, the feedback to the physician or to the office— 

maybe it’s not the physician, maybe it’s the practice manager about 

hey, you know, I’m reading all this stuff and it looks like if I treat 

this pancreatic patient this way, based on national data that we’ve 

helped supply, is that stuff out there or is that the stuff you’re talking about hopefully will come? 

Dr. BAILET. Well, I think it’s embryonic. I mean, it’s coming on 

but it is not ubiquitous across the system right now. I think that, 

you know, electronic health records are not perfect and no one has 

quite figured it out. 

Epic, obviously, comes from Wisconsin. We transitioned. We were 

Cerner’s largest client in the United States. We had deployed it 

fully across our system and we decided after 20 years it did not 

give us the lift that we needed going forward and we changed it 

out, $300 million later. 

That is no small undertaking and I do believe there’s not a CPT 

code that you can charge for changing out your EHR. 

Mr. SCHRADER. Probably not. 

Dr. BAILET. But we believed, again, that’s just the platform. So, 

yes, there are predictive analytic models out there and I’m not advertising for one versus the other. 

But they’re just beginning to demonstrate the power and, again, 

approaching the diseases that matter. So heart failure, COPD, diabetes—these are the diseases where a lot of funds are being expended on behalf of our patients and I know a lot of our conversation has been talking about the financial piece. 

Obviously, that’s important. But I think we cannot—we cannot 

minimize the impact on really transforming patients and what we 

were able to do at Aurora by changing their health status. 

So they were going down a track of outcomes. We were able to 

take them off that track and improve their health status which, 

again, that’s where the predictive analytic tool provided us the insights to be able to do that. That is significant. 

Mr. SCHRADER. Excellent. I yield back, Mr. Chairman. Thank you 

all very much. 

Mr. PITTS. Chair thanks the gentleman and now recognizes the 

gentleman from Indiana, Dr. Bucshon, 5 minutes for questions. 

74 

Mr. BUCSHON. Thank you, Mr. Chairman. Thank you for holding 

this hearing. Thank you all for being here. 

I was a healthcare provider before and a heart surgeon, as probably many of you may or may not know. I trained at the Medical 

College of Wisconsin in Milwaukee, which Dr. Bailet is familiar 

with. 

Dr. BAILET. Yes. Yes, I am. 

Mr. BUCSHON. I’m going to make a couple of things—first of all, 

just to remind everyone, you know, provider reimbursement is 

about 8 to 10 percent of the overall healthcare dollar. 

Obviously, MACRA was really—is extremely important but getting it right is even more important. But I think it’s important for 

the American public to know that we still continue to have cost 

challenges in our healthcare system and addressing things at the 

provider level is only one part of the equation. 

That’s where, you know, I hope we’re not talking about a zero 

sum game when it comes to specialists and primary care because 

primary care clearly has been under valued in our system. 

That said, also as a specialist I can say that, you know, specialists are also very important. And so if we end up doing this very— 

this poorly where we address this as a zero sum game, resulting 

in provider reimbursement cuts for quality care depending on what 

type of medicine that you practice, the only thing that’s really 

going to result is access issues for the America’s seniors because of 

the—what I said earlier. It’s only 8 to 10 percent of the overall 

healthcare dollar. That’s why these hearings are extremely important. 

So since I trained at the Medical College of Wisconsin I’m going 

to ask Dr. Bailet—— 

Dr. BAILET. I knew it was coming—a question. 

Mr. BUCSHON. No, I know you’re not testifying on behalf of this, 

but you were selected to chair the Physician Technical Advisory 

Committee, PTAC. 

Dr. BAILET. Yes. 

Mr. BUCSHON. Can you just kind of go over and explain briefly 

to the committee what you perceive as the role of PTAC—- 

Dr. BAILET. Sure. 

Mr. BUCSHON [continuing]. Why you wanted to be part of it, and 

what role you think it’s going to play in development of physicianled APMs. 

Dr. BAILET. So PTAC was set up to be an independent advisory 

committee that advises the secretary of HHS on alternative payment models specifically related to physician-focused payment models. 

The committee started in January. We had our first public meeting in February. We have our second public meeting in May. 

As the chair, my goal is to because, again, the rules have not 

been released so the activities of the committee we are functioning 

and spending a lot of time familiarizing ourselves with each other 

because this committee needs to work at a high level. 

We’re also right now creating bylaws and rules of engagement so 

that when the rules are out we will be prepared to start looking 

at model proposals straightaway. 

75 

One of the areas that we’re working on and we’re looking at 

stakeholder input right now is what is the scoring system the committee is going to use to look at models—what are we going to look 

at as it relates to important elements—what weight will those individual elements get. 

We want to be able to have a transparent process that the stakeholders have input into developing with us but more importantly 

that they understand when they’re submitting models that the 

process for submission is streamlined, they know what needs to be 

in their models. We’re going to provide assistance as best we can 

for select submitters and, again, we’re advising. 

If you ask me 2 years from now what would I consider a success 

for the PTAC committee it would be that the committee has the 

level of credibility with the stakeholders but also the secretary and 

our recommendations have a high level of influence and we are 

willing and able to put together recommendations for models that 

in fact CMS will see the merits and undertake them. 

Mr. BUCSHON. That’s great, and I had a conversation with CMS 

earlier this week about the RUC recommendations on provider reimbursement and I also spoke to them about PTAC and my hope 

would be as exactly as you say is that the recommendations that 

you’re going to be creating in a very thoughtful and fact-based 

process, through a thoughtful and fact-based process we’ll be taking 

into serious consideration in contrast to sometimes RUC recommendations on provider reimbursement which seem to mostly be 

ignored. 

So developing these APMs can be a—I don’t want to necessarily 

focus on you but this—but I have this question for you. It can be 

very difficult for small specialties in diverse skills and medicines. 

Can you maybe—and anyone can discuss this—can you discuss 

the challenges with that and how PTAC might be able to engage 

in that discussion to help smaller practices and, you know, we talk 

about rural communities and others developing and participating 

in APMs. 

Dr. BAILET. Well, I’ll be brief and let my colleagues also answer. 

The PTAC needs to be reflective of the fabric of the United States 

and the care systems that are delivered from rural communities. 

We have communities in Wisconsin of towns of a thousand that 

we have to provide care for. So we need to as we look at models 

make sure that it’s inclusive of the population that we’re trying to 

treat. 

So yes, there will be large metropolitan communities and specialties that can put forth models but we also have to make sure that 

the elements of the model as we weight them reflect and respect 

the smaller communities and allow them to participate and—— 

Mr. BUCSHON. My time has expired so—— 

Dr. BAILET. Oh, I’m sorry. 

Mr. BUCSHON [continuing]. And I appreciate that input, and I 

would just reiterate that we do have to make sure that all of our 

communities are included. Thank you. 

Mr. PITTS. Chair thanks the gentleman and recognize Mr. 

Ca ́ rdenas, 5 minutes for questions. 

76 

Mr. CA ́ RDENAS. So thank you very much for enlightening us with 

your information, and hopefully we’ll learn more about what’s 

going on in the streets and corridors of your side of the world. 

But in a nutshell, if you could please expand on at least one example of how we could make sure that what is going on is being 

implemented for the benefit of our constituents, maybe some things 

that need to be clarified or at least one example of what we can 

help you do better. 

Dr. WERGIN. I could start off. The one area that I think it’s interoperability of electronic health record, and again, being a rural 

family physician that treats children to adults who sometimes or 

in other urban ERs I get 18-page fax notes from an ER that I have 

to go in and ask the patient why did you go to the ER and what 

did they do—I can see your mother was of Mediterranean descent 

but I don’t think that’s why you went to the ER. There’s lots of information there. It’s faxed into my record, making it nonsearchable. 

So I think one thing we could do is set a platform to push the 

vendors to say you have to have some level of interoperability that 

it will help me take care of your mother or your child when I have 

to coordinate that care, and that’s important. 

And one other point I’d make, if you look at Medicare expenditures 1 percent costs 23 percent, 5 percent costs 50 percent, I think 

the rule of thumb there is don’t let them get in the 5 percent or 

1 percent. That’s my job. 

Dr. MCANENY. I would add to that that one of the concerns that 

we have is what is nominal risk and defining nominal risk in such 

a way that I as a small practice managing physician can cope with 

it. 

For me, since I am not an insurance company, I do not have reserves. There’s other types of risk besides financial risk. If I hire 

a new employee I’m guaranteeing a salary and benefits. 

To me, that’s financial risk. If I’m leaving gaps in my schedule 

for same day patients to me that’s financial risk. So one thing that 

Congress in particular and this committee definitely can help with 

is to let CMS work with us for that understanding of risk and also 

let practices as they develop their measures give us a chance to try 

that. 

Help us along with what we need to learn from the PTAC and 

from the AMA and from other organizations so that we can try 

things. Some of it won’t work but don’t put us out of business if 

it doesn’t work because then we can’t serve the patients in that 

community. 

Mr. CA ́ RDENAS. So we’re not—just so the people watching on 

SPAN are clear, you’re not talking about trying things that puts 

the patient at risk—you’re just talking about administrative aspects of how to be more efficient and do a better job? 

Dr. MCANENY. I apologize for that. You’re absolutely correct. 

New structures of care—if we try a specific team approach if it 

doesn’t save money but it delivers better care we don’t want that 

one thrown out, the baby with the bath water. 

Dr. BAILET. Yes, I would agree. I think the flexibility is absolutely key that things like the definition of what’s nominal risk 

that may come out in the proposed rules but I think that’s a big 

uncertainty—what does that mean—and I think the goal is to 

77 

broaden the appeal of this to different size, different geographic 

area so that everyone can be trying to do this right. 

But it’s going to take some trial and error in some ways in terms 

of how physician practices do it. Clearly, we don’t want any sort 

of risk to be at the level of the patient. 

mean, there are other things where I think things need to be 

done well and carefully and thus far CMS has done, I think, a good 

job of getting our organization’s input on how to do it right but 

things like patient attribution, risk adjustment—those are really 

complicated concepts and I think it would really frighten physicians if they thought that bureaucrats in Washington were making 

those determinations and not the physicians who actually understand that a bit better. 

So I think really kind of making sure that CMS is going through 

that process the right way with the appropriate input, which 

they’ve done so far, is probably one of the most important things 

that you guys can do. 

Mr. CA ́ RDENAS. In the interest of time, I would love to hear more 

dialogue but my time is winding down. But how many of you have 

had the opportunity to personally get to know how health care is 

delivered in another country? So if you have, please say yes. If you 

haven’t—it’s not a criticism. I’m just curious because a lot of Americans think that we’re embarking on models and practices that nobody in the world has ever done and I don’t think that’s true. 

Heaven forbid we would admire another country for what they 

do. We wouldn’t do that as Americans but have any of you actually 

been to another country in the healthcare space and got to see 

what they do? Yes or no. 

Dr. BAILET. Yes. Yes. 

Mr. CA ́ RDENAS. Yes? One? So two yes, two no. Well, in the interest of time, a million more questions but not enough time. But 

thank you so much, Doctor, Doctor, Doctor, Doctor. Thank you. 

Mr. PITTS. Chair thanks the gentleman and now recognizes the 

gentlelady from North Carolina, Mrs. Ellmers, 5 minutes for questions. 

Ms. ELLMERS. Thank you, Mr. Chairman, and thank you to our 

panel. I’m going to follow up on the gentleman’s line of questioning 

because I was going to ask about nominal risk and how we should 

be best defining and in your opinion—and this is going to go to the 

entire panel—on some more of this discussion because I think this 

is very, very important, especially for individual physician practices. 

You know, we sometimes take the hospital setting which, obviously, has a little bit more ability to incorporate and utilize those 

resources for a better product where our physician practices, you 

know, really have minimal resources to dedicate. 

So, one, you know, and it goes into the discussion of interoperability. That has to be part of what is considered in that risk as 

well, I believe. 

So I look at risk as how are we able to better empower our physician offices to be able to—to have that ability to share information, 

one, the infrastructure itself, the HIT—the health records themselves and establishing the personnel. 

78 

And this is kind of that conversation that we’ve been having now 

for a couple of years and the promises that were made initially 

that, you know, we were just going to go through this learning 

curve and everyone was going to be in a better place obviously has 

not taken place yet and it’s very difficult for our physician offices, 

especially with all of the other rules, regulations, changes in health 

care that have taken place. 

So I guess I just want to hear a little bit more conversation from 

all of you on what we do need to be doing here in Congress to help 

all those things, especially when it comes to the interoperability. 

How can we help physician offices to be able to have that knowledge on that patient when they come to the office after being seen 

in the emergency room? How can we make sure that that information is being shared and how can we better help our physicians to 

incorporate that as the risk that they’re assessing? 

Dr. MCLEAN. So I think that the interoperability is, obviously, a 

big issue and I think has been one of the frustrations that even as 

physicians have gotten into electronic health records they can’t access data elsewhere, and what I’d mentioned earlier—big data. 

You know, part of big data is big data at the small practice level 

and what do I need to access and my patient, who was at an ER 

at another part of the State. But then there’s also the big data of 

if in fact my practice small or large is looking at my population of 

patients and my population health, which is kind of whole other 

concept when you’re looking at trying to deliver good care, making 

sure that, you know, all of my diabetics have X, Y and Z done because there are people that fall between the cracks. 

And until you’re able to look at big data and have the analytics 

to do it you don’t even know that. Everyone thinks they’re doing 

a great job until they actually look at the data and they realize 

that there are things that they’re missing despite their good intentions. 

So interoperability is key to that and I think that while there are 

different State initiatives that have tried to break down some of 

those barriers I think at least in Connecticut it has not worked 

well. 

There was kind or a commission that was trying to do it. It just 

didn’t happen. I think other States have done it very successfully. 

I think Rhode Island in particular, if I can think of one. 

But I think a Federal guide to making interoperability happen 

because people need care across State lines. So even if you have 

rules in one State, it’s not going to necessarily, you know, work. 

So it’s really incredibly important to allow for accessibility of 

data for direct patient care but also for the big picture of big data 

analytics and data management when you’re looking at trying to 

take care of your population of people. 

Ms. ELLMERS. All right. Thank you. 

Dr. WERGIN. I had a comment about the virtual risk and, especially, again, being in a small practice, which, you know, there are 

actuarial pools of patients, but if you’re in a small, limited area or 

geographic, you can do it with virtual groups to get larger numbers 

of patients. 

79 

But how do you define what the nominal risk is for that pool, 

and that comes down also to the attribution process. We’d hope it 

would be prospectus—that we know what patients were. 

In primary care we’re responsible for and set up treatment plans 

and ahead of time rather than how it usually is. You get a list of 

patients and say who are these 10 people—I don’t even know who 

they are. 

So we need to know that, but a way to make these smaller practices pull together if that’s how they’re going to define nominal 

risk. 

Dr. MCANENY. A couple ideas that I would love to throw out. One 

is that a lot of States have tried to create health information exchanges yet some of the big institutions put walls around their 

data so that they can keep the patients to themselves and not let 

them go elsewhere. 

Those walls need to come down so that we can take care of patients wherever the patients want to be taken care of. 

The law of small numbers concerns me a lot in the attribution. 

If my primary care colleagues happen to have 10 patients with cancer that year instead of the 5 that they thought they would and my 

expensive drugs become attributed to them, they will have a problem in trying to be compared fairly. 

So we’re very concerned about being able to have good attribution and that’s still a science in its infancy. And the other thing 

that will help a lot is if we can get Medicare claims data back to 

us in a timely fashion because if I can see a problem and I can figure out a way to fix it, that gives me a lot more ability to take care 

of patients than if I learn about something 2 years later when I 

don’t even remember or have any idea what I did right or wrong. 

Ms. ELLMERS. Right. Absolutely. And I do want to add to your 

comment about, for instance, patients with cancer and, you know, 

the smaller practice because I know that, you know, CMS is proposing some more changes to Medicare Part B drug reimbursement 

and that is going to play in—and just there again if you don’t mind 

commenting. 

I didn’t really want to go into that aspect of this because it kind 

of gets into the weeds. But how do you think that plays into this 

conversation that we’re having today? Do you agree that it’ll become more difficult I guess is what I’m asking. 

Dr. MCANENY. Well, we didn’t come here to talk about the ASP 

changes so I’d be happy to talk with you offline about that issue. 

But yes, it’s very important to us. 

Ms. ELLMERS. And we will follow up with you on that. Thank 

you. 

Dr. MCANENY. I will. 

Ms. ELLMERS. Dr. Bailet. 

Dr. BAILET. So I concur the interoperability is a problem. I think 

that feedback so the CMS is going to be tasked with providing real 

time feedback on profiles of their effectiveness particularly in the 

MIPS and alternative payment models. 

So I, again, fundamentally believe, having led physicians for a 

number of years they want to do the right thing and they will respond to data that is meaningful and when they look at it it says, 

you know, this reflects my practice. 

80 

So that feedback is going to be important. So getting access to 

the claims data but in a way where, again, it’s real time and it can 

make a difference. If it’s too far out of line of sight the impact is 

going to be limited. So I think in the interests of time I would stop 

there. 

Ms. ELLMERS. Well, I just thank you so much and we went way 

over and I ask apology from the chairman. But thank you and 

thank you to the panel. 

Mr. PITTS. Chair thanks the gentlelady and now recognize the 

gentleman from Missouri, Mr. Long, 5 minutes for questions. 

Mr. LONG. Thank you, Mr. Chairman, and I am not a doctor but 

I did play one on the—play one on the radio for several years and 

I remember my first trip to my doctor on one of my semiannual visits after the passage of some call it Obamacare, others call it 

Greencare. 

But we—from somebody from Texas it’s hard not to get the word 

out. But on that visit to the doctor right after Obamacare had 

passed I thought I was going to have to prescribe him a blood pressure medication because he said—at the end of my visit he said, 

you sit right there—he said, you’re going to sit there and I’m going 

to turn around and I’ve got to enter all this into the computer. 

He said it used to be—remember what used to happen? He said, 

I’d send you out and you’d get your next visit and you’d be out of 

here, but you sit right there while I enter this. 

He was several years from retirement age, and he retired about 

six months after that. Such as my district director’s doctor also retired. I could go down the laundry list of people that have retired— 

doctors that have retired. 

And I do have something in common with the author of this, Mr. 

Green. Both of us have daughters that are doctors, and my daughter is a pediatrician who’s in her first year—wrapping up her first 

year of residency. 

So I’m sure the young doctors out there as my daughter is coming on want to know what’s going to be out there in the future. 

So with that being said, Dr. Wergin, you bring several unique 

perspectives to the panel. Can you describe some of the specific 

challenges of practicing in rural areas? 

I have a lot of rural areas in my congressional district and the 

pressures providers in similar situations face to remain in practice 

like my doctor. 

Dr. WERGIN. Yes, I think the rural providers that I represent and 

I represent personally—I am one—that you have limited resource. 

Mental health services, for one, are tough. That’s where telehealth 

might be able to help us. But we need infrastructure to do that. 

I mean, they don’t do it. But really finding the resources in your 

communities and identifying them and you have to be in—meaning 

using church groups. I use church groups for people that run out 

of food and it’s kind of nice because I don’t have to give them 5 

years of tax forms and all that. I just call the minister and say, 

this lady is out of food. So identifying resources in my rural areas 

and the challenges there. 

The other thing is burnout. Your patients love you and they almost love you to death. In primary care, our care is delivered. 

81 

We’re a continuous time in a relationship, tremendous confidence 

in my care. 

Sometimes I even have trouble getting patients to go to other 

providers and like Dr. Bucshon—they say, well, can’t you put my 

new aortic valve in, Dr. Wergin, and I have to say no, I got to draw 

the line somewhere on comprehensive. 

So I think that relationship-based care, and then I think the 

other thing we see is how do you recruit people—the millennials 

into rural-based care and in rural States I’m sure you face that is 

how do you—debt relief, there’s carrots out there you can give them 

but who’s going to take my place, et cetera. 

But the resource utilization you have, especially care, is usually 

miles away but they’re great in creating that and systems like in 

Wisconsin are a way to do it. 

But it’s a rewarding career but we have to sell that to the medical students and mainly their wives because they’re going to move 

to a rural area. 

Dr. BAILET. Or husbands. 

Mr. LONG. Dr. Bailet, in your testimony you discussed challenges 

faced by small, solo and rural practices also. Can you speak to your 

efforts to provide these critical access points of care with tools they 

can utilize to succeed, particularly through your clinically integrated network? 

Dr. BAILET. Yes. In these smaller communities we philosophically 

believe the care is local and should be delivered locally as best it 

can. But there are times when patients have to leave these smaller 

communities to get specialty care. 

So we spend a lot of time making sure that the physicians in 

these smaller towns and clinicians, because it’s not just physicians, 

have the resources—the support of a larger system. 

We try to create virtual outreach. So we have TelePsych, for example, that we’re offering these physicians. Again, for them to 

want to go into smaller communities they don’t want to be an island. 

They want to be connected to the physician community at large 

because, again, they want to have these assets for their patients. 

So the more we have these interconnected points with our patients whether it’s TelePsych or we have TeleStroke, we can bring 

those attributes out to the community so these physicians in smaller communities feel like they have a team behind them to be able 

to manage the patients. 

And yes, there are times when you have to convince the patients 

to leave the community for their care. But we work very hard to 

return those patients as soon as possible, again, with that electronic record, with that team support so that the physicians who 

are treating these patients feel like they have a safety net to be 

able to manage them if there’s a complication or additional questions that come—that come up. 

Mr. LONG. OK. I think I’m out of time so if I had any I’d yield 

it back. 

Mr. PITTS. Chair thanks the gentleman. That concludes the question from members present. We’re going to go to one follow-up per 

side. Chair recognizes Dr. Burgess, 5 minutes for a follow-up question. 

82 

Mr. BURGESS. Thank you, Mr. Chairman. This really has been a 

wonderful panel. I do feel obligated to mention since interoperability has come up so much this morning that yes, part of the effort in passing the H.R. 2 was to deal with that but then a larger 

effort is—has been included in H.R. 6, which was the Cures for the 

21st Century and that bill, of course, passed the House last summer and is pending before the Senate. So please don’t think we’ve 

taken our eye off the ball on interoperability. It remains an important marker to achieve. 

Dr. McLean, let me just ask you, and you all have been very 

thorough in your testimony today. But I’m always struck in dealing 

with the stupid SGR that it was the update adjustment factor that 

really did violence to doctors. 

Now, that’s the conversion factor. You talk about every doctor 

gets their own—can create their own conversion factor. And at the 

risk of being too wonky, can you kind of go through that at a high 

level so our friends in the press can get that? 

Dr. MCLEAN. No, no. I thank you very much. I’m very happy to 

answer that question. So I’m not certain how wonkish some of the 

committee is. 

But when the Medicare physician fee schedule is calculated on 

a fee basis—you know, it’s fee for service—there is every item, procedure, office visit, E&M code—evaluation management code, as we 

call it—has an RVU—relative value unit—kind of number and this 

is what the RUC works on, kind of changing and calculating year 

to year. 

And that number, that RVU, is multiplied times a conversion factor every year to end up giving you kind of the dollars per visit for 

a—whatever. 

And that conversion factor was changed—I mean, so with the 

SGR, depending upon what the SGR kind of kicked out as what the 

adjustment should be, that conversion factor for every service— 

physician service was cut by a certain percentage to begin with and 

then because the can got kicked down the hill it kept going—growing and growing. So it was, whatever, 28 percent in the—at the 

end. 

And so now it’s effectively—the conversion factor will be individualized based upon, for example, their MIPS score. So it’s tremendously empowering to physicians to kind of think that if I’m actually doing a better job in some of these various quality measures 

and things, I will be judged myself for how I did. 

And I think when we talked about burnout a little bit I think one 

of the—one of the factors of burnout in addition to regulation and 

trying to deal with EMR and other changes is that financial anxiety and the fact that now at least they have control over that anxiety I think is huge. 

Mr. BURGESS. What is the—you know, we talk about things 

being iatrogenic in health care. What would be the congressional 

equivalent of that? Because the anxiety—much of the anxiety that 

many of you have spoken about this morning was actually generated by Congress or the agency. 

It wasn’t directed—it wasn’t generated by physicians or the practice of medicine. There’s enough anxieties in the practice of medicine but we generated anxieties here. 

83 

Dr. Bailet, let me just ask you a question on that. We kind of 

covered some of the stuff with the physicians technical advisory 

committee. 

But can you give us perhaps a bit of a sense of how this compares and contrasts with the Center for Medicare and Medicaid Innovation that was also—is also one of the things that’s been visited 

upon physicians? 

Dr. BAILET. The CMMI? 

Mr. BURGESS. Yes. 

Dr. BAILET. Yes. So I think that the work that was done under 

CMMI was sort of planted the seeds of innovation and those kinds 

of models and our care designs that came out of that I believe 

they’re going to be contributing to the innovation that’s injected 

into the models that the PTAC will consider. I’m hoping I’m answering your question. 

Mr. BURGESS. Well, I guess the one philosophical difference that 

I see, CMMI is driven by the agency and it may or may not make 

sense to the practicing physicians. 

PTAC is driven by docs. 

Dr. BAILET. Yes. 

Mr. BURGESS. And my hope is that that will make sense to the 

practicing physician. Is that a fair assessment? 

Dr. BAILET. Yes. It has to. 

Mr. BURGESS. OK. 

Dr. BAILET. And I think that I’ve heard and I can say—speak for 

the committee to the individual level that is absolutely paramount 

and that is—that is the desire of this committee. 

Again, we respectfully understand that it is an independent body 

and an advisory body but absolutely, and we are—we are doubling 

down on our efforts to listen to the stakeholders and, frankly, our 

output is to some degree—to a large degree going to be as good as 

the input of the stakeholders as they come forward. 

Mr. BURGESS. Much of this—as the bill itself was into the development stages, stakeholders, especially groups’ physicians, would 

come to us and say we’ve been doing this for a while and we think 

this is a good idea. 

But we’ve got no way for CMS to—no way to bring it to CMS and 

have them evaluate it and incorporate it. And now PTAC actually 

provides that avenue and, importantly, if it’s not accepted people 

have to be told why it wasn’t accepted and my hope is that will 

give them another opportunity to impact it. 

Dr. BAILET. Resubmit. Right. Again, that is our plan, to come up 

with a blueprint for people to be able to follow and to provide advice and guidance to allow resubmission if there are challenges or 

potential weaknesses with their proposals. 

And, again, we want to be as comprehensive and transparency 

is key here to make sure that once we get the feedback from the 

specialty communities and the other societies that we develop a 

model that is transparent and anybody wherever they are, wherever they are in their readiness and abilities can look at this and 

say look, I want to participate—I want to create a model and they 

have—they have the blueprint that then they can apply their potential proposal in order for the PTAC to critically evaluate it, and 

84 

right now we are right in the middle of that—developing that process of analysis. 

Mr. BURGESS. Great. That’s the right answer. It gives me great 

peace. 

Mr. Chairman, I would just say after well over 10 years on this 

subcommittee one of my fondest wishes was to come in here someday and have a panel of doctors tell us how much economists 

should be paid. So if you all want to respond to that in writing I’ll 

be happy to listen. 

Mr. PITTS. All right. The Chair thanks the gentleman and now 

recognize Mr. Green, 5 minutes for questions follow-up. 

Mr. GREEN. Thank you, Mr. Chairman. 

Dr. Bailet, you brought up the potential impact of MACRA to 

transform patient care. Can you describe how you can see the 

APMs are beneficial to the—to the patients? 

Dr. BAILET. Well, I mean, these models are—the underpinnings 

of these models are to impact patient care to provide high-quality 

care, enhanced patient care, obviously, with smarter spending. 

But the elements in the models will be—the underpinnings will 

be moving the quality spectrum forward to make sure that that 

outcomes, and that really is the point of the round here is the actual outcome. 

You know, there are—there are metrics A1C—there are targets 

that we—that we strive for as a practice. But I also think what 

these APMs will be able to do across populations is actually look 

at outcomes, not just the fact that the diabetic patient has an A1C 

less than seven but what are some of the other parameters of their 

functionality, some of the other morbidity and mortality associated 

with the disease—what are we actually changing their health status and being impactful and I believe the APMs will allow us to 

do that. 

Mr. GREEN. Any of the other panel? 

Dr. MCANENY. Yes. I would like to add on that on a very personal experience because in participating in my oncology medical 

home process we’ve had—in order to have that money from the innovation center come to us to be able to allow the practices to 

spend money on nurse educators who could teach patients what’s 

going on, nurses doing triage on the phone. 

We brought patients in, 15 to 20 same-day visits every day. We 

cut the rate of hospitalization for cancer patients by over half. 

Patients were thrilled to be able to see us on the weekends and 

on the same day that they needed to see us. And so it was a very 

immediate way that we were providing patients because of this 

APM with the care that they needed when they needed it and 

where they could get it at a lower cost. 

Mr. GREEN. Dr. Wergin. 

Dr. WERGIN. I just had a brief comment. Moving away from a 

face to face volume-based system to an APM will give you the resources that is focused on the patient and the patient-centered 

home it starts with the name patient, and that’s what it means. 

You focus on the patient, the care they need, when they need it 

and that’s been addressed. So I think APMs can move not to just 

save money because I’m interested in that—more importantly, I 

want to improve the health of the community I live in. 

85 

Dr. MCLEAN. I was just going to add I think that moving—the 

APMs incentivize physicians and physician groups to get into kind 

of systems or affiliations that allow them to, as I mentioned before, 

to deal with big data, and that big data is not just seeing how 

many people, you know, got their A1C done in six months. 

But it’s looking at well, the people who didn’t what’s different 

about them—what happened—why is this group of people not getting, you know, diabetic foot exams. 

It allows people to kind of intervene and make a difference in 

health care, and when you’re in small kind of groups sometimes 

you don’t have that big data to do and as I say people fall between 

the cracks and you don’t even realize where the system is failing 

a lot of our patients. 

There’s less duplication, which saves money. Interoperability 

helps with that. I mean, it just—it aligns very many things into 

one kind of direction and that’s really one of the major things we’ve 

been lacking. 

Mr. GREEN. OK. Thank you, Mr. Chairman. I yield back. 

Mr. PITTS. Chair thanks the gentleman. That concludes the follow-up questions. We will have other follow-up questions in writing 

that we’ll send to you and other members who aren’t here will have 

some questions. 

We’ll ask you please to respond promptly. I remind members 

they have ten business days to submit questions for the record and 

that means they should submit their questions by the close of business on Tuesday, May the 3rd. 

Excellent hearing, very thorough testimony. Really exciting and 

optimistic hearing today. We’ll monitor closely this implementation. 

This is the second hearing. We will have more. 

We look forward to working with you. Thank you very much for 

coming and presenting your testimony and sharing your expertise 

with us. 

Without objection, the subcommittee stands adjourned. 

[Whereupon, at 12:08 p.m., the hearing was adjourned.] 

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