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2011

NEW MODELS FOR DELIVERING AND 

PAYING FOR MEDICARE SERVICES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

MAY 12, 2011

Serial No. 112–HL3 

Printed for the use of the Committee on Ways and Means 

( 


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COMMITTEE ON WAYS AND MEANS 

SUBCOMMITTEE ON HEALTH 

WALLY HERGER, California, Chairman 

SAM JOHNSON, Texas 

PAUL RYAN, Wisconsin 

DEVIN NUNES, California 

DAVE REICHERT, Washington 

DEAN HELLER, Nevada 

PETER ROSKAM, Illinois 

JIM GERLACH, Pennsylvania 

TOM PRICE, Georgia 

FORTNEY PETE STARK, California 

MIKE THOMPSON, California 

RON KIND, Wisconsin 

EARL BLUMENAUER, Oregon 

BILL PASCRELL, Jr., New Jersey 

JON TRAUB, Staff Director 

JANICE MAYS, Minority Staff Director 


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C O N T E N T S 

Page 

Advisory of May 12, 2011 announcing the hearing .............................................. 2 

WITNESSES 

Stuart Guterman, Vice President, Payment and System Reform, Executive 

Director, Commission on a High Performance Health System, The Commonwealth Fund .......................................................................................................... 5 

Lisa Dulsky Watkins, MD, Associate Director, Vermont Blueprint for Health, 

Department of Vermont Health Access .............................................................. 26 

Dana Gelb Safran, Sc.D, Sr. Vice President for Performance Measurement 

and Improvement, Blue Cross Blue Shield of Massachusetts .......................... 41 

Keith Wilson, M.D., Chair, Governing Board and Executive Committee, California Association of Physician Groups .............................................................. 52 

SUBMISSIONS FOR THE RECORD 

AARP ........................................................................................................................ 89

American Chiropractic Association ........................................................................ 93 

American College of Cardiology .............................................................................. 95 

American College of Rheumatology ........................................................................ 98 

American Geriatrics Society ................................................................................... 105 

American Occupational Therapy Association ........................................................ 111 

American Physical Therapy Association Private Practice Section ...................... 113 

American Physical Therapy Association ................................................................ 117 

Association of American Medical Colleges ............................................................. 120 

Coalition of State Medical and National Specialty Societies ............................... 122 

Garrison Bliss .......................................................................................................... 129 

PTPNSGR ................................................................................................................. 133 


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(1) 

NEW MODELS FOR DELIVERING AND 

PAYING FOR MEDICARE SERVICES 

THURSDAY, MAY 12, 2011 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON WAYS AND MEANS, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The Subcommittee met, pursuant to call, at 2:45 p.m., in Room 

1100, Longworth House Office Building, Honorable Wally Herger 

[Chairman of the Subcommittee] presiding. 

[The advisory of the hearing follows:] 


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HEARING ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

Chairman Herger Announces Hearing on 

Reforming Medicare Physician Payments 

Thursday, May 05, 2011 

House Ways and Means Health Subcommittee Chairman Wally Herger (R–CA) 

today announced that the Subcommittee on Health will hold a hearing to explore 

new models for delivering and paying for services that physicians furnish to Medicare beneficiaries. In what will be the first in a series of hearings on this topic, the 

Subcommittee will focus on models that have the potential to improve quality and 

constrain the rate of cost growth. The Subcommittee will hear from witnesses who 

are participating in delivery reform models. The hearing will take place on 

Thursday, May 12, 2011, in 1100 Longworth House Office Building, beginning at 2:00 P.M. 

In view of the limited time available to hear from witnesses, oral testimony at 

this hearing will be from invited witnesses only. However, any individual or organization not scheduled for an oral appearance may submit a written statement for 

consideration by the Committee and for inclusion in the printed record of the hearing. A list of witnesses will follow. 

BACKGROUND: 

The Sustainable Growth Rate (SGR) formula was implemented in 1998 as the 

mechanism that determines the rate by which Medicare fee-for-service payments to 

physicians are updated on an annual basis. The SGR limits the growth in Medicare 

physician service spending to the rate of growth in the overall economy. The formula 

is cumulative in that the tally of actual and target expenditures is maintained on 

an on-going basis since the formula’s inception. If expenditures are lower than the 

target, physician payments are increased. If expenditures are higher than the target, payments are decreased. As the rate of growth in expenditures on physician 

services has consistently exceeded the rate of growth in the economy in recent years, 

the SGR system has called for a cut in physician payments in each of the past ten 

years. Congress has intervened to avert the cuts each year since 2003 through numerous pieces of legislation. As a result of this legislation and the cumulative nature of the SGR, the magnitude of the projected cuts to physician reimbursements 

and the cost to override future cuts have grown. The Centers for Medicare and Medicaid Services (CMS) projects that physicians will receive a 29.5% rate cut next year, 

absent Congressional action. The nonpartisan Congressional Budget Office (CBO) 

estimates that freezing payment rates at their 2011 levels for the next 10 years 

would increase Medicare spending by $298 billion. 

The Medicare fee-for-service payment system provides an inherent financial incentive for physicians to increase the number of services they provide. The SGR formula has failed to constrain fee-for-service expenditure growth, primarily because 

of increased utilization but also because Congress has repeatedly passed legislation 

to override the cuts called for by the SGR. In addition, Medicare payments to physicians are currently made without taking into account the quality of the services provided. There is broad acknowledgement of the shortcomings of the current payment 

system and the growing importance of moving to payment models that incentivize 

patient-centered, high-quality, and outcomes-oriented care. 

In announcing the hearing, Chairman Herger stated, ‘‘There is widespread 

agreement that Congress must abandon the practice of short-term patches 

to avoid cuts to physician payment rates, which only make the problem 

larger and more expensive to fix. The SGR system creates tremendous uncertainty year after year forphysicians and Medicare beneficiaries alike. 

This hearing will enable the Subcommittee to hear details about other payment approaches that hold promise for driving high-quality, efficient care. 

The experience of those at the forefront of these innovative efforts will 


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help the Subcommittee as it considers how to better reimburse physician 

services.’’ 

FOCUS OF THE HEARING: 

The hearing will focus on innovative delivery and physician payment system reform efforts. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

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

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘Hearings.’’ Select the hearing for which you 

would like to submit, and click on the link entitled, ‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, submit all requested information. ATTACH your submission as a Word document, in compliance 

with the formatting requirements listed below, by the close of business on 

Thursday, May 26, 2011. Finally, please note that due to the change in House 

mail policy, the U.S. Capitol Police will refuse sealed-package deliveries to all House 

Office Buildings. For questions, or if you encounter technical problems, please call 

(202) 225–1721 or (202) 225–3625. 

FORMATTING REQUIREMENTS: 

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

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

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

to a request for written comments must conform to the guidelines listed below. Any submission 

or supplementary item not in compliance with these guidelines will not be printed, but will be 

maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word format and MUST 

NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised 

that the Committee relies on electronic submissions for printing the official hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

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

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone, and fax numbers of each witness. 

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

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

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

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

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

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

Chairman HERGER. The Subcommittee will come to order. We 

are meeting today to hear from four individuals who have experience to share that will inform us as we consider how to reform 

Medicare payments to physicians. This is a priority for the Subcommittee as Medicare physician payment rates will be cut by 

nearly 30 percent on January 1 unless Congress acts. 

The flaws of Medicare’s sustainable growth rate are well known 

to members of this Subcommittee. Congress has repeatedly enacted 

legislation to avert scheduled rate cuts that have been called for 


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under the SGR every year since 2003. This has created deeper 

holes for the following years, and next year, with the scheduled 30 

percent cut, is no different. 

These cuts could be devastating for patients and physicians, especially in rural areas like my northern California district. Many 

physicians have warned they will have little choice but to stop participating in Medicare, leaving seniors without access to the medical care they need. 

Republicans and Democrats alike have kicked the can down the 

road long enough. We cannot continue to patch over this problem 

with short-term fixes of a few months or a year at a time. The uncertainty of Medicare payment policies is taking a toll on physicians, and with each passing year the cost of a long-term solution 

grows larger. It is time that we work together to find a fiscally responsible solution to this problem. 

In addition, we need the physician and provider community to be 

willing participants in this endeavor to reform the SGR. Medicare 

spending is on an unsustainable path, and we must find a better 

way. 

This is the first of what will be a series of hearings the Subcommittee will hold on physician payment reform. It is my hope 

that by starting early, we will arrive at a payment system overhaul 

that can pass the House. 

Today we will explore innovative delivery models that are taking 

place across the country. The testimony we will hear shares a common theme that coordinated care produces more efficient care with 

better outcomes at a lower cost, and that fee-for-service delivery 

systems encourage higher spending without regard to quality. 

I believe that the future of Medicare depends on a transition 

away from the fragmented fee-for-service system to a system where 

the incentives are aligned with better patient care, not just more 

patient care. I am also open to hearing other ideas as we continue 

to explore alternatives to the SGR. 

Chairman HERGER. Before I recognize Ranking Member Stark 

for the purposes of an opening statement, I ask unanimous consent 

that all Members’ written statements be included in the record. 

Without objection, so ordered. 

Chairman HERGER. I now recognize Ranking Member Stark for 

5 minutes for the purpose of his opening statement. 

Mr. STARK. Thank you, Mr. Chairman, and I want to thank 

your staff for working with us to put together this first hearing on 

the SGR reform. It is not a partisan issue, it is a problem that has 

been around for more than a decade, and neither party has been 

able to enact a permanent solution. 

That said, it is not the Democrats that haven’t tried, and last 

year we passed a permanent reform of the SGR system that would 

have gotten us out of this annual kick-the-can approach, but our 

legislation would have essentially reset the existing system and 

started over with a formula that divided physicians into two 

groups, primary care, including the preventive service and specialty 

care, and with different expenditure targets for each group. While 

the physicians would still be accountable for spending growth, access to primary-care services would have been promoted by getting 

an extra allowance for the primary care. Unfortunately, only one 


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Member on your side of the aisle, Dr. Burgess, was willing to join 

with us in that legislation, but it was endorsed by virtually the entire physician community. 

Today’s hearing is going to focus on a component of reforming 

the physician payment system, delivery system reform, and I think 

we will hear the witnesses say that we have no chance of reforming 

that until we change the way we pay for medical care, and that the 

existing fee-for-service system merely incentivizes the provision for 

additional care. 

So our witnesses today provide great examples of experimentation going on across the country. I want to thank them for taking 

the trouble to be here. 

I also want to tell them that as an incipient receiver of cataract 

surgery in the next week, I can’t see you. I have your names down 

here, and you are kind of that nice blur, so if I misdirect a comment to you, please, please forgive me. 

Again, thank you, and I look forward to hearing our witnesses. 

I want to thank them for coming today and being so patient because of the voting schedule that necessitated our stretching this 

out into the late afternoon. 

Thank you, Mr. Chairman. 

Chairman HERGER. Thank you. 

Chairman HERGER. Today we are joined by four witnesses. The 

first witness will share ideas on how Medicare can encourage physicians to participate in care models supported by different payment systems. The following three witnesses will describe their efforts to promote high-quality care at a lower cost under these types 

of payment systems. 

Our witnesses are Stuart Guterman, who is vice president of 

payment and system reform at the Commonwealth Fund in Washington, DC; Dr. Lisa Dulsky Watkins, M.D., who is the associate 

director of the Vermont Blueprint for Health and an employee of 

Vermont Department of Health Access; Dana Gelb Safran, who is 

the senior vice president for performance measurements and improvement at Blue Cross Blue Shield of Massachusetts; and Dr. 

Keith Wilson, who is the chair of the governing board of the California Association of Physician Groups. 

You will each have 5 minutes to present your oral testimony. 

Your entire written statement will be made part of the record. 

Mr. Guterman, you are now recognized for 5 minutes. 

STATEMENT OF STUART GUTERMAN, VICE PRESIDENT, PAYMENT AND SYSTEM REFORM, EXECUTIVE DIRECTOR, COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM, THE 

COMMONWEALTH FUND, WASHINGTON, DC 

Mr. GUTERMAN. Thank you, Chairman Herger, Congressman 

Stark and Members of the Subcommittee for this invitation to testify on Medicare physician payment. 

I am Stuart Guterman, vice president for payment and system 

reform at the Commonwealth Fund, which is a private foundation 

that aims to promote a high-performance health system that 

achieves better access, improved quality and greater efficiency, particularly for society’s most vulnerable members, including those 


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with low incomes, the uninsured, young children and elderly 

adults. 

The Congress faces a challenging dilemma in considering Medicare physician payment. On the one hand Medicare spending is rising at a rate that threatens the program’s continued ability to fulfill its mission. On the other, the sustainable growth rate mechanism, which is intended to address that problem, produces annual 

reductions in physician fees that are equally difficult to accept. 

This dilemma arises from the underlying mismatch between the 

primary cause of rising spending, which is the volume and intensity of services provided, and the focus of the SGR, which is to set 

the fees that physicians receive for each service they provide. 

Determining how much to pay physicians certainly is an important issue, but what is critical is determining how to pay physicians so that the Medicare program gets the best care possible for 

its beneficiaries. 

We do get what we pay for in our health system, more volume 

and more intensity, with little reward for high performance either 

in terms of effectiveness or efficiency. We need to start paying for 

what we want; to reward providers for the kind of care they would 

like to be providing, but all too often are discouraged from or even 

penalized for under our current system. 

In changing how we pay for health care, we must recognize the 

diverse array of organizational models that make up the health 

care delivery system and the differences in the environments in 

which those organizations operate. 

Provider organizations vary widely in size, scope and degree of 

integration and in the extent to which they may be willing or able 

to assume broader clinical or financial accountability for their patients’ care. One size will not fit all, which means that payment 

and health care delivery reform must provide an array of payment 

approaches that apply to providers in the context of their current 

organizational structure, while at the same time establishing rewards and requirements that both encourage high quality and 

value, and provide incentives for those organizations to evolve as 

necessary to meet the needs of their community. 

The availability of more sophisticated and more substantial rewards for high performance for organizations that can deliver more 

effective and efficient care can be used to provide an incentive to 

move toward more coordination and accountability and away from 

the fragmented delivery system that patients currently face. The 

right incentives can encourage providers to work together either in 

formal organizations or in less formal relationships in ways that 

enable them to take broader responsibilities for the patients they 

treat and the resources they use, and to benefit from doing so. 

As organizational arrangements evolve, payment methods can be 

adjusted to encourage and reward increasing levels of accountability with continuous development and improvement over time, 

but even over time different payment approaches and organizational models may be required in different areas and different circumstances to accomplish the goals of health reform. 

An important vehicle for developing an array of new approaches 

to payment, organization and delivery is the new Center for Medicare and Medicaid Innovation in the Centers for Medicare and 


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Medicaid Services. The innovation center is mandated to pilot innovative payment and delivery system models that show significant 

promise for maintaining or improving the quality of care in Medicare, Medicaid and the Children’s Health Insurance Program, while 

reducing program costs. 

These pilots provide a mechanism for identifying, developing, implementing, testing and spreading innovative approaches to health 

care financing and delivery that can help improve health system 

performance. The underlying philosophy should be one of rapid development and spread of innovative payment and delivery models 

with the ability to move quickly, learn as one proceeds, and try 

multiple strategies rather than focusing on a single model; in other 

words, for CMS and other payers, as well as providers, to move beyond business as usual. 

Medicare, by promoting an array of innovations in payment, organization and delivery, could lead the Nation to higher health system performance and yield great benefits for individuals, providers 

and society as a whole. 

I am honored to be here with representatives of three innovative 

organizations and interested to learn more about what they are 

doing. Thanks. 

Chairman HERGER. Thank you. 

[The prepared statement of Mr. Guterman follows:] 


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Chairman HERGER. Dr. Watkins, you are recognized for 5 minutes. 

STATEMENT OF LISA DULSKY WATKINS, M.D., ASSOCIATE DIRECTOR, VERMONT BLUEPRINT FOR HEALTH, DEPARTMENT 

OF VERMONT HEALTH ACCESS, WILLISTON, VERMONT 

Dr. WATKINS. Thank you very much. Chairman Herger, Congressman Stark, Members of the Subcommittee, thank you for this 

opportunity to address you today. 

I don’t think there is any question that fee for service promotes 

volume and rushed care, as Mr. Guterman has pointed out. And 


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the point of the Vermont Blueprint is to address that very issue 

with an emphasis on moving in a transition from episodic or acute 

care to planned and preventive care. 

The Vermont Blueprint for Health is leading system delivery reform in our State and nationwide. We have been successful in some 

ways largely due to strong bipartisan support from our legislature 

and from our Governor over the last 8 years. 

The 2003 launch of the blueprint, in response to the overwhelming, looming problems with the cost of chronic disease, as we 

look at the baby-boom generation aging and increasing obesity-related problems such as diabetes and heart disease, was a very specific chronic-care initiative. It has since transformed significantly 

into a true spectrum of prevention with health maintenance that 

is appropriate to age and gender, now moving into pediatrics and 

‘‘birth to earth,’’ if you will. 

The overall goals are obviously to improve health care services 

both in terms of the outcomes that are able to be demonstrated 

clinically, as well as the experience with patient care; look at the 

health of the population as a whole; and control health care costs. 

Our innovations in terms of payment reform have been twofold 

and very specific. We are continuing with fee for service because 

that is the nature of payment in our country today. But, in addition, we have two new streams of funding specifically for primary 

care, which has been the emphasis of our work thus far. 

One, it revolves around true, enhanced payments on a per-patient, per-month basis attributed to those practices that are recognized as Patient-Centered Medical Homes through the NCQA recognition process, a grade, if you will, from 0 to 100. The higher the 

grade, the higher payment per patient per month. That goes directly to the practice. And this is not a function of lab tests or cutoffs that are punitive; this is truly a function of communication and 

access to the practice. 

A second new stream of funding comes to the practice and the 

community through the hiring of individuals at a Community 

Health Team, a very novel approach to actually care coordination 

at the local level. These multidisciplinary, locally based care-coordination teams serve multiple practices and actually do the outreach 

and coordination that desperately needs to be done in primary care, 

but is not compensated for and, therefore, often falls between the 

cracks. 

As I said, these are two new funding streams, and the innovation 

in Vermont has required that all insurers who do business in the 

State of Vermont, our major commercial payers, Vermont Medicaid 

and now Medicare, will be joining us to actually pay for these innovations. So it is additional funding to the primary care practices to 

benefit the patients and their families. The Center for Medicare Innovation has made that possible through the Multipayer Advanced 

Primary Care Practice Demonstration, allowing Medicare to join 

with private insurers and Vermont Medicaid in these innovations. 

We do have trends that are very encouraging in terms of cost 

and decreased utilization. A lot of that detail obviously cannot be 

shared in 5 minutes, but we are actually seeing decreased utilization of emergency rooms and inpatient days, both of which are exVerDate Mar 15 2010 05:06 Dec 02, 2011 Jkt 070868 PO 00000 Frm 00031 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\70868.XXX GPO1 PsN: 70868

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traordinarily expensive. And this is very encouraging as we look at 

our trends. 

We have over 2 years of experience now in our first pilots. We 

are rolling out to the entire State because we have legislation that 

mandates that the insurers continue to allow us to do this work 

and actually support every primary care practice in the State of 

Vermont that chooses to be part of them. 

Our evaluation infrastructure is extraordinarily robust. We are 

very excited to have probably more data than we will know what 

to do with, hopefully within the next year or so, both in terms of 

clinical data, experience of care, as well as a return-on-investment 

model that is allowing us to look at the financial impact and examine the efficacy of our program. 

I don’t have enough time to describe the anecdotes, but I think 

I can really very clearly state that in terms of the experience of 

this program, that both providers and patients are extremely 

happy with it. Patients will describe the sense of feeling someone 

cares about them, really wrapped around them, and getting services that fall far outside the normal traditional health care experience of going to the doctor’s office. And the providers who have 

been involved in this process through these last couple of years 

have actually said in very clear terms and in public that the joy 

of the practice of medicine is back. 

Thank you. 

Chairman HERGER. Thank you. 

[The prepared statement of Dr. Watkins follows:] 


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f 

Chairman HERGER. Ms. Safran, you are recognized for 5 minutes. 

STATEMENT OF DANA GELB SAFRAN, SC.D., SENIOR VICE 

PRESIDENT FOR PERFORMANCE MEASUREMENT AND IMPROVEMENT, BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, BOSTON, MASSACHUSETTS 

Ms. SAFRAN. Thank you, Mr. Chairman, Congressman Stark, 

Members of the Committee. I am Dana Gelb Safran, senior vice 

president for performance measurement and improvement at Blue 

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tunity to speak today about the work that we are doing on payment 

reform. 

As this committee considers the important issue of physician 

payment, and specifically the SGR, I am pleased to have this opportunity to share a model that has taken hold in Massachusetts. 

This work and its early results suggest that it may indeed be 

necessary to think beyond physician payment to consider overall 

system payment in order to realize the goal of sustainable growth. 

A holistic view of payment may also be necessary to reduce the 

fragmentation of care that we all recognize as a key failing of our 

current system. 

In 2007, Blue Cross of Massachusetts recognized that to address 

the unrelenting and unsustainable medical cost trends would require fundamental change in provider payment and incentives. 

With an annual medical spend of about $13 billion, we sought to 

develop a model that would do two things, significantly improve the 

quality, safety and outcomes of care, and significantly slow the rate 

of growth on that 13 billion. The alternative quality contract, or 

AQC, developed in 2007 and launched in 2009, was our effort to advance these twin goals. 

Approximately 40 percent of our provider network has now contracted under the AQC model. There are five features of the model 

that differ from our traditional contracts. First, a provider organization that enters an AQC contract agrees to accept accountability 

for the full continuum of care for their patients from prenatal care 

to end-of-life care and everything in between. This doesn’t mean 

that the provider organization itself must be capable of providing 

every aspect of care, but they must agree to be accountable for both 

the cost and quality of care provided to their patients, regardless 

of where it is provided. 

Second, the AQC contract is a 5-year deal, which is considerably 

longer than our traditional contracts. 

Third, payment is based on a global budget for a defined patient 

population. The AQC thereby moves way from fee-for-service incentives and establishes a model in which the provider assumes accountability for total medical spending on its patient population. 

Importantly, each AQC provider’s budget is set based on that organization’s historical rate of spending for its patient population. In 

this way providers are assured that their starting budgets contain 

sufficient funds to care for their patients, but have a strong incentive to spend those dollars prudently. 

A fourth distinguishing feature of the AQC is that the rate of inflation on total medical spending over the 5-year contract is negotiated up front and is designed to come down to rates approximating general inflation over the 5-year period. 

A fifth and very important feature of the AQC is that it includes 

financial incentives tied to performance on a broad set of quality 

and outcome measures. In total, the model includes 64 nationally 

accepted, clinically important measures of hospital and ambulatory 

quality. 

To our knowledge, the AQC is the first contract that requires 

providers to assume responsibility for the outcomes achieved 

through their care, not solely for the care delivered in the four 


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walls of their setting. The importance of this feature cannot be 

overstated. 

Finally, let me highlight some early results of the AQC. With respect to medical spending, year 1 results show the AQC is on track 

to achieve its original goal of cutting spending growth rates in half 

over a 5-year contract period. Each and every AQC organization 

was successful in managing to their year 1 budget and achieving 

savings, despite the fact that AQC groups vary enormously with respect to size, organizational structure, geography and, importantly, 

their prior experience with accountability for medical spending. 

With respect to quality, each and every AQC organization made 

significant improvements across a broad set of quality and outcome 

measures. By the end of year 1, quality of care in the AQC segment 

of our network was significantly higher than the non-AQC segment, and rates of improvement were several fold higher than prior 

improvement rates. 

These early findings hold several important lessons, but perhaps 

foremost among them is that the model provides evidence that a 

payment system that creates provider accountability for both medical spending and health care quality and outcomes appears to be 

a powerful vehicle for realizing the goal of a high-performance 

health care system with a sustainable spending growth rate. 

I thank you very much and look forward to your questions. 

Chairman HERGER. Thank you. 

[The prepared statement of Ms. Safran follows:] 


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Chairman HERGER. Dr. Wilson, you are recognized for 5 minutes. 

STATEMENT OF KEITH WILSON, M.D., CHAIR, GOVERNING 

BOARD AND EXECUTIVE COMMITTEE, CALIFORNIA ASSOCIATION OF PHYSICIAN GROUPS, DIAMOND BAR, CALIFORNIA 

Dr. WILSON. Thank you, Chairman Herger, Ranking Member 

Stark and members of the Health Subcommittee for inviting me to 

testify on potential new models of health care delivery and physician payment models for Medicare beneficiaries. 


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I am here representing the California Association of Physician 

Groups, also known as CAPG, and its over 150-member multispecialty and IPA groups. Together we care for over 15 million Californians, or one-half of the insured population of California. 

I am also here as a practicing physician and regional medical director of HealthCare Partners, a large multispecialty medical 

group, and IPA serving much of greater Los Angeles Orange County area. 

I would like to speak to the virtues of capitation in contrast to 

the unsustainable nature of fee-for-service medicine. I would also 

like to highlight the value of capitation leading to a system of coordinated, integrated care that is not usually replicated in the feefor-service model. 

In California we have over two decades of experience in making 

prepaid medicine work, and I would like to share with you some 

of the lessons learned. 

Capitation is great at creating an environment in which the atrisk provider groups are forced to focus on the total cost of health 

care and consequently figure out creative ways to impact the cost. 

This is usually best done by keeping patients as healthy as possible 

and out of the hospital. 

We have designed systems of care that treat the patient based 

on their individual need and disease burden so that we may improve and stabilize their condition. We do this through a patientcentric model, allocating resources in a targeted manner. 

My written testimony highlights a few of these creative interventions California groups have deployed, such as risk stratification 

and disease-specific care management programs. 

We have learned to protect the public from groups taking excessive risk and subsequent failure through the implementation of 

regulatory oversight by the Department of Managed Health Care. 

California groups are required to report quarterly on solvency 

metrics, such as tangible net equity, timely payments and cash-toclaim ratios, among others. 

We have also learned to avoid denial of care through public reporting of quality metrics and patient satisfaction scores deployed 

by the Integrated Healthcare Association. 

Health plans incentivize physician group performance through 

pay-for-performance quality metrics developed by multiple stakeholders. 

Capitation, if I might describe it a bit, consists of a fixed payment paid directly to the medical group, usually in the form of a 

PMPM, or per-member per-month payment. The physician group, 

or IPA, is then accountable for providing care for patients assigned 

to them within that budget. This payment methodology allows a 

predictable revenue stream that enables groups to plan for capital 

improvements and investment in infrastructure, like health information technologies. Indeed, some of the most sophisticated and 

advanced IT infrastructure exists in California groups as a direct 

by-product of capitation. 

CAPG has developed a Standards of Excellence program that allows groups to compare their internal processes and capabilities on 

a voluntary basis. This program also provides a roadmap to upVerDate Mar 15 2010 05:06 Dec 02, 2011 Jkt 070868 PO 00000 Frm 00057 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\70868.XXX GPO1 PsN: 70868

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and-coming groups, identifying the tools and capabilities they will 

need to provide patient-centered care. 

We think the California model can be a model for the rest of the 

country as we seek an alternative to fee-for-service medicine and 

to promote the spread of ACOs. We see the ACO model, however, 

as being handicapped, as they will need similar infrastructure to 

California groups, but there is no source of revenue such as capitation to benefit from. 

We call for the deployment of capitation as the law allows for 

groups that are ready to take risk. We also suggest a means of 

front-loading revenue to groups and potential ACOs be sought and 

found so that they can develop the systems of care necessary to be 

responsible for a population of patients. 

In closing, I would like to emphasize the superior performance of 

capitated model in delivering better quality, superior outcomes 

with great cost savings. One example of this is the comparative bid 

days between capitated Medicare in California yielding bed days of 

982 per 1,000 versus traditional fee-for-service Medicare yielding 

bed days of 1,664 per 1,000. This relative value to overall system 

in terms of dollars and cents is astronomical. 

I would like to thank you for the opportunity to speak to the 

committee today. I hope this information has been useful, and I 

would be happy to answer questions as I can. 

Chairman HERGER. Thank you. 

[The statement of Dr. Wilson follows:] 


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Chairman HERGER. I want to thank each of our witnesses for 

describing their involvement and efforts that use payment models 

that encourage coordinated, efficient care. One goal of today’s hearing is to understand the impact of Medicare paying physicians on 

a fee-for-service basis, including its contribution to the SGR problem. 

With that in mind, I would like to ask the three witnesses involved with different payment models to briefly state their view of 

the fee-for-service payment method. 

Dr. Watkins, if you could respond first, followed by Ms. Safran 

and then Dr. Wilson. 


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Dr. WATKINS. I believe the fee-for-service model has been severely detrimental, especially to primary care. I believe that is true 

nationwide and not just in Vermont. The sense that primary care 

providers have of being on a hamster wheel, of having to see patient after patient and being rewarded for seeing more patients in 

a day, as opposed to the quality of the services they provide, is a 

never-ending negative cycle. 

Chairman HERGER. Ms. Safran. 

Ms. SAFRAN. I believe you summed it up well in your opening 

remarks, actually, that fee-for-service payment system has delivered to us really what it was designed to, which is a system that 

incentivizes more services. 

But now we realize that more services don’t necessarily provide 

to us better quality or better outcomes for the patient population, 

and that, in fact, we will need a different system of payment if, in 

fact, what we are looking for out of our health care system is not 

simply a larger quantity of care, but better quality and outcomes 

of care. And also we will have to move away from a fee-for-service 

system if we look to resolve the fragmentation that we have today, 

because paying each for their own individual piece adds up to 

pieces not tied together as a whole. 

Thank you. 

Chairman HERGER. Thank you. Dr. Wilson. 

Dr. WILSON. Yes, sir. As a practicing provider, I have worked 

under both fee and payment methodologies, fee-for-service as well 

as capitation, and I can say pretty unequivocally that I much enjoy 

the practice of medicine in a capitated environment than I do in 

a fee-for-service environment. 

And as I have shared, you know, physician locker rooms with 

docs who practice fee-for-service medicine, the motivation behind 

those doctors’ behavior is vastly different than the doctors who 

practice under a capitated or a salary model. And I think patients 

oftentimes are harmed by fee-for-service models that are overly 

zealous, and they don’t lead to coordination and integration of care. 

So in summary, I would just say that capitation and/or other 

means of payment, even if it is just a salary model, lead to a purer 

form of medicine being practiced than fee-for-service, and I think 

patients benefit more in that model. 

Chairman HERGER. Ms. Safran, your health plans go by the Alternative Quality Contract Program of increased quality and a 

slower rate of growth as the one we share. I have a few questions 

related to your success in achieving these goals. How much has 

provider-spending come in under budget? 

Ms. SAFRAN. Well, in year 1 of the first 5-year contracts, every 

AQC provider organization came in under budget, and that ranged 

from 1 to 2 percent under their budget in what they were able to 

achieve in just the first year of savings. 

Chairman HERGER. Are you surprised that the AQC provider 

groups have fared so well on 64 quality measures of outpatient and 

inpatient care? 

Ms. SAFRAN. I was very surprised. I have spent my career as 

someone developing and implementing quality measures and have 

never seen anything like the magnitude of improvement on a very 

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tract. So it was really clear that not just the incentives that are 

in front of them that make a difference, though I will not say that 

they don’t, they are a very important piece, but also important is 

the fact that they are receiving, on an ongoing basis, information 

over the course of the year about how they are doing on those 

measures so that they are able to manage to success. And every 

one of those organizations has put in place leadership that is very 

much dedicated to working with the front-line physicians on that 

broad set of quality and outcome measures. 

Chairman HERGER. How have the AQC participants been able 

to reduce costs through important improvements, such as decreased hospital infections, so quickly? 

Ms. SAFRAN. Well, in year 1 of the contract, the improvements 

on spending really came through—more through the work on 

thinking carefully about where those providers were referring patients for things like standard laboratory tests and imaging and 

other forms of care in which there are no relationships in place, 

where, roughly speaking, it is a commodity service. And the provider now was quite aware of the fees that we pay for those services in different areas, and it became important to them to refer 

their patients to lower-cost settings for services where it was a 

commodity like a lab test or imaging. 

The harder work of reducing readmissions, changing overall utilization of care, reducing non-urgent ED use, is work that some of 

the more mature AQC organizations did make progress in, and significant progress, in year 1. But those types of more difficult 

changes are things that we know we are going to see greater 

progress on in years 2 through 5 over the contract. 

Chairman HERGER. Thank you. 

Ranking Member Stark is recognized for 5 minutes. 

Mr. STARK. Thank you, Mr. Chairman, and I would like to 

again thank the witnesses for their very informative testimony. 

Dr. Wilson, you have huge numbers in your groups. Now, are the 

Kaiser physician groups part of your group? 

Dr. WILSON. Yes, they are. 

Mr. STARK. They are, I gather, I have been led to believe, the 

largest professional partnership and the largest professional corporation in the country; is that not correct? 

Dr. WILSON. To my understanding, they are the largest professional physician group in the country. 

Mr. STARK. I know that in my district, or in the county that I 

represent, there are 1.2 million people, and half of them belong to 

Kaiser. They always say if you are run over by somebody, you have 

a 50 percent if you take them to the Kaiser emergency room that 

you are going to the right place. 

Do you think that the Kaiser model, the staff model, could be 

used in other areas? Kaiser has worked here in the Washington 

area with not any great success, because they have been unable to 

hire physicians, they have had to contract with groups, and they 

have had to rent hospital rooms the same as any other managedcare plan. 

But if we could establish some type of staff model outline, do you 

think that we could transmit that success to other parts of the 

country? 


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Dr. WILSON. The answer would be yes. I think, you know, there 

are obvious challenges in importing a new model of care to a delivery system, and, you know, often there is a requirement of critical 

mass before you can actually start to impact the culture of that environment. 

Kaiser, you are right, is the largest physician delivery system in 

the State of California. The company that I work for, HealthCare 

Partners, is the second largest physician organization in the State 

of California, with practices in Florida and Nevada. 

I know Kaiser has exported its model to other parts of the country successfully. Washington seems to be one of the exceptions in 

which it didn’t quite succeed, and, I guess, Maryland as well. 

But I do think the model is transplantable. I think physicians 

coming out of training now are more likely to seek a Kaiser type 

of practice than they are to hang their own shingles. I think, you 

know, that the types of doctors graduating training have changed. 

They are different than the doctors that graduated with me. 

But so in short, yes, I do think that model can be explored. 

I do think there are other models in California, I think, that are 

potentially more easily exported than Kaiser, because Kaiser is a 

bricks-and-mortar kind of organization, and so it requires significant up-front cost. And so, you know, the ability to just sort of 

plant that in an environment in which, you know, the economics 

haven’t been established is a little bit more challenging. 

But, you know, a large number of California physician groups, or 

IPAs, Independent Practice Associations, which don’t have the 

overhead of a Kaiser model, but do bring the infrastructure, the coordination of care, the integration, the IT capabilities and the other 

things that capitation, as I spoke of, lends itself to, but it is probably more easily transplantable. 

Mr. STARK. Thank you. 

Ms. Safran, do you suppose that the recent Massachusetts universal care law, or whatever it is, adds to the performance that you 

noticed in the insurance plans, or adds to the participation, I guess 

I should say? 

Ms. SAFRAN. Well, without question, universal insurance has 

drawn our attention now in Massachusetts to the cost of health 

care and importantly to the rate of increase in that cost. 

And so without a doubt the providers in the Massachusetts market are aware that attention is on cost, that payment reform is 

happening. They are very active conversations, not just because of 

our model, but in the State as a whole. So absolutely, I think that 

uptake of providers into our AQC model happened much more 

quickly because of the attention to costs that came upon us as we 

had universal insurance. 

Mr. STARK. And in the great State of Vermont, is there something we can learn there that can be exported? You are the only 

single-payer State; is that right? Or the only single-payer plan, I 

guess. 

Dr. WATKINS. We have legislation that was passed in this most 

recent session and will be signed into law by Governor Shumlin. 

That legislation could best be described as a first step towards an 

integrated payment system for the State of Vermont. 


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Chairman HERGER. Excuse me. The gentleman’s time has expired. Thank you very much. 

I recognize the gentleman from Washington Mr. Reichert for 5 

minutes. 

Mr. REICHERT. Thank you, Mr. Chairman. I will add my 

thanks to all of you for being so patient and waiting in our waiting 

room while we have been so busy voting. 

I have just jotted down some common themes here. I know that 

all of us—I think the good thing, as Mr. Stark has stated, we are 

all here, this is a bipartisan effort, recognizing that the patients 

are the focus of this effort, trying to provide high-quality health 

care, cost-effective and accessible, as we use those three 

descriptors. 

But the witnesses today have been pretty consistent in mentioning coordinated care, coordinated team, community care, overall system payment, holistic system, holistic approach, a full continuum of care, patient-centric model, coordinated, integrated. I 

think that is what everyone is hoping for and wishing for, and it 

looks like some of you on the panel today have at least begun to 

accomplish some of those goals in making the patient the center. 

I am really interested, of course, in the seniors in this discussion. 

And as we look forward to reforming the current formula, I think 

it is important that we ensure that our seniors continue to have access to quality and effective care and affordable care. So I think it 

is key—and this question is for Ms. Safran—it is key to communicate and educate our seniors. So under your AQC plan, is there 

an education component, you know, one where you would educate, 

especially seniors, or anyone under the plan for that matter, about 

their care provider now is an AQC plan member and, therefore, 

would deliver service in a different way? 

Ms. SAFRAN. The answer to your question is that we gave an 

enormous amount of thought to how and whether to do education 

for our members about the AQC, and in the end the plan has not 

done any kind of proactive outreach and education to our members 

about the AQC. And the reason for that is that the AQC has a contract with our physician network and, in some cases, with hospitals 

party to those contracts. 

Our members have bought products from us that still stand, that 

are unchanged by those contracts, and that in our experience, when 

we have a communication with our members, it won’t surprise you 

to know members get confused and worried when they hear from 

their health plans. And so we really hold ourselves to a standard 

that we will communicate with our members when there is something that they need to do, when there is something that they need 

to pay attention to. 

And as we struggled with what exactly would we tell them about 

the AQC, it wasn’t clear, in fact, that there is anything different 

that they need to do. And, in fact, when we had the impressive 

year 1 results, we thought again about communicating with them 

and saying—you know, congratulating them on how fortunate they 

are to be in practices like this. But in the end we have left it to 

the physicians to communicate if they want, but really there is 

nothing the plan needs to advise the members about. 


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Mr. REICHERT. There is nothing in part of the contract that 

would require the doctors to communicate any difference. And 

wouldn’t it be important for the patients to know that they are now 

in this holistic sort of preventive care arena, or they just, as they 

go through it, kind of realize that in communicating with their provider? 

Ms. SAFRAN. Well, I think they do realize it, and they realize 

it in a very positive way. That is to say, in order to be successful 

on the quality and outcome measures, these practices are interacting with their patients in a way that the patients, when they 

communicate with us, tell us that it feels like concierge care, but 

they never paid a concierge fee, because the practice is suddenly 

doing outreach to them between visits to let them know about care 

that they need, to find out how their management of their chronic 

condition is going and what barriers they are facing. So that is 

what the members and the patients are experiencing. 

Mr. REICHERT. I appreciate that. 

I notice that my time is getting short, and my next question is 

going to be a little bit longer, Mr. Chairman, and I will submit that 

question to Dr. Wilson in writing. 

[The information follows: Dr. Wilson] 


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Mr. REICHERT. Thank you. I yield back. 

Chairman HERGER. The gentleman yields back. 

The gentleman from Wisconsin Mr. Kind is recognized for 5 minutes. 

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

this very important hearing, and I want to thank our witnesses for 

your testimony here today. 

Listen, we have just gone through a very gut-wrenching health 

care reform debate ourselves here in Washington, and incorporated 

a lot of aspects of what is happening around the Nation. I assume, 

Ms. Safran, the Massachusetts model, too, is something that was 

under consideration. 

And I think the ultimate verdict on health care reform is going 

to be not only changing the way health care is delivered, but how 

we pay for it. I mean, it is replete with studies here that show that 

close to one out of every three health care dollars is spent on tests 

and procedures and things that don’t work. They don’t improve patient care. And oftentimes, because of the overtreatment patients 

are receiving, they are being left worse off rather than better off. 

That is close to $700 billion a year in a 2.3-, $2.4 trillion system 

that we are not getting a good bang for the buck for. 


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And I have been encouraged hearing the testimony here today, 

and perhaps there is an opportunity for some bipartisan cooperation to move forward on a lot of the reforms that you are all testifying about, a more integrated, coordinated, patient-focused care 

system. 

Now, for the sake of full disclosure, I come from a country, western Wisconsin, that has the Mayo system in it, Gundersen, 

Marshfield, Dean, that are doing this already and producing tremendous results. And it sounds like that is a model that we should 

be encouraging. And, in fact, it is something we incented in the Affordable Care Act, those types of models of care that are more coordinated and patient-focused, which is really at the heart of the 

Affordable Care Act, including payment reform. 

And I am convinced that fee for service, as I am hearing from 

all of you today, is an unsustainable model of payment for our 

health care providers. It is not fair to them; it is not fair to the patient. We are not getting a good bang for the buck, and how do we 

get to a value- or quality-based reimbursement system, that is 

going to be crucial. 

And, Ms. Safran, you were talking about the quality measurements that Massachusetts was just establishing, I think 64 criteria 

so—that you are using right now. My question to you is who is establishing those quality measurements, and what type of buy-in 

have you gotten from the practicing physicians and the care providers in Massachusetts for that type of criteria? 

Ms. SAFRAN. So, that was my job, to establish which measures. 

And we really drew from nationally accepted measures wherever 

we possibly could, so that means NQF endorsed almost every single 

one of those 64 measures. We then put the measures through some 

additional paces to be sure that we think they are ready for the 

high-stakes use involved, meaning attaching dollars to payment on, 

you know, a score. And it was important to us that that measure 

set include inventory and hospital measures, and that in both of 

those settings that the measures include clinical process, clinical 

outcome and patient care experience measures. So that is how we 

have—and they have been completely accepted because of the rigor 

that we paid attention to in the measures that we chose. 

Mr. KIND. Because some of the concern, I think, many of us had 

or shared in regards to what Massachusetts was moving forward 

on, so you are doing coverage before cost. And now it seems like 

you are trying to play catch up with the cost issue right now. And 

we are trying to get out ahead of that ourselves with the Affordable 

Care Act to not fall into a similar type of box as we move forward. 

I know it is very unfair to ask it, you know, because volumes and 

books can be written on each topic, but if I can get just a quick 

response from you on a couple of key issues, I think it is important 

as we move forward. 

The role of comparative effectiveness research. Important or not, 

Mr. Guterman? 

Mr. GUTERMAN. I think comparative effectiveness research is 

key, because if we are going to spend the vast amount of resources 

that we spend on health care, and if we are going to address the 

issue of the massive amount of waste in the health care system, we 

need to know how to spend that money more wisely so that we can 


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get a better return on it for our patients. And comparative effectiveness research is intended to provide information to help decisionmakers, the physician and the patient, make the decision for 

the appropriate care. 

Mr. KIND. Dr. Watkins. 

Dr. WATKINS. I completely agree with my colleague that it is 

absolutely essential. We have the opportunity, because of our involvement in the Multipayer Advanced Primary Care Practice 

Demo through CMS Center for Innovation, to actually work closely 

with our colleagues in other States and have a multi-State collaborative that is actually beyond those States involved. 

Mr. KIND. Ms. Safran. 

Ms. SAFRAN. No question that we need a better evidence base 

to guide us. Less than 3 percent of medical decisions are made 

every day—every minute of every day are based on solid evidence. 

Comparative effectiveness is absolutely one important way to do 

that. I think there are others, but we absolutely need a better evidence base. 

Mr. KIND. Dr. Wilson. 

Dr. WILSON. I would agree with all that has been said before 

me. Yes, comparative effectiveness would be good, and I agree also 

that too little medicine is done through evidence-based medicine. 

Mr. KIND. Now, another big role that we had here, unfortunately, under the Affordable Care Act was talking about reimbursing providers in regards to counseling for advanced directives. Good 

idea, Mr. Guterman. 

Mr. GUTERMAN. When decisions get made about medical care, 

having that decision be made between the patient and the physician is always a good idea. And the more information people have 

in making those decisions, the better it is. 

Mr. KIND. May I get a written response from the rest of the witnesses because I see my time has expired? Thank you, Mr. Chairman, for your indulgence. 

Chairman HERGER. Thank you. 

The gentleman from Pennsylvania Mr. Gerlach is recognized for 

5 minutes. 

Mr. GERLACH. Thank you, Mr. Chairman. 

Thank you for coming today and being part of the panel. 

Let me ask, Ms. Safran, in Massachusetts, a State that has undergone tort reform relative to medical liability and medical malpractice cases, and are there protections, medical malpractice protections, for physicians in Massachusetts, like, say, Texas and California, where there are caps on noneconomic losses in medical malpractice cases? 

Ms. SAFRAN. I apologize. That is a question that is out of my 

area of expertise. I would be glad to get the answer, though. I don’t 

believe there has been significant tort reform in Massachusetts 

that has been discussed. 

Mr. GERLACH. Yes, I don’t think so either, but I don’t know exactly if that is the case. But that really is the premise for my question, because I am thinking in the AQC model that you have, what 

has been the impact of an AQC contract with a group of physicians 

relative to how they otherwise may be practicing defensive medicine if their tort liability may still be just as high as it might be, 


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say, in New York, Pennsylvania, other States where there are no 

tort reforms to protect them against the medical liability cases? 

What have you seen as the difference between a physician practicing in Massachusetts who is not in an AQC arrangement versus 

one that is relative to the types of defensive medicine costs that 

they produce? 

Ms. SAFRAN. Well, the answer is that it is early right now to 

know, to notice or see really any differences in the patterns of use. 

And so I think if we were to look at the data—and we have a formal external evaluation by Harvard Medical School that is looking 

at the data to see how things are changing—they would find that 

for the most part, the savings in year 1 were based on choosing 

lower-cost settings where that could be done, not by doing the hard 

work of changing use. 

However, there is a lot that these practices are doing to start to 

try to understand the vast practice pattern variation that exists 

even within a group of physicians who practice together, caring for 

the same condition, how differently they care for that. And we are 

helping to fuel that with data that we provide on a very regular 

basis to highlight these differences and what we hope is promote 

physicians discussing with each other what best practice would 

look like, and to form that consensus and reduce that variation. 

Mr. GERLACH. Assuming the American Medical Association is 

accurate in its estimate that in any given year there is approximately 100- to $150 billion in defensive medicine costs that are incurred around our Nation each year, and you could probably extrapolate out from that overall figure how much of that is out of 

Massachusetts, is this Harvard study that is being undertaken, is 

it going to compare and contrast the national experience relative 

to defensive medicine costs with what is happening in Massachusetts both within an AQC setting and a non-AQC setting? 

Ms. SAFRAN. Yes. I don’t know that they will bring in national 

data specifically, but they absolutely have information and will be 

studying over a long period of time to see how practice patterns 

change in the AQC compared with how things change or don’t 

change outside of the AQC. 

Mr. GERLACH. I would like to yield the balance of my time to 

Dr. Price, if I may. 

Chairman HERGER. The gentleman yields to Dr. Price. 

Mr. PRICE. I thank the gentleman for his time, and I appreciate 

his question because I think it is an interesting line. I just want 

to say that all of us agree that the status quo is unacceptable. It 

is just where we go from here. 

I was curious about the response of the panel to the question 

about comparative effectiveness research and the overwhelming 

support for it. And I assume that would be the same for the Independent Payment Advisory Board. Mr. Guterman, you are wholly 

in favor of the Independent Payment Advisory Board? 

Mr. GUTERMAN. The notion of having a mechanism to translate 

the best policy ideas into focusing on Medicare programs to try to 

slow down cost growth is an interesting one. I think there are—— 

Mr. PRICE. You support the IPAB? 

Mr. GUTERMAN. Do I support the IPAB? 

Mr. PRICE. Yes. 


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Mr. GUTERMAN. I would like to see, frankly, the IPAB have 

broader powers because I suspect that a lot of the issues that they 

will have to deal with in terms of Medicare cost growth are driven 

by the same factors that—— 

Mr. PRICE. Dr. Watkins, do you support the IPAB? 

Dr. WATKINS. I don’t feel qualified to answer your question. 

Mr. PRICE. As a physician running a large entity, you don’t feel 

qualified to answer whether or not the IPAB you support or not? 

Dr. WATKINS. I am sorry. 

Mr. PRICE. Ms. Safran, do you support the IPAB? 

Ms. SAFRAN. I apologize. I don’t have enough information. 

Mr. PRICE. Dr. Wilson, might you have an opinion on the Independent Payment Advisory Board? 

Dr. WILSON. Unfortunately I am not adequately familiar with 

the expectations of that Board to render an intelligent response. 

Mr. PRICE. I thank you. 

Chairman HERGER. The gentleman’s time has expired. 

The gentleman from New Jersey Mr. Pascrell is recognized for 5 

minutes. 

Mr. PASCRELL. Thank you, Mr. Chairman. Thanks for having 

the hearing, and thanks to the panelists. Excellent. 

We are sitting here talking about changing the way we pay providers, and I have listened to my friend from Wisconsin over the 

last 3 years talking about containing costs enough times to not only 

believe him, but listening to the specifics of where he is coming 

from, and I think that is very, very important, containing costs. 

We might start, I think, maybe the four of you could agree with 

me on this, by having patients look at their bills, if we are talking 

about containing costs. Nobody knows what—particularly if they 

are covered—what do I have to worry about what is in the bill? My 

insurance covers, the Lord covers me, whoever covers them. And 

you don’t look at the specifics of what is in that bill. And I think 

that that is a very dangerous practice that we have gotten into. 

The first words out of the patient is usually, don’t worry about 

it, I am covered. And what we should be concerned about of what 

that means in the minutiae of the bill, how much things cost. 

And so we are moving away. I think both sides agree that we 

need to move away from paying physicians for a specific service. 

Fee for service, I think, is a dog that is not hunting anymore, and 

we need to look for other models, and that is one of the many of 

the questions that have gone in that direction today. 

I have said many times health care reform is entitlement reform. 

I think it has already started. It will help us to transform this 

health system. One-third of the entire new Health Care Act is devoted to Medicare and Medicaid and how we can contain those 

costs. Some of the ideas being discussed were included in the 

Health Care Reform Act. 

I am interested if these ideas are what you support, what is contained in the Health Care Act? One proposal I think we do have 

some bipartisan agreement on is the issue of the IPAB, the Independent Payment Advisory Board. At least I have gathered that 

from your written testimony. 

I think this committee already has the knowledge, the experience 

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viders as opposed to an independent body, and we may debate that. 

We may debate that. But I think that this group has done a pretty 

good job. If we can agree on this, I think we can find other areas 

of agreement in terms of provider payments. 

We are here to specifically focus on physician payments, and I 

hope we don’t have to have another patch. I think the chairman 

shares my view. We have had enough patches over the last several 

years, and we need a permanent solution. It reduces the anxiety 

in terms of the doctor, and we need to reduce the anxiety in the 

patient. Of course, there is a lot of questions out there as to what 

is a guaranteed benefit, what is not a guaranteed benefit. We want 

to reduce anxiety in all parties. 

On our side we passed a permanent fix for Medicare physician 

payment in H.R. 3961. We did that in 2009. The other side of the 

building, of the Capitol, they are still trying to clean out the offices, 

I think. I don’t know what they are doing over there. 

So I have a couple of questions. On physician shortages, workforce, we spent a lot of time on that when we put this legislation 

together. Many of you know in the health care reform bill that we 

did change and try to provide incentives to respond to the shortage 

of physicians, of primary physicians, and also nurses. A National 

Health Care Workforce Commission was established and associated 

grants to help States improve their efforts to promote an adequate 

health care workforce. We can’t ignore the growing shortages. Here 

we are changing, reforming health care. Will we have enough folks 

to deliver the service? That is not a good idea. 

My question is for the witnesses. In Massachusetts, Vermont and 

California, can you tell me how your models affect workforce shortages, and do they create more stability in the system for physicians? Who would like to take the first crack at that? Doctor. 

Dr. WILSON. I will take it. 

In California, yes, we are very concerned about physician shortage, especially in the primary care ranks. We anticipate, if you look 

at the numbers, 45,000 physician shortage in the next decade by 

2020. 

We think our model—and there has been probably as much experience, if not more, in using midlevels as teams of care and using 

physicians to coordinate that care. And so that is one of the ways 

we anticipate mitigating this problem. 

I still have anxiety because I think that looming physician shortage is going to be a challenge for the Nation and not just for California. 

Chairman HERGER. The gentleman’s time is expired. Perhaps 

the witnesses could respond in writing to the question, please. 

Chairman HERGER. The gentleman from Georgia Dr. Price is 

recognized on his own time, 5 minutes. 

Mr. PRICE. Thank you, Mr. Chairman. 

Let me just first say that I am astounded at the lack of responsiveness to my question about the Independent Payment Advisory 

Board by three of the witnesses. This is a major, major undertaking by this Federal Government to impose upon physicians what 

they may or may not do for their payments, and to have three supposed experts, individuals who lead large physician groups and 

health care groups, not be able to opine for this country about their 


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stance on the Independent Payment Advisory Board is amazing. It 

is astounding to me, absolutely astounding. 

So let me go to the other extreme. Do you believe that fee-forservice medicine ought to outlawed? Stu. 

Mr. GUTERMAN. No. We ought to look for different ways of paying. There are different ways, in fact, of modifying fee-for-service 

medicine so it serves the purpose better than unfettered fee-forservice medicine that typifies most of the health care system. 

Mr. PRICE. And you believe one can have a coordinated care system in a fee-for-service model? 

Mr. GUTERMAN. I think it is more difficult unless you get ahold 

of some of the incentives that fee-for-service medicine provides. 

Mr. PRICE. Dr. Watkins, do you believe that fee-for-service medicine ought to be outlawed? 

Dr. WATKINS. I do not. 

Mr. PRICE. That is encouraging. 

Dr. WATKINS. I believe that in our program we have actually 

already demonstrated that with fee for service unchanged, we have 

improved the quality of care delivered, the perception of care on the 

part of the patients, and the perception on the working conditions, 

if you will—— 

Mr. PRICE. That is within the fee-for-service model right now. 

Dr. WATKINS. That is true. 

Mr. PRICE. Thank you. 

Do you believe, Mr. Safran, fee for service ought to be outlawed? 

Ms. SAFRAN. I believe that we have to move our system away 

from fee-for-service medicine for all the reasons that we have 

talked about this afternoon. Whether we have to do that through 

the use of law, or whether through a demonstration that we have 

a way to do it that works better and provides better quality and 

outcomes, I couldn’t say. I would hope that we can reform the system and move to another model of payment without necessarily 

legislating away the fee for service. 

Mr. PRICE. I think we need to move to another model as well, 

but what I hear you talking about is coordinated care and whether 

or not one can have a payment model for physicians that appropriately compensates them for the wonderful work that they do, 

and whether or not that needs to be in the kind of model that you 

describe, I think, is really open to question. 

Do you believe that one patient ought to be able to visit a single 

physician and contract for that service individually between those 

two individuals? Should that be legal? 

Ms. SAFRAN. I want to understand better how that would look 

and, for example, is that a physician—— 

Mr. PRICE. I walk into a doctor’s office. I say, I am feeling a little ill, I would like to have you evaluate me, will you do that for— 

what is the charge—50 bucks, okay? Is that all right? Should that 

be legal? 

Ms. SAFRAN. That should be legal. 

Mr. PRICE. Thank you very much. 

Dr. Wilson, do you believe that fee-for-service medicine ought to 

be outlawed? 

Dr. WILSON. No, I do not. If I were just to refer to our California model, we use fee-for-service medicine as well as capitated 


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and sub-capitated medicine, and I think the sort of the overlying 

important issue here is how is care coordinated, and how is it managed. 

Mr. PRICE. Exactly. And that may be completely different than 

the cost of it or how it is paid for, correct? 

Dr. WATKINS. Correct. 

Mr. PRICE. Mr. Chairman, I was struck yesterday by an article 

from the Associated Press entitled ‘‘Obama Plan for Health Care 

Quality Dealt a Setback,’’ which highlights accountable-care organizations, and in it the article states that at the Mayo Clinic, the administrator of the Mayo Clinic wrote that 90 percent of their members, physician members, would not participate because the rules 

as written were so onerous, it would be nearly impossible for them 

to succeed. And the American Medical Group Association went on 

to say that their members, including the Cleveland Clinic, Intermountain Utah, Geisinger Health Systems in Pennsylvania, et 

cetera, would find that significant change to be much more difficult 

to provide care. And I ask unanimous consent that that be included 

in the record. 

Chairman HERGER. Without objection. 

[The information follows: The Honorable Mr. Price] 


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Mr. PRICE. I would just caution this panel and this committee 

and this Congress that the SGR system was this Congress’ solution 

to how to pay physicians a few short years ago, and it has run 

amok, clearly. It doesn’t work. What we ought to take from that, 

I believe, is that solutions imposed from Washington often times 

result in terrible consequences for patients, which is where we are 

right now with this system. 

And I yield back. 

Chairman HERGER. The gentleman’s time has expired. 

The gentleman from Oregon Mr. Blumenauer is recognized for 5 

minutes. 

Mr. BLUMENAUER. Thank you, Mr. Chairman, and I really do 

appreciate your bringing before us people who are on the front 

lines of trying to squeeze more value out of the system and give 

us different approaches in how that can be accomplished. 

Half of us on the committee come from regions of the country 

that are low cost, high value. If they practice medicine the way 

they do in Congressman Kind’s district; my district in Portland, Oregon; Seattle; and some parts of the bay area, we wouldn’t have a 

Medicare funding crisis. We would have better outcomes. People 

would live longer. They would get sick less often. They would get 

well faster. And you have described ways—and I do, Ms. Safran, 

at some point like to get information about your notion that only 

3 percent of the medical decisions were based on objective evidence. 

I want to get that right. 

I do agree with my friend from Georgia, the mess we have got 

is imposed by Congress. And one of the reasons why some of us 

supported the IPAB and, in fact, wanted it stronger is because Congress has proven itself incapable of being able to make some of the 

really difficult decisions with this fix and that fix, and the SGR is 

a perfect example, which I didn’t vote for, was wishing away outcomes. 

We are on a path now where much of what you have talked 

about we attempted to incorporate in the reform legislation. It 

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ate, and we couldn’t legislate it, but we have got embedded some 

pilot projects and whatnot. The approach is in some instances repeal it and start over. Part of it is to trim back the bill. For example, there is some bipartisan interest in reining in what powers we 

have given to the IPAB because people are afraid it might work. 

Another alternative is to actually accelerate the reforms that 

were envisioned, demonstration projects. Things that you are doing 

now appear to me to have been part of what at least some of us 

wanted to see, hope will happen, and, in fact, can occur under the 

framework, but it was made more complicated because we didn’t 

have a particularly functional legislative arena. 

But it is the law of the land now. There are elements in place. 

I would like to know from each of you the extent to which elements 

that are there in the reform legislation now can incorporate your 

experience, build upon it, and perhaps be strengthened by it. 

Maybe we can talk to the three practitioners here who are representing the systems. 

Dr. Watkins. 

Dr. WATKINS.I would be glad to speak to that. The Community 

Health Teams, our multidisciplinary, locally based care coordination teams are actually clearly outlined in the ACA in Section 3502. 

And we are very clear that that level of coordination is essential 

to providing quality care regardless of what the structure is, where 

the payment is being made, whether that is fee-for-service, if it is 

single payer. It doesn’t matter on some level. The need to do quality improvement and to push that side of the equation is going to 

be uniform regardless. 

Mr. BLUMENAUER. Ms. Safran. 

Ms. SAFRAN. I think that the proposed regs have within them 

a working excellent framework that, in fact, bears a lot of resemblance to what I have described to you about the AQC. But fortunately, there is this comment period that hopefully can provide 

feedback to CMS and create the changes that will enable those who 

currently perceive that the risk/reward threshold is such that they 

would be concerned to participate to change that sum, because we 

have seen in our model that it is possible to do that, as we have 

talked about, and have very quick uptake in even a two-sided 

model such as the one that we have. So I am optimistic that we 

can get it right. 

Mr. BLUMENAUER. Thank you. 

Dr. Wilson. 

Dr. WILSON. I think the ACL model holds a ton of promise and 

opportunity, and I think it would be a great benefit to this country 

if it could be rolled out and adopted. 

I have some concerns, as I mentioned in my testimony, about 

with the funding of it, and I think many of the groups that have 

spoken in that letter share those concerns. I think those groups 

also agree with the intent of the ACL model and the benefit it 

would bring to the American people. And so I think if some things 

can be fixed, it still has an opportunity to succeed. 

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

Chairman HERGER. Thank you. 

The gentleman’s time has expired. 


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The gentleman from Washington Mr. McDermott is recognized 

for 5 minutes. 

Mr. MCDERMOTT. Thank you, Mr. Chairman. Thank you for 

having this hearing and having these witnesses. 

I was reading the material here, and I am a physician, and I am 

a general practitioner, and I would like to join, okay? So look at 

me as a somebody walking into the door in Vermont and Massachusetts and California. 

I saw in the California stuff Monarch Health in Irvine covers all 

of Orange County, 2,500 physicians, 200,000 patients, and that is 

about 80 patients per doc if you just sort of divide it by 2,500. 

Two questions. Do I have to bring patients in to your system to 

join it, or can I walk in the door and you will assign me a panel? 

That is the first question. 

And the second question is how am I going to be paid for my patients? Because I have this general practice of kids and people between 18 and 50 or 65, and then I have got some seniors. Will I 

be capitated on all of them about the same way, or what Medicare 

pays and what the commercials pay? Or how does this work is 

what I want to hear from being a physician. Because Dr. Price has 

raised all the questions. People understand fee-for-service: Patient 

comes in, you do something, you put out your hand, they give you 

money, that is it. How does yours work? Please, the three of you, 

tell me what would happen to me. 

Dr. WATKINS. We are dealing exclusively at this point with primary care. 

Mr. MCDERMOTT. Yes. 

Dr. WATKINS. So for our practices, when the practice goes 

through the process of being recognized nationally for its quality 

through the NCQA recognition process, once they get that recognition, a fixed dollar amount per patient per month—— 

Mr. MCDERMOTT. How much? 

Dr. WATKINS. It varies. Somewhere between $1.29 to $2.39, I 

believe, per patient per month, for every patient attributed to that 

practice covered by one of the three major commercial insurers in 

Vermont, Vermont Medicaid and soon to be Medicare. 

Mr. MCDERMOTT. So it doesn’t make any difference whether 

they are commercial or Medicaid or Medicare, I still get the same 

$1.29 or $1.39. 

Dr. WATKINS. That is exactly right, and it is a function of what 

kind of score they got on that rubric. 

Mr. MCDERMOTT. Do I have to bring my own patients, or will 

you set me up in a practice somewhere and say, go to that practice, 

they have got a bunch of extra patients? 

Dr. WATKINS. Yeah, I wish we had a whole bunch of doctors 

coming into the State that we could have that problem. We are actually dealing with currently existing practices, and they get enrolled through a process, a queue, if you will, that we are rolling 

out through the State. 

The fee-for-service schedule still exists, so the patients who are 

seen in that practice are being—generating income for the practice 

because of having their normal visits. But in addition, if those patients are attributed to the practice by the insurers, then they generate that income for the practice. So that is additional money. 


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On top of that, a Community Health Team is established in that 

area, also paid for by the insurers as a shared resource. They each 

split it approximately 25 percent of the cost. 

Mr. MCDERMOTT. This social worker and a visiting nurse—— 

Dr. WATKINS. Exactly. It is multidisciplinary team that is locally based in contrast to the remote disease management programs that the insurers also still have. But they really do one-onone counseling and interventions, outreach, panel management—— 

Mr. MCDERMOTT. Let me stop you because I want to hear what 

happens in Massachusetts. 

Ms. SAFRAN. The answer is that your day-to-day existence as a 

physician under an AQC model and how you would see patients, 

who you would know who to see, and how you would get paid for 

that would be largely the same. What would be—that is to say 

there is still—as in Vermont, there is still a fee-for-service payment 

schedule, we still have a fee schedule with you, you still bill for 

that service. However, you are now part of an organization that 

has assumed accountability for the total cost of care for your population. So even while you are going about your day-to-day business 

of taking care of patients in much the same way, you are having 

a new level of information and support from your practice, however 

that is defined, about how you are doing, about how you are doing 

on your quality measures, about which of your patients need things 

that they haven’t gotten yet, about which of your patient have 

blood pressures that are out of control and you need to adjust their 

medicines, about how your overall level of use of lab tests and highcost imaging compares with other PCPs who practice in the same 

hallways that you do. 

Mr. MCDERMOTT. How do I get paid? 

Ms. SAFRAN. You get paid by us, by Blue Cross. You get paid 

for the claims that you submit. 

Mr. MCDERMOTT. Exactly the way they are talking about in 

Vermont; that is, a certain amount each month for every patient 

I got enrolled. 

Ms. SAFRAN. Yes—no. Just paid for your claims. For the visits 

that you have generated, you are still getting paid for that; however, there is now accountability in your practice for whether you 

are at the end of the day spending too much, and the practice as 

a whole will have its own way of dealing with the individual clinicians. It is not proscribed by Blue Cross for how they address that. 

Primary care physicians under the AQC have gotten enormous 

increases in revenue because of the quality dollars that we have 

put on the table that these organizations feed right back to primary care, because that is who is generating those quality dollars. 

Chairman HERGER. The gentleman’s time is expired. 

The gentleman from Louisiana Dr. Boustany—— 

Mr. MCDERMOTT. Mr. Chairman, can I ask the gentleman from 

California to submit in writing—I would appreciate knowing how 

you do it in California. 

Chairman HERGER. Yes. And all of our members, if we have 

questions, should be—I would like to request to be able to submit 

our witnesses in writing, and that within a reasonable amount of 

time they be responded to. 


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Chairman HERGER. With that, again, the gentleman from Louisiana Dr. Boustany is recognized for 5 minutes. 

Mr. BOUSTANY. Thank you, Mr. Chairman. 

I am a cardiac surgeon, and my father was a physician, so I 

know a little bit about physician behavior. And I was involved very 

much in attempts to put different groups together back in the 

1990s, and also initiated a number of quality initiatives at the hospitals where I practiced that allowed us to achieve top 100 status 

for heart surgery. 

I am kind of concerned that these ACO regulations as we have 

seen them appear to be a little bit overly proscriptive and burdensome. And, Mr. Guterman, I would be curious to know your opinion. I know it is a first impression based on what has just come 

out, but could you give me your opinion on that? 

Mr. GUTERMAN. We have heard some feedback, as Mr. Price 

cited, that some folks are feeling that way. And we have called for 

CMS to work with the provider community to be able to come up 

with a set of rules that is viewed as reasonable from both sides. 

Unfortunately, we can pay however we want, but we still—in 

order to really achieve improvement in the health care system, we 

need to have both sides kind of build up enough thrust to escape 

the gravity of business as usual, and that applies both to the government and to the providers of health care. 

Mr. BOUSTANY. Thank you. 

Do you think gainsharing might be a useful way to incentivize 

more integration and coordination of care? 

Mr. GUTERMAN. Before I was with Commonwealth Fund, I was 

at the Centers for Medicaid and Medicare Services, and we did develop a gainsharing demonstration. We think it can be promising. 

As with any innovation in payment approach, it needs to be monitored so that the right incentives get transmitted, but it certainly 

could be a promising way as a tool to achieve the kind of efficiencies and effectiveness that you want to achieve. 

Mr. BOUSTANY. I have had conversations with CMS, and it is 

felt there that no further statutory authority is needed to proceed 

with a gainsharing demonstration or model. But I have concerns 

that if we were to do so, physicians in hospitals that might be willing to do this would want statutory protection, because based on 

some of my previous experiences with this, oftentimes lawyers will 

say, well, we think you can do this, but it hasn’t been to court yet; 

we think it will pass muster. 

Do you think if we are going to move forward, we need further 

statutory protections to allow this sort of model to go forward? 

Mr. GUTERMAN. I don’t think I have the expertise to answer 

that question definitively, but I do remember when I was at CMS, 

we ran into difficulties in the court in getting the first attempts at 

gainsharing demonstrations to be put into place. 

Mr. BOUSTANY. Thank you, sir. 

And one other question for the panel, I know you have had success with your models, capitation and so forth. It seems to me a 

lot of what has been focused on here has been the primary care 

piece to this. And you have to bring in the specialties, and then you 

have got specialties like cardiac surgery and liver transplantation. 


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Do you have surgeons, all those surgeons, in your plan, and are 

they on some salary? How does that work? 

Dr. Wilson. 

Dr. WILSON. Sure. Cardiac surgeons, neurosurgeons, surgeons 

that typically require a larger population base to fill out their practice typically don’t sign on as employee docs in practices of any reasonable size. And so typically those relationships exist in one of 

several contracted methodologies. 

For some of our network, and I am now going to refer to my network specifically, we have sub-capitated contracts with our thoracic 

surgeons. They take on responsibility for a population of patients 

and provide that care and have their own quality metrics, and then 

they are responsible to us, and we hold them accountable for the 

care that they provide and the responsiveness they have to their 

patients. 

We also conduct patient satisfaction surveys and look at their 

performances. And in other parts of the network, we may have case 

rates that define the cost of an episode of care based on whatever 

intervention is needed, and even still in some other parts of our 

network, we may have just a strictly fee-for-service arrangement. 

And all of the above. 

Mr. BOUSTANY. Is it the same thing in Vermont with the specialties, the surgical specialties, the procedure-based specialties? 

Dr. WATKINS. We are a very small State, as I am sure you are 

aware. Our total population is just over 600,000. There are only a 

few people that actually practice medicine at that level. There is 

one academic medical center in the State and one in neighboring 

New Hampshire. The Blueprint for Health has, as I said—and we 

are in our early days still focused exclusively on primary care, but 

we do have ongoing discussions around a much broader view of 

what payment reform means, obviously having to loop in specialists. So that is in the future. 

Mr. BOUSTANY. Thank you. 

I see my time has expired, Mr. Chairman. 

I think we probably need to look at how specialties are reimbursed. That is one of the big drivers of cost, and it is going to be 

different than what would apply to primary care. At least that is 

what my instinct tells me on this. So thank you. 

Chairman HERGER. And thank you. I believe that is something 

that the committee should be looking into as well. 

With that, I want to thank each of our witnesses for your testimony today. Your experiences with delivery models that have 

shown to improve care and reduce spending would be of great benefit as the subcommittee seeks to reform Medicare physician payments. 

Our work in this area has perhaps never been more important. 

As the Medicare Board of Trustees will report tomorrow, the current rate of growth in Medicare spending is unsustainable. The 

program will soon go bankrupt if changes are not made. 

There has been a vigorous debate over the future of Medicare in 

recent weeks. I, along with many of my colleagues on the Republican side, believe we ultimately need to bring competition and 

market forces into the Medicare program in order to reduce costs, 


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which is in sharp contrast to the approach the President has proposed. 

Regardless of the outcome of the debate over Medicare’s longterm future, we will continue to focus our efforts to finding the best 

way to fix the SGR. 

As a reminder, any Member wishing to submit a question for the 

record will have 14 days to do so. If any questions are submitted, 

I ask that our witnesses respond in a timely manner. 

[Whereupon, at 4:10 p.m., the subcommittee was adjourned.] 

[Submissions for the Record follow:] 

AARP 


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American Chiropractic Association 


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American College of Cardiology 


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American College of Rheumatology 


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American Geriatrics Society 


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American Occupational Therapy Association 


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American Physical Therapy Association, Private Practice Section 


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American Physical Therapy Association 


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Association of American Medical Colleges 


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Coalition of State Medical and National Specialty Societies 


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Garrison Bliss 


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PTPNSGR 


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Æ 


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