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MEDPAC’S JUNE 2010 REPORT TO CONGRESS: 

ALIGNING INCENTIVES IN MEDICARE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

JUNE 23, 2010 

Serial No. 111–139 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 


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SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

NATHAN DEAL, Georgia, 

Ranking Member 

RALPH M. HALL, Texas 

BARBARA CUBIN, Wyoming 

JOHN B. SHADEGG, Arizona 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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C O N T E N T S 

Page 

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

New Jersey, opening statement .......................................................................... 1 

Hon. John Shimkus, a Representative in Congress from the State of Illinois, 

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

Hon. Kathy Castor, a Representative in Congress from the State of Florida, 

opening statement ................................................................................................ 5 

Hon. Joe Barton, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 8 

Hon. John D. Dingell, a Representative in Congress from the State of Michigan, opening statement ....................................................................................... 13 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement .................................................................................... 14 

Hon. Phil Gingrey, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 14 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 16 

Prepared statement .......................................................................................... 18 

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 24 

Hon. Donna M. Christensen, a Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 25 

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

Texas, opening statement .................................................................................... 25 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 27 

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 28 

WITNESSES

Glenn Hackbarth, J.D., Chairman, Medicare Payment and Advisory Commission ........................................................................................................................ 29

Prepared statement .......................................................................................... 33 

Answers to submitted questions ...................................................................... 74 


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MEDPAC’S JUNE 2010 REPORT TO CONGRESS: 

ALIGNING INCENTIVES IN MEDICARE 

WEDNESDAY, JUNE 23, 2010 

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

The subcommittee met, pursuant to call, at 2:04 p.m. , in Room 

2123, Rayburn House Office Building, Hon. Frank Pallone, Jr., 

[chairman of the subcommittee] presiding. 

Present: Representatives Pallone, Dingell, Eshoo, Engel, Green, 

Schakowsky, Baldwin, Weiner, Barrow, Christensen, Castor, Space, 

Sutton, Waxman (ex officio), Shimkus, Whitfield, Myrick, Murphy 

of Pennsylvania, Burgess, Blackburn, Gingrey and Barton (ex officio). 

Staff Present: Phil Barnett, Staff Director; Karen Nelson, Deputy 

Committee Staff Director for Health; Katie Campbell, Professional 

Staff Member; Stephen Cha, Professional Staff Member; Tim 

Gronniger, Professional Staff Member; Virgil Miller, Professional 

Staff Member; Anne Morris, Professional Staff Member; Allison 

Corr, Special Assistant; Karen Lightfoot, Communications Director, 

Senior Policy Advisor; Elizabeth Letter, Special Assistant; Lindsay 

Vidal, Special Assistant; Mitchell Smiley, Special Assistant; Emily 

Gibbons, Professional Staff Member; Clay Alspach, Minority Counsel, Health; Marie Fishpaw, Minority Professional Staff, Health; 

Sean Hayes, Minority Counsel; and Ryan Long, Minority Chief 

Counsel, Health. 

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

Mr. PALLONE. The subcommittee hearing will come to order. 

Today the Health Subcommittee is meeting to hear about the Medicare Payment Advisory Commission’s, or MedPAC, June 2010 report on aligning incentives in Medicare. And let me begin by welcoming to the subcommittee Mr. Glenn Hackbarth, who currently 

serves as Chairman of the Commission and will be our only witness testifying before us today. So thank you for being here. 

I am going to recognize myself for an opening statement initially. 

Every year MedPAC is required under the law to issue two reports 

and advise Congress on issues affecting the Medicare program. I 

believe that the report we are discussing today holds particular significance because it is the first report issued by MedPAC since passage of the new health reform law. 


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I think that is significant for a couple of reasons. First, the contents of this report demonstrate the need for some of the policies 

that were included in the new health reform law, including provisions that will improve the quality of care and strengthen the financial sustainability of Medicare. 

Take, for example, the first chapter of this year’s report, which 

examines opportunities to enhance Medicare’s ability to innovate. 

The report notes that the Secretary of Health and Human Services 

and the Administrator of the Centers for Medicare & Medicaid 

Services need greater flexibility to implement innovative payment, 

coverage and delivery system reform policies in Medicare. As the 

Commission’s report currently points out, as part of the Patient 

Protection and Affordable Care Act, Congress authorized the creation of a Center for Medicare and Medicaid Innovation within 

CMS. In addition, the new health reform law improves the flexibility that HHS and CMS have over Medicare by—and I will give 

you some examples first—simplifying the demonstration approval 

and implementation process within CMS; second, authorizing new 

funding for CMS to carry out important new demonstrations that 

will improve quality and lower health care costs; and third, creating a new process by which the Secretary of HHS can expand 

successful demonstrations without further congressional approval. 

Now, on that last note, while I agree the agency needs further 

flexibility to test new models and improve Medicare’s health delivery system, I am not in favor of giving carte blanche to the Secretary of HHS or the CMS Administrator. I believe that this committee and the members who serve on it carry out an important 

oversight and regulatory role, and I am not eager to hand over all 

of our responsibilities to effectively manage this program to our 

friends at HHS. 

This year’s report also talks about the need for better care coordination, especially among some of Medicare’s most vulnerable patients, such as those that are dually eligible for both Medicare and 

Medicaid. The new health reform law also makes inroads in this 

area with the inclusion of new team-based and integrated care 

models for delivery of health care services such as accountable care 

organizations, medical homes and bundled payments. 

It is clear to me that there is a lot of correlation between some 

of the recommendations made in this month’s report and some of 

the initiatives that were included in the new health reform. But 

the Commission’s new report also seeks to examine other opportunities for the Congress to improve the Medicare program. For example, the Commission takes a fresh look at the way Medicare 

funds graduate medical education in the country and makes recommendations on how to improve it. The Commission also looks at 

the growth of payments for in-office ancillary services, an issue 

that they have examined in the past. However this year, instead 

of simply looking at how physician behavior is adding to the growth 

of these services, MedPAC also looks at the role beneficiaries play 

in driving up the volume of these services. 

I am also anxious to hear about MedPAC’s research and recommendations in these areas, but also think that we need to proceed carefully. I have concerns and questions that need to be answered. For example, what would be the impact of your recVerDate Mar 15 2010 13:53 Mar 06, 2013 Jkt 077916 PO 00000 Frm 00008 Fmt 6633 Sfmt 6602 E:\HR\OC\A916.XXX A916

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ommendations with regard to teaching hospitals that rely heavily 

on these funds? Can hospitals that operate on very slim margins 

or in the red like those in my State, will they continue to operate 

and provide the same level of services if they begin to lose GME 

funding? 

I also worry about imposing new cost-sharing requirements on 

beneficiaries as part of a new value-based insurance design and the 

impact that might have on beneficiaries who might forego important treatment rather than pay a cost-sharing requirement. Also, 

in terms of value-based insurance designs, who decides what services are high-value, what services are low-value? These are important questions and I look forward to hearing the answers in today’s 

hearing. 

And finally, let me note that it would be inappropriate for the 

subcommittee to hold a hearing on Medicare payments and incentives without addressing the elephant in the room, which is the annual payment cut that doctors face. This year, as everyone knows, 

physicians participating in Medicare face a 21 percent cut. We have 

been able to prevent this cut from taking place thus far through 

a series of temporary delays. 

As you know, before the Memorial Day recess, the House passed 

a bill that would provide another temporary reprieve to physicians 

by delaying that cut from being imposed and replacing the modest 

increase to the end of 2011. Our colleagues in the Senate have advocated for a shorter-term pared-down package—nothing new—and 

we have been unable to find agreement up to this point. So we all 

realize the need for swift action. 

I don’t have to tell you how many doctors come to my office—not 

so much here, but in New Jersey—complaining about the fact that 

they would like to see a permanent fix, which obviously we have 

also voted on in the House, but we can’t get passed in the Senate. 

So the Democrats and the Republicans in both Houses as well as 

the physician community need to work together to develop a permanent fix. We simply can’t continue to kick the can down the 

road. 

I know I feel like I am talking to the choir here because the 

members on this committee are not, for the most part, the bad guys 

on this one. But we have to mention it. 

So I want to recognize Mr. Shimkus. 

OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Mr. SHIMKUS. Thank you, Mr. Chairman. And thank you for joining us. 

We all know that MedPAC is critical in advising us as we make 

legislative decisions to alter Medicare. We must find ways to reform entitlements, including Medicare, to make them sustainable 

into the future. By 2020, almost 93 cents of every dollar of Federal 

revenue will be spent on entitlements and net interest costs. By 

2030, net interest payments on our Federal debt will exceed 8 percent. This will make interest payments the largest single expenditure in the Federal Government and leave little room for all other 

spending. 


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Change is necessary, but we should do what we can to avoid unintended consequences. MedPAC’s June report raises concerns over 

rapid growth on ancillary services in physician offices. The report 

provides options to address growth in diagnostic imaging, radiation 

therapy and physical therapy in physician offices. These are very 

different services, and an option appropriate for one of these services may not be for the others. We must use caution to not paint 

all ancillary services with the same broad brush. 

I am pleased to report it covers the graduate medical education 

system. I hear from hospitals already in my district all the time 

over the unmet need of residency slots and from the physician community on wanting more flexibility to train in settings outside the 

hospital. While I believe we must examine these GME issues, I am 

hesitant in removing 3.5 billion in funds hospitals rely on through 

their indirect medical education payments. I look forward to hearing more from MedPAC on working to strike a balance. 

As we seek MedPAC’s guidance for Medicare, what does the 

health reform law do to sustain quality and access to care? As 

Chairman Pallone mentioned, the new law does nothing to address 

the 21 percent cut. He didn’t mention that. He did address the concern about the cut to our doctors now taking as a turnaway from 

Medicare patients. In Illinois, 18 percent of all doctors are now restricting the number of Medicare patients in their practice. That 

story just broke yesterday. The law does, however, cut $500 billion from Medicare, billions 

of dollars in cuts that would not enhance the ability of the government to pay for future Medicare benefits, according to CBO. Medicare D premiums will rise for all of the nearly 28 million participants. Again, this is from the nonpartisan CBO. Half of seniors enrolled in Medicare Advantage will lose their plans, and all seniors 

will have access to care in hospitals jeopardized with the law, causing 15 percent of party hospitals to become unprofitable within 10 

years, a figure CMS’ own actuaries say may lead some to terminate 

their participation in Medicare entirely. And this is only some of 

the effects on Medicare. 

Yesterday the President remarked the new law will cut costs, 

make coverage more affordable. Last month the CBO said the price 

tag is actually higher, with an additional 115 billion in discretionary spending. And before then CMS and the country will spend 

310 billion more under the new law than we would have without 

it. 

As for affordability, CBO concluded self-employed small business 

workers, early retirees and millions of other Americans who buy 

their own health insurance plans will pay on average $2,100 a year 

more. Again, yesterday we heard the President using the bully pulpit to tout the benefits to small businesses and the relief it would 

provide. But only 12 percent of businesses would see any relief at 

all, with even fewer eligible for the full tax credit. To get that full 

tax credit, you can only have 10 or fewer employees making an average of $25,000 or less. The message to employers is clear: Don’t 

hire, and don’t pay your current employees more. 

Finally, the Majority continues to claim the high-risk pools provide immediate access to insurance to those uninsured because of 

preexisting conditions. Now, the high-risk pools are set to go on 


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line in July, and CBO tells us the number of people who may be 

eligible for this program is in the millions, yet enrollment will be 

around 200,000 people. And in Illinois, they will miss the deadline 

altogether and might start enrolling people in its pool mid to late 

August. For those in current high-risk pools in Illinois, they will 

pay higher premiums than those in the Federal one. Illinois will receive 196 million to set up the pool. That would cover only about 

5,000 people between now and 2014; 5,000 people among its 2.5 

million people in Illinois living with chronic conditions. 

I warned as recently as last week that the 5 billion would not 

be enough to fill this need, and now those warnings are proving 

true. The Illinois insurance commissioner said this week demand 

will almost certainly outstrip funding, and eligibility will probably 

be limited at first to people with a fairly narrow list of health conditions. So the high-risk pool is going to pick and choose. 

Not enough money, not meeting deadlines and limiting the enrollees. Can we honestly say to Americans we are providing immediate access to affordable insurance for those with preexisting conditions? If all these experts’ analyses are true, shouldn’t the committee hold hearings and take immediate action and address these 

problems? And if the claims are inaccurate, should we not clear the 

air? Republicans have asked for multiple hearings on the law, and 

wait as the deadline passes and promises to the American people 

are broken. 

And I yield back my time. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you, Mr. Shimkus. 

The gentlewoman from Florida, Ms. Castor. 

OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF FLORIDA 

Ms. CASTOR. Thank you very much, Mr. Chairman, for convening 

this hearing today. 

And welcome, Mr. Hackbarth. 

This hearing is vital to all of our parents and grandparents that 

rely on Medicare for their health care. It is also vital to all of our 

families as Medicare often sets the course for health care and 

health care delivery in America. So I am very encouraged by 

MedPAC’s recommendations to continue to focus on the quality of 

care and increasing value of our health care delivery system. 

I am also encouraged by MedPAC’s concept of creating Medicare 

payment incentives as we improve quality. Chairman Hackbarth, 

you have mentioned in your testimony patients do not always receive the recommended care for their health conditions, and they 

may receive care that is not clinically appropriate, and this must 

continue to be our focus. 

I have introduced legislation, the Eliminating Disparities in 

Breast Cancer Treatment Act, which speaks to some of the same 

strategies that is tying Medicare payments to quality care and rewarding efficiency and quality, And this will help to see that patients receive higher-quality care based upon the recommended 

quality standards. 

And I am interested in hearing from MedPAC on incentives in 

the Medicare fee for services, a payment system that may be at the 

root of our primary care shortages if indeed the current payment 


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system, which, according to MedPAC, rewards volume and favors 

certain specialties which may be more lucrative simply because of 

higher volume of individual procedures offered as compared to primary care—this is something we have got to continue to address 

beyond what we have already done in the health reform area. 

I am also very concerned where we stand on graduate medical 

education, and you see where we start puts my home State in Florida—we are in such a deep hole, I am very concerned if we go full 

speed ahead on reform, Florida is going to continue to be left behind. You see, we are the fourth largest State in the country, very 

dynamic State with strong medical schools, and we are 44th in the 

number of medical residencies. So that means that the folks I represent may not be getting the care that they need because oftentimes those doctors in training, they will go and take their residency in another State, and they don’t come back. So I want to get 

into that discussion with you today. 

We also have an aging physician population, one-quarter over the 

age of 65 in my State. So you can see we have a looming crisis on 

our hands. 

So I look forward to hearing from you on all of these issues as 

we continue to ensure that health care reform works for all American families. 

Mr. PALLONE. Thank you, Ms. Castor. 

Ranking member, Mr. Barton. 

OPENING STATEMENT OF HON. JOE BARTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BARTON. Thank you, Mr. Chairman. 

I want to thank Mr. Hackbarth for testifying before the committee today. MedPAC provides a valuable service to Congress. We 

always appreciate the candid and detailed analysis of the Medicare 

program that they give. 

I am pleased to see that MedPAC has addressed graduate medical education and has recommended ways to encourage teaching 

programs that emphasize nonhospital care and care coordination, 

focus on the delivery of efficient, quality care. 

Just recently we learned that a number of doctors are now refusing to take new Medicare patients because government reimbursement rates are so low. It is simply too costly for those doctors to 

take new patients. We are hearing this at a time when baby 

boomers are increasingly entering the program. Meanwhile, the 

Majority has failed to fix Medicare’s sustainable growth rate, or 

SGR, resulting in a 21 percent cut in payments to doctors. Thus 

it is imperative that we listen to MedPAC’s advice on how to 

produce professionals with the skills to practice in the Medicare 

system now more than ever. 

The recommendations in this report only scratch the surface of 

what must be done not only in Medicare, but our entire health care 

system. We are only a few months into the implementation of the 

new health care law pushed through recently on a purely partisan 

vote. We already see strong evidence that the new law is not solving our health care problems; rather, it is increasing costs and crippling health care. 


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I think it is a fair observation that the evidence is mounting on 

how and when President Obama’s new law will make health care 

worse for many Americans. Internal documents requested by the 

Majority show that companies across the country are engaged in a 

serious discussion about dropping health care coverage for their 

employees. It looks like the increased costs and disincentives of the 

law are simply more than many employers can afford in the middle 

of a recession. 

Finally, we also understand something all too well now that 

President Obama would not admit when his health care bill was 

up for debate. It will strangle Medicare. The chief actuary of Medicare now reports that the health care law just passed cuts approximately $575 billion from Medicare over the next 10 years. 

Mr. Chairman, I think it is a good thing that you have called this 

hearing. I look forward to our witness and then asking questions. 

Thank you. 

Mr. PALLONE. Thank you, Mr. Barton. 

[The prepared statement of Mr. Barton follows:] 


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Mr. PALLONE. Next is chairman emeritus Mr. Dingell. 

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF MICHIGAN 

Mr. DINGELL. Thank you, Mr. Chairman. I commend you for the 

hearing. 

Established in 1997, the Medicare Payment Advisory Commission has provided invaluable advice to the Congress concerning the 

Medicare program. Through their biannual reports, they have consistently advocated for a more efficient Medicare program that ensures beneficiary access to high-quality care, pays health care providers and health plans fairly, and spends Federal tax dollars properly. 

It is important to note that many of the recommendations included in the recent MedPAC reports, including many recommendations in the current report, were included in the landmark health care reform legislation passed by the Congress and 

signed by President Obama earlier this year. These regulations include providing a payment bonus to physicians who practice primary care, reducing payments to hospitals with high preventable 

readmission rates, and testing the feasibility of a bundled payment 

for an episode of care. This is a testimony to the efforts of the sponsors of that bill and the administration to do all we can to make 

the Medicare program and, indirectly, private insurance a smarter, 

more efficient deliverer and payer for high-quality health care. 

In addition to the work accomplished by the new health reform 

law, MedPAC has provided a number of additional recommendations to consider on ways to improve the ability of the Center for 

Medicare and Medicaid Services to innovate, ensure the health care 

workforce is adequately trained, and to assist Medicare beneficiaries in making better decisions about the course of their health 

care treatment. 

I look forward to Mr. Hackbarth’s testimony. I look forward to 

spending more time exploring the goals and the impact, both direct 

and indirect, to the recommendations included in the June report, 

and I hope that this subcommittee and committee will do so alike. 

Finally, I am very interested in exploring MedPAC’s future relationship with the new, independent Payment Advisory Board created by the new health reform law. This legislation envisions some 

interaction between the two. It is my hope that will occur, but that 

it will occur in a beneficial way. However, we must think very carefully about how the two entities coexist beyond the specifics of the 

legislation, and this committee must again direct its attention to 

that. 

So thank you very much, Mr. Chairman. I yield back 2 minutes 

and 10 seconds. 

Mr. PALLONE. Thank you, Chairman Dingell. 

Next we will go to the gentleman from Kentucky Mr. Whitfield. 

Mr. WHITFIELD. Thank you, Mr. Chairman. I am going to waive 

my opening statement. 

Mr. PALLONE. And next is the gentlewoman from California, Ms. 

Eshoo. 


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OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Ms. ESHOO. Thank you, Mr. Chairman, for holding this hearing 

on MedPAC’s latest report to Congress, and our thanks to Mr. 

Hackbarth and the members of MedPAC for your work on the report and for being here to testify today. 

I just can’t help but say something before I make the rest of my 

remarks. My friend from Illinois keeps hacking away at the national health care plan which we passed in talking about the cuts 

to Medicare. I think that we need to get the record set straight. 

There are—or were insurers in the country that were receiving up 

to 135 percent more in payments than others. So while it is called 

Medicare Advantage for some of my constituents, it was clearly 

Medicare Disadvantage for other constituents. Now, all of those 

moneys that went into the overpayments for those insurers are 

being plowed back into Medicare. So I think we need to keep—we 

all have our opinions—— 

Mr. SHIMKUS. Would the gentlelady yield? 

Ms. ESHOO. No. I am not going to yield. No. It is my time. But 

to just try and shape—to pretend that something is a fact when it 

is not—— 

Mr. SHIMKUS. Is the gentlelady questioning my—— 

Ms. ESHOO. No, no, no. 

Mr. GREEN [continuing]. Out of order. 

Ms. ESHOO. Anyway, getting back to our hearing today, I am 

very pleased that a significant portion of your report, Mr. 

Hackbarth, focuses on the signals that Medicare sends to medical 

students through the GME financing, the graduate medical financing. From the point of view of hospitals, though, not all residencies 

are created equal. And I think that this is something that—and 

Medicare largely funds them as if they were. 

I think that we have had a long struggle with the problem that 

medical students are choosing to subspecialize rather than choose 

family care or primary care, which is one of the things that we, I 

think, addressed in the health care legislation, and Medicare-supported residency slots, I think, should aim to create the correct proportion of specialists and not just the current proportions. And I 

think this is a discussion we have to continue to have, especially 

in view of the millions of Americans soon to be insured. 

So I look forward to your testimony, and I thank you for your 

work. And I thank the chairman for calling this important hearing. 

Mr. PALLONE. Thank you, Ms. Eshoo. 

Next is the gentleman from Georgia, Mr. Gingrey. 

OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. GINGREY. Thank you, Mr. Chairman. 

Mr. Chairman, our Medicare program is facing a dark future 

made worse by President Obama’s health reform law that this Congress passed back in March. As Chairman Hackbarth will outline 

in his testimony, the Medicare Hospital Trust Fund’s expenses exceeded its income in 2008, meaning that its current trajectory is 


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unsustainable. This path, if left unaddressed, could rob future generations of quality Medicare benefits. Over the last 18 months, Democrats in Congress cut $500 billion 

from the Medicare program in order to help pay for President 

Obama’s health care bill. And by the way, the gentlelady from California Ms. Eshoo says that that $500 billion cut of Medicare, much 

of which comes from Medicare Advantage, was plowed right back 

into the Medicare program. Nothing could be further from the 

truth. In fact, I have an amendment when the bill was marked up 

in the House, H.R. 3200, that would have affected that, but it was 

rejected by the Democratic Majority. The Majority said the $500 

billion came from ending waste, fraud and abuse. CMS actuary 

Robert Foster countered that argument by stating that the cuts 

would result in 9.4 million seniors losing their current Medicare 

benefits primarily in the Medicare Advantage program and paying 

higher out-of-pocket costs for their health care. Make no mistake, 

seniors’ costs will go up because of Obama care. 

Congress could have used that money to cap out-of-pocket expenses or help offset doubles under Medicare in order to truly 

lower health care costs for lower-income seniors with chronic illnesses, but the Democratic Majority could have put those funds 

back into the Medicare Trust Fund so that seniors don’t wake up 

one day soon and find their health care program bankrupt. Speaker 

Pelosi could have taken that 500 billion and permanently addressed the physician payment crisis under Medicare that is currently threatening our seniors’ access to quality care. If cutting $500 billion from a Medicare program that is going 

broke does not worry seniors enough, the President is now pushing 

Dr. Donald Berwick for the post of CMS Administrator. He is a 

self-described proponent of rationing health care from sick Americans. A New York Times piece that ran just yesterday quotes Dr. 

Berwick as, quote, ‘‘in love with the British health care system,’’ 

unquote, and stating that, quote, ‘‘the national health system is not 

just a national treasure, it is a global treasure,’’ unquote. This is 

the same British system that routinely makes coverage decisions 

based on cost and life expectancy. This is the same British system 

that denied coverage for the breast cancer drug Herceptin because 

it was not deemed cost-effective. It took a protest march by thousands of women in the streets of London to change that decision. 

Simply put, our seniors’ health care program cannot afford Dr. Berwick. 

Mr. Hackbarth, with these thoughts in mind, I look forward to 

your testimony today. You and your staff have served this Congress 

well, offering technical advice and insight into ways that we might 

restructure our Medicare program so that seniors’ health care and 

needs and taxpayer interests are indeed safeguarded. 

Particularly I am interested in your thoughts on how we might 

overhaul our current system of reimbursing physicians under Medicare, the sustainable growth rate, and how properly aligning incentives in the program might encourage a greater efficiency and collaboration. 

With that, Mr. Chairman, I yield back, and I thank you for your 

patience. 

Mr. PALLONE. Thank you. 


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Next is our chairman, Mr. Waxman. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you, Chairman Pallone, for calling this 

hearing. 

We are going to hear from a representative of MedPAC, which 

is an organization set up to advise the Congress about the Medicare program, and they have done an excellent job over the years. 

In fact, many of their recommendations were incorporated into the 

recently passed comprehensive health insurance bill. That bill is 

going to extend health insurance coverage to 50—to 30 million 

Americans. It is going to hold down costs, and it is going to benefit 

the Medicare beneficiaries. 

You wouldn’t believe it by the propaganda line we have gotten 

from the Republican side of the aisle. They were against working 

on a bipartisan basis with us. They complained about the bill before it was enacted; they have complained about the bill since it 

has been enacted, and it is not even implemented. 

But some things are going to be implemented. For example, we 

heard about the high-risk pools being a failure. The high-risk pools 

are a temporary way to cover people with preexisting medical conditions who cannot buy insurance at all. Well, this will give them 

a chance to buy insurance until the insurance system is implemented where they can no longer be discriminated against, something the Republicans would not support. 

They have complained that this is going to do a disservice to 

Medicare. Well, the truth of the matter is that the Medicare Trust 

Fund is going to be extended for many, many years. The Medicare 

Trust Fund will be extended for 12 years, to 2029. 

They have talked about some of the cuts in Medicare, but those 

cuts are wasteful expenditures to insurance companies that are 

telling Medicare beneficiaries that they should have more money 

for their overhead. We said, no, the money ought to go for health 

care services, and this was one of the recommendations of 

MedPAC, not to have these so-called Medicare Advantage plans get 

overly compensated. 

But not only are we saving money in the expenditures of Medicare, we are also going to be closing the doughnut hole so seniors 

will not find themselves going broke having to pay 100 percent of 

the full cost for their prescription drugs, something the Republicans provided for when they adopted their original Part D Medicare legislation. We will close the doughnut hole. 

We will provide preventive services without costs to the seniors. 

They won’t have to come in with copayments. We extended the life 

of the Medicare Trust Fund. 

You would think we ended Medicare. You would have thought we 

were putting the American people on the British system, to hear 

my colleague from Georgia a minute ago talking about the result 

of the health care bill. 

The hearing we are having today is not the first hearing we have 

had on the whole health care system. The Congress of the United 

States, in fact the House, held 79 bipartisan hearings and markups 


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on health insurance reform over the past 2 years. We had hearings. 

We got full input from everybody, people who had different points 

of view, those that were in favor and those who were against. And 

out of those hearings, we worked on legislation, but we had to do 

it on a partisan basis, because like every bill that we have considered in the last year and a half, the Republicans have decided to 

vote no. They voted no on the stimulus bill. They voted no on the 

energy bill. They voted no on the health bill. They voted no on the 

financial reform bill. They are the party of no. And now when we 

are trying to learn more about what we need to do to keep Medicare the program it is as a way to provide health care services for 

our seniors and our disabled people, they want to complain, not 

talk about how we can work together. 

MedPAC is giving us a report. That is the reason for this hearing. Their report is always useful. They have suggested that there 

are ways we should deal with graduate medical education to try to 

get physician services based more on quality and not on quantity. 

They are recommending what we should do with people who are 

both Medicare and Medicaid—the dually eligibles. They have given 

us a lot of good, substantive things to look at and to work on, and 

I am pleased with what they have done in the past, that has been 

part of the health care bill that is now law. And I am looking forward to the testimony and about further things we need to do to 

strengthen the Medicare program. 

But let no one be fooled. What we are seeing is a lot of propaganda from our Republican colleagues, and it is the same thing we 

have heard at every hearing over and over again, that you are 

going to have rationed care, you are not going to have care, that 

everybody is going to drop the care, and meanwhile they wouldn’t 

even eliminate the barrier for people to buy insurance because of 

preexisting medical conditions. 

I am glad the health care bill passed, and the American people 

will welcome it as it goes into effect. 

Yield back. 

Mr. PALLONE. Thank you. 

[The prepared statement of Mr. Waxman follows:] 


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Mr. PALLONE. Next is the gentlewoman from Tennessee, Mrs. 

Blackburn. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

Mr. Hackbarth, we are pleased that you are here. As you can see, 

we are going to have a very robust discussion today. I know you 

are looking forward to it. 

And I think we all agree that there are some improvements that 

are needed in the current delivery system. But I will have to tell 

you, there is a lot of concern out there that Obamacare is going to 

be detrimental to Medicare, and that it has the potential not only 

to cripple the Nation’s health going forward, but also to cripple and 

compromise those health care delivery systems. 

And most recently we have had concerns expressed from physicians, and I know you are hearing this, too, about being able to 

meet the cost of their practices while they are facing reductions 

even to the point of phasing out of programs like Medicare Advantage. And yesterday there was a USA Today article, and I am sure 

you probably saw this. There was a quote in there, the number of 

doctors refusing new Medicare patients because of low government 

payment rates is setting a new high. And this is of concern to us. 

The AMA has even reported that 31 percent of primary care physicians are no longer accepting new Medicare patients. We are hearing quite a bit about this, and what we hear is that this 21 percent 

reduction in the SGR is forcing more doctors to make those reductions and dropping patients, and seniors are very concerned about 

this. 

Now, I think that they are speaking up in expressing concerns, 

and one of the reasons we want to hear from you is because my 

colleague across the aisle just said we are the party of no. I would 

change that to—for him. We are the party of K–N-O–W, know, and 

what we have worked diligently to do is make certain that seniors 

have the information in front of them, whether it is about their 

Medicare Advantage and their concerns of that program being 

phased out, or whether it is about the current Medicare coverage 

that they have. And they continue to come to us and say, we 

thought we were going to be able to keep the benefits and the programs that we have, but we don’t see how this is going to work. 

And what we are hearing from insurers is that changes are coming 

towards us, and when you see numbers like 136 billion being cut 

out of Medicare Advantage over the next 10 years, this is of concern. 

I will also highlight that we have to remember that our seniors, 

today’s seniors, have prepaid their access to Medicare, and we need 

to be mindful of that. We need to be respectful of that, and we welcome your insight and look forward to the hearing. 

I yield back. 

Mr. PALLONE. Thank you, Mrs. Blackburn. 

Next for an opening statement is the gentlewoman from the Virgin Islands, Mrs. Christensen. 


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OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. And thank you 

and Ranking Member Shimkus for holding this hearing. 

And thank you, Dr. Hackbarth, for joining us this afternoon to 

report on the Commission’s June 2010 report to Congress. 

The Medicare program has been in many ways an indispensable 

asset to the American elderly and disabled, and I welcome every 

opportunity to review and discuss aspects of the program that can 

be improved to increase the efficiency and quality of health care 

given to these populations. 

Approximately 20 percent of the enrollees served through Medicare are racial and ethnic minorities, and roughly half of all beneficiaries are within 200 percent of the Federal poverty line. This is 

significant because these are the very beneficiaries who are extremely vulnerable, who suffer most detrimentally from health care 

inequities within the current health care system. 

Although Medicare provides health care access to millions of 

Americans who otherwise would go without coverage, the fact remains that prior to enrollment in Medicare, most were either uninsured or grossly underinsured, two scenarios that we know have 

deleterious health impacts. This means often by the time they enroll in Medicare, many of the health issues that may have been— 

might have been addressed relatively easy with access to care have 

now been compounded and exacerbated by a lack of care or poor 

care when it was available. 

Because of this, it was especially interesting to me to read the 

recommendations of the Commission, particularly as it pertained to 

focusing more on a payment method that encourages quality over 

quantity service, and promoting more participation from both patient and provider in the decisionmaking process, and in attracting 

a more racially and ethnically, geographically and 

socioeconomically diverse health care workforce. 

I am interested also in hearing more about how MedPAC suggests addressing the numerous health disparities that have been 

documented within the Nation’s Medicare population. 

And so, again, I thank you for today’s hearing, and I look forward to a very informative and thought-provoking discussion. 

Thank you, Mr. Chair. I yield back. 

Mr. PALLONE. Thank you, Mrs. Christensen. 

Next for an opening statement, the gentleman from Texas, Mr. 

Burgess. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS. Thank you, Mr. Chairman. 

And a couple of reasons why today’s hearing is notable. Once 

again we have a chance to hear from our good friend Mr. 

Hackbarth, who is no stranger to this committee. Time for us to dig 

down deep and take a look at whether Medicare does a good job 

of shepherding the enormous resources available to the program to 

provide health coverage for millions of older Americans. That is the 

larger and the grander goal. 


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But today is also notable because doctors across the country who 

participate in the Medicare system are receiving 21 percent less for 

the services they performed last month for taking care of all of our 

Nation’s sickest and most needy patients. Congress has broken the 

contract that we have with the Nation’s seniors and the Nation’s 

physicians by allowing this dramatic cut to take place. 

Let me point out I have voted for some very bad policy in the 

past, very bad policy that had at its base stopping those cuts from 

occurring. Unfortunately, we have not had—in all the hearings that 

were referenced by Chairman Waxman, we have not had since 

2006 a hearing on the sustainable growth rate formula, and I think 

it is time we do that. 

I have a bill, 3693. I would like to see that get a full and fair 

hearing. Since this committee will not hold a hearing next month, 

I will be holding a forum by myself to talk about this very issue. 

And then what is worse is we have the Speaker, astonishing in 

her cruelty, holding up a bill. OK, the bill is delinquent, maybe 

criminally so; it is insufficient, perhaps scandalously so; but still it 

is a reprieve for the Nation’s seniors and doctors, but the Speaker 

won’t let it come to the floor because it doesn’t comport with everything that she wants. I voted for very bad policy in the past just 

to prevent these problems from happening to our seniors and doctors. The Speaker should do the same thing. 

Very few Members of Congress, outside the physician Members, 

have any appreciation for what this delay and our inaction does to 

physician practices. When you have a small physician practice, 

even with as small a population as 15 percent Medicare, and you 

don’t get paid for 3 weeks, that is a big deal. This decision will lead 

businesses to closing and patients losing their doctor. 

We have got price controls in this country. Most of us don’t admit 

that in health care, but we do. Every private insurance company 

in the country pegs to what we do in Medicare. That is why it is 

so critically important that we get off our duff and do the right 

thing. 

We talk about the fact that people aren’t going into the specialties that we want them to go into. We have administrative pricing. 

We are driving people, driving people into the specialties that we 

now decry and keeping them out of the specialties we wish they 

would go into. But we are doing it by our administrative pricing. 

What about quality over quantity? When the only lever you pull 

is to rachet down reimbursement rates, the only lever the doctor 

has to pull is to increase the number of hours they work or work 

a little harder, spend a little bit less time with each patient. The 

only way they can pay their overhead—and let me remind members of this committee that doctors who would see patients in the 

Medicare program have not had any increase in their reimbursement since the year 2000. 

Now, I know we need a long-term strategy, and I have not always agreed with MedPAC’s findings on the sheer amount of 

money and layer upon layer of bureaucracy that defines our current program. But that in and of itself calls out for a dramatic rethinking of the program. As a committee we do need to have a bipartisan dialogue. Unfortunately, Mr. Waxman has left, but I 

would remind him that I met with him early in 2009 to talk about 


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was there a possibility to work in a bipartisan fashion on this 

health care bill. I have met with the transition team in November 

of 2008 to ask that very same question. I got no response as an answer. What did we get? We got a bill thrown over the transom on 

July 15th, and then we were brought to committee and told to 

mark it up. 

Mr. PALLONE. Dr. Burgess—— 

Mr. BURGESS. I had 50 amendments on that—I had my own 

table for amendments, and yet you say that the Republicans refused to participate. 

Mr. PALLONE. All right. 

Mr. BURGESS. Where do you get this stuff? Do you just make it 

up? 

Mr. PALLONE. You got it. You are over a minute, Dr. Burgess. 

Mr. BURGESS. I thank the chairman for his indulgence. I look forward to the hearing we are going to have on the SGR formula in 

short order, and we might also bring—— 

Mr. PALLONE. I am going to have to rule you out of order. 

Mr. BURGESS [continuing]. And talk about the administrative 

function—— 

Mr. PALLONE. You are a minute over. I recognize Mr. Barrow. 

Mr. BARROW. I thank the chair. In the interest of time, I will 

waive an opening. 

Mr. PALLONE. No, he is not yielding to you. 

Mr. Murphy of Pennsylvania. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY of Pennsylvania. Thank you, Mr. Chairman. 

It is good to have you here today, sir. I am looking forward to 

a number of things. I am looking forward to reading this book. I 

am going to draw the committee’s attention to something very important in the executive summary where you say Medicare oftentimes lacks the authority to deal with some prospective payment 

systems that would improve payment accuracy. Similarly, a change 

in law is also necessary for Medicare to implement policies that pay 

providers based on their quality. Medicare needs authority to make 

such changes in its current payment system. 

A while ago, when our new President took office, I sent letters 

to his staff and other folks asking that Congress and the White 

House put together a blue ribbon panel to really review Medicare, 

which was designed in 1965 and designed really from the bottom 

up. What would Medicare look like if we designed it now in 2010? 

Back when it was designed, as you know, some of the most advanced instruments hospitals had was an X-ray machine on 

wheels. We obviously have come a long way since then. And back 

then it worked then, with the limited things we had with medications and other treatments, to pay a fee-for-service system. Now we 

have a substantial amount of research which says that quality is 

important, and that care management is important, and those 

things can indeed save money. 

When we look at some of the things that happen now in Medicare, and it will be interesting to hear your comments on this, it 


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looks like many of the things require an act of Congress to change 

it. For example, we are still in a system that doesn’t pay for someone in the nurse’s office to coordinate care even though that call 

to a diabetic is far cheaper than amputating a diabetic’s legs. 

Stroke victims oftentimes can save money if you have a teleconference video, but that depends on where that hospital is, rural versus 

suburban, even if both are an equal distance in time by ambulance 

to the base hospital. Home infusion therapies are still limited even 

though some of those save time and reduce the risk for infection. 

There are also things that have to do with how we even order 

wheelchairs and canes, and deal with wage indexes that on the 

east side of Harrisburg in Pennsylvania may get paid one way and 

the west side of Harrisburg in Pennsylvania may get paid a rate 

that is so much lower, the doctors can’t handle it. 

It is of concern, and I am pleased you are addressing this issue 

that we cannot expect to prop up a system of Medicare that is 

struggling financially just with saying we are not going to pay. I 

believe the analogy we all understand is if someone comes to work 

on our home, and we can have two estimates, one will say it is 

going to cost you this much to fix your roof, and another guy will 

say, I am just going to charge you for each item I put up there and 

my hourly rate. We all know which one is going to cost a lot more. 

In each case we are just looking to have the roof fixed. 

I hope that you can let us know, if not in today’s hearing, in the 

future. It is extremely important to this committee and to me that 

we have got to revise this system of Medicare and make it up to 

date and give Medicare the flexibility to redesign itself as we have 

more breakthrough information in how we can best administer 

medicine. Putting it on the backs of physicians and saying we are 

not going to pay you isn’t going to work. 

Thank you so much. I yield back. 

Mr. PALLONE. Thank you, Mr. Murphy. 

The gentleman from Texas, Mr. Green. 

Mr. GREEN. Thank you, Mr. Chairman. 

I would like to waive opening statement, but also remind my Republican colleagues the health care bill that came out of the House 

had a permanent fix of the SGR. In lockstep, my Republican colleagues voted against it. 

Mr. BURGESS. Will the gentleman yield? 

Mr. PALLONE. I think the gentleman actually waived his—well, 

not waived—didn’t use his time, but somehow managed to get a 

statement in as well. So I don’t know. 

Anyway, let us move on to Ms. Schakowsky, who is recognized. 

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman, for this opportunity to discuss MedPAC’s June 2010 report to Congress. 

I want to thank Mr. Hackbarth for appearing before the committee, and thank the staff at MedPAC for their work putting this 

together. 

Today’s hearing is about improving the access to and effectiveness of Medicare. This Congress has implemented historic reforms 


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to our broken health care system that takes gigantic steps forward 

to improve access and quality in health care for millions of Americans. We have extended the Medicare Trust Fund by an additional 

12 years so that we can keep our promise to older Americans and 

disabled Americans. We have done what MedPAC has recommended that we do for years, which is to cut excess payments 

to private insurance companies for Medicare Advantage. We have 

eliminated cost sharing for preventive care in the Medicare program, and we are getting rid of the Republican-created doughnut 

hole. Moreover, health reform will reduce the national deficit by 

more than $100 billion in the first decade, $1 trillion in the decade 

after that. 

Your testimony discusses the highly unpredictable and highly 

variable cost of Medicare cost sharing. It is a point I fear many 

miss. According to AARP, people on Medicare spend an average of 

30 percent of their income on out-of-pocket health care costs, including premiums for supplemental coverage. As cochair of the seniors’ task force, I often hear from constituents who pay hundreds 

of dollars a month for their Medicare. In 2010, it is $110.50 for 

most Part B premiums. The Kaiser Family Foundation reports that 

Part D premiums or prescription drug plans have jumped by 50 

percent since 2006. And MedPAC’s March report shows substantial 

increases in cost-sharing requirements for both brand name and 

generics in 2010. 

Finally, the NAIC statistics from a recent MedPAC report show that Medigap coverage costs—policyholders pay 2,000 to $3,000 a 

year. Medigap policies are expensive, but they can protect against 

highly variable and unpredictable out-of-pocket expenses that you 

reference in your testimony. It is critical to note that Medigap policies aren’t being used by people trying to shirk their health care 

responsibilities. They are being used by Americans who are a bit 

too rich for Medicaid, but don’t have the savings to pay for potentially devastating, uncertain medical expenses. 

I look forward to hearing your testimony today, and I yield back 

the balance of my time. 

Mr. PALLONE. Thank you. 

The gentleman from Ohio, Mr. Space. 

Mr. SPACE. I will waive my opening, Mr. Chairman. 

Mr. PALLONE. The gentleman waives. 

I think that concludes our opening statements. So we will go now 

to our witness. First of all, let me welcome you again. I know you 

have been here before, and we always enjoy your insight. We have 

limited you to 5 minutes. I hope that is OK. If you need more, you 

can use it because you are the only witness. And if you would proceed. Thank you. 

STATEMENT OF GLENN HACKBARTH, J.D., CHAIRMAN, 

MEDICARE PAYMENT AND ADVISORY COMMISSION 

Mr. HACKBARTH. Thank you, Chairman Pallone, Ranking Member Shimkus and other distinguished members of the subcommittee. I welcome this chance to talk about our June 2010 report to Congress. 

Let me begin by briefly reminding you about exactly who we are 

and how we do our work. MedPAC is a nonpartisan advisory group. 


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We have 17 members. The process for appointing the members is 

run by GAO. The Commission that produced the June report had 

six physicians and one registered nurse on the Commission. In addition, we had five Commissioners that had executive-level experience in running health care delivery organizations. Another five 

had had experience in running private health plans. And some 

Commissioners have more than one of these credentials in their 

background. 

As Chairman of MedPAC, I believe we can best serve the interests of Congress by wherever possible finding a consensus point of 

view among these diverse perspectives included on MedPAC. Usually we succeed in doing that, and just to illustrate that point we 

have published two reports to Congress this year, March and June. 

In total there are 26 recommendations in those 2 reports, which 

represents roughly 400 individual votes by MedPAC Commissioners. On this 400 individual votes were zero no votes and 3 abstentions. So we are able to take a diverse group of people, diverse 

group of experiences in health care, and find common ground on 

how to improve the Medicare program. 

Our examination of any given issue usually spans multiple public 

meetings. We have eight public meetings a year and often will take 

up a complex topic, have discussions that explore the available information, ask our staff for additional analysis, then we begin the 

discussion of options. At each point of the process, we reach out to 

parties in the outside world that would be affected by the recommendations who have expertise to bring to bear and make sure 

we have the benefit of that information. So it can be a rather 

lengthy process to getting to final recommendations, but we believe 

that approach allows us to provide the best possible advice to the 

Congress. 

To provide a little bit of context for our discussion of the June 

report, I thought it would be useful for me to highlight some of the 

areas where MedPAC has made recommendations in the past and 

where there is a strong consensus among Commissioners. First and 

perhaps foremost is that Medicare simply cannot go on as it is. The 

rate of growth and expenditures eventually will become unacceptable, and so we need to look in every way possible to find ways to 

slow the rate of growth in Medicare expenditures while preserving 

or hopefully improving quality and access to care. 

To slow growth and increase value for Medicare beneficiaries, we 

will have to act in a broad front; there is no single thing that we 

can do. Among the recommendations that we have made in the 

past are there needs to be consistent pressure applied to the unit 

prices for individual services, whether they be for physician services, hospital services, home health agency services, whatever the 

provider type. 

We need to look for ways to change the relative values of payment. Some of the Members earlier mentioned primary care physicians versus subspecialty physicians. We need to look at opportunities to change those relative values in a way that signals which 

sort of care Medicare beneficiaries need more of and reward the 

provision of that care. 

Third, we need to look at reforming payment methods, using new 

payment methods, whether that is paying for quality or bundling 


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services around hospital admissions, medical home. Those are several examples of what we consider to be payment reform. 

Fourth, there is a broad consensus within the Commission that 

we need a robust and value-focused Medicare Advantage program, 

because private plans have the ability potentially to do things that 

traditional Medicare finds difficult. 

And finally, and most relevant for our June 2010 report, we 

think it is important for Medicare to begin the process of reforming 

its contributions to graduate medical education. And, Mr. Chairman, I would like to close with just a few comments about graduate 

medical education. 

I have a slide here that briefly summarizes our recommendations. In the interest of time, I am not going to go through all of 

the points in the slide. I would like to focus instead on the context 

for our recommendations. 

MedPAC Commissioners believe that our system of graduate 

medical education is in many respects the envy of the world. The 

system produces thousands of superbly skilled physicians each 

year, physicians who are trained to apply the latest technology, latest technique to aid Medicare patients and other patients in need. 

On the other hand, there is a broad consensus within the Commission that the current GME system is not consistently producing the 

physicians we need to reorient our health care system toward a 

higher level of performance. 

Mr. PALLONE. Mr. Hackbarth, I cannot read that. I must be getting old. Is that in the book somewhere? 

Mr. HACKBARTH. Yes, it is. Actually, I will have somebody behind 

me find the page, and I will tell you what the page is. 

Page 103 in the red book, the June—— 

Mr. PALLONE. Thank you. 

Mr. HACKBARTH. So another element of the consensus within 

MedPAC is that the GME system is not consistently producing the 

physicians we need to move towards a higher-value health care 

system, and I would emphasize that is not just our judgment, that 

is the judgment of many other people that we consulted with, including many people within the graduate medical education system 

itself. 

Broadly speaking, we find two types of deficits in the GME system. One is in the mix of physicians being produced by the system. 

That includes the specialty mix, the number of primary care physicians relative to subspecialty physicians and the like. But it also 

includes the racial, ethnic and geographical diversity of the physicians we train. 

The other area of deficit is in the content of training. While physicians are very well trained in advanced technology and techniques, we are concerned, as are many others, that there are important areas that are not as well focused upon, including evidencebased medicine, cost awareness, team-based care, care coordination, shared decision making with patients and the like. 

It is important to emphasize that as MedPAC sees it, the GME 

system does not bear full responsibility for these deficits. For example, in the area of specialty mix, Medicare payment policies and 

those of private insurers strongly influence the choices that physiVerDate Mar 15 2010 13:53 Mar 06, 2013 Jkt 077916 PO 00000 Frm 00037 Fmt 6633 Sfmt 6602 E:\HR\OC\A916.XXX A916

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cians in training make. They also influence the sort of training programs that teaching institutions decide to engage in. 

Moreover, I would add that the GME system deserves credit for 

its efforts to reform the content of training. For roughly the last 

decade, ACGME, the accrediting body for graduate medical education has been engaged in what they refer to as an outcomes 

project which is designed to refocus training on new skills that 

physicians need to produce high value health care. We believe that 

that movement is largely in the right direction, but we think that 

the pace needs to be accelerated. And we propose to do that by 

making a portion of Medicare funding contingent on the development of and adherence to new standards of performance for graduate medical education. 

And we urge that all of the relevant voices be included in developing those standards not just people involved in academic medicine but also representatives of patients, purchasers and high-performing delivery systems. 

Thank you, Mr. Chairman. Those are my opening remarks. I look 

forward to your questions. 

[The prepared statement of Mr. Hackbarth follows:] 


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Mr. PALLONE. Thank you, and we are going to have questions, 

obviously, and I will start with my questions. 

I want to focus on the GMEs. I am concerned about the fact that 

we are apparently suggesting taking some of the existing funding 

and redirecting it based on the standards of performance, and I am 

worried about placing further financial strain on safety net hospitals, some of which I represent. Many of them already called me 

about this proposal. 

And also I am not really sure now, again I haven’t read the report in all its detail, but you know, what is the significance of this 

empirically justified amount? In other words, what you are saying 

is, if it is above the empirically justified amount, then that is the 

money that would be redirected. 

Mr. HACKBARTH. Yes. 

Mr. PALLONE. What is that criteria, empirically justified amount? 

Mr. HACKBARTH. OK. Medicare pays roughly $9.5 billion for 

graduate medical education each year, and it basically is broken 

into three relatively equal parts. The first is what we refer to as 

the direct medical education payments. Those dollars pay for resident salaries, faculty salaries, direct expenses of that sort. The 

other two pieces are paid with the indirect medical education adjustment. 

Teaching hospitals receive a percentage add on to each payment 

they get for a Medicare admission based on a formula that includes 

the resident-to-bed ratio. When Congress enacted that adjustment 

back in 1983, it asked for an analysis of how much costs increased 

to hospital due to teaching activity. And that amount was calculated. 

Congress basically doubled that amount. So we refer to the actual increased cost—increased cost in hospital care is the empirical 

amount and then the additional doubling of it as the extra IME. 

Mr. PALLONE. You see the problem that I have is, you know, one 

could argue that all of this is very artificial and that we should 

have a totally different method of financing graduate medical education. We could have a series of hearings on that, and maybe we 

should. But the problem is the reality. The reality is that these 

hospitals are depending on this money, and it may be somewhat of 

an artificial formula, but at this time, if you are just going to say, 

OK, we are going to take some of the money away, I just think, 

I am concerned that this is not the right time to do that. We can 

argue about how this formula was set up. But right now, at this 

time, given the recession, given all the things that we face out 

there, why does the commission feel that this is a wise step right 

now? 

Mr. HACKBARTH. Well, we are, I would like to emphasize that we 

are not saying, take the money away. 

Mr. PALLONE. But isn’t that, in effect, what will be happening? 

Mr. HACKBARTH. What we are saying is, establish accountability 

for the use of the funds. Let’s make sure that—— 

Mr. PALLONE. But my point, Doctor, is that, you know, we get 

to the point where the way we have gotten to this formula now, 

you can argue how we got there or not, but you have to be concerned, or at least I think I do and I think many of my colleagues, 

about the consequences of it. And I am just concerned that—I want 


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you to be innovative and come up with new ideas, and many of 

your ideas we have incorporated in the health care reform. I am 

not suggesting otherwise. It just seems right now if the consequence of this is that money is taken away from some of these 

hospitals that are barely, that are in the red, have you taken that 

into account? 

Mr. HACKBARTH. We have. And what we have proposed is that 

the new standards would take effect 3 years from now so there 

would be a 3-year period to develop the standards that would guide 

the new payment policy and to give the institutions an opportunity 

to prepare to adhere to those standards. 

Mr. PALLONE. I think I am going to stop because I have additional questions. I am sure my other colleagues are going to delve 

into this GME thing more. 

Let me just ask about the diagnostic tests. In your report, you 

explore the suggestion that reducing payment rates for diagnostic 

tests performed under the in-office ancillary exemption would help 

to slow growth for these services. 

But I wanted to ask you, beyond the 2006 and 2008 data you examined, to what extent did you take into account the cuts that 

have occurred in the recent past, for instance the impact of the 

Deficit Reduction Act, the reductions in payments due to January 

1, 2010, changes in the physician fee schedule? 

The concern I have is the rates for these services, particularly 

advanced imaging, have declined significantly in recent years. And 

so, again, I am again hearing from them about how this is going 

to be a problem because of all the cuts we already had. 

Mr. HACKBARTH. What we propose is a series of very targeted reductions in payment for imaging. And we have taken into account 

the effect of those. And we think that the payments would continue 

to be adequate to assure reasonable access. 

What we have right now is very rapid growth in high end imaging and a lot of people investing equipment, and once it is in the 

office using it at a high rate. And to us that signals that the payments have been quite generous in the past. And what we need to 

do is bring the payments more in line with the cost of that care, 

and then we have recommended redirect those funds to other higher value uses for the Medicare program. 

Mr. PALLONE. OK. Thank you. 

Mr. Shimkus. 

Mr. SHIMKUS. Thank you, Mr. Chairman, and Mr. Hackbarth, I 

apologize for you getting involved in the health care law food fight, 

but we only get the opportunity to openly discuss this, and I think 

it does call for a hearing. That is all we are saying. That is our 

point. If they are right, let’s have a hearing; if we are right let’s 

have a hearing. And there are problems that in this law we know 

that need to be fixed. They are smaller ones, but, so we just take 

the opportunity, the limited opportunity we have to address our 

concerns. 

In response to the chairman, we did pass a bipartisan bill called 

the food safety bill. It passed out of here on a voice vote I think 

and passed on the floor, and we were involved in that and when 

we are asked to work together, I think we can do so effectively. 


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The health care bill creates a $1 trillion new cost. And I am just going to ask on this $500 billion, $500 billion wasn’t all the Medicare Advantage, as you know; $20 billion was revision to the Medicare Improvement Fund, which is to help doctors continue to take 

Medicare patients, $20 billion over 5 years; $156 billion came from 

ensuring Medicare sustainability, revision in the Market Basket 

Updates, which is payments to hospitals; $156 billion out of 5 years 

on this new law; payment adjustments for home health, $40 billion. So, I would caution my colleagues that there is $135 billion on 

the Medicare Advantage. That is something they did mention. But 

I would question to make sure we do a total of the entire $500 billion in cuts because some of it is to hospitals; some of it is to individuals, and that is what this law did. 

I look at the, trying to find the mission statement, and under the 

front cover says, Medicare, you are supposed to help us on the 

Medicare Advantage program, providers in the Medicare traditional fee-for-service, and analyze care, quality of care, and other 

issues affecting Medicare. And you do. But I think for macro versus 

micro, you have gone into a lot of the micro aspects, and you have 

done it for a long time and, again, well respected and been around 

for a long time. We are worried about some of the macro issues, 

too, and I know, because implementation takes time, it is tough to 

check the implications of the new law, especially in this report, but 

I think that is an important aspect to look at, especially when you 

have the, whether they like it or not, $500 billion of cuts, and it 

is not all coming from Medicare Advantage. It is coming from hospitals. It is coming from physicians. There are tax increases that 

are going to effect service. 

Having said that, are the people on the committee, I was going 

through the bios, are there any economists on here? 

Mr. HACKBARTH. Yes, there are. 

Mr. SHIMKUS. And the physicians are for-profit, not-for-profit, the 

hospital administrators from both for-profit hospitals and not-forprofits hospitals? 

Mr. HACKBARTH. Currently not-for-profit. 

Mr. SHIMKUS. Not-for-profit. No for-profit hospitals? 

Mr. HACKBARTH. No for-profit hospitals, no. 

Mr. SHIMKUS. Is there a reason, do we know? 

Mr. HACKBARTH. Well, as I say, the GAO does the appointments. 

So we don’t select our own members. And so I don’t know the answer to that question. I wouldn’t expect that we would never have 

a for-profit. We just currently don’t have for-profit. 

Mr. SHIMKUS. I am a market-based capitalist, conservative. I believe in supply and demand. I believe individual consumers, given 

the ability to access information, will drive prices. You will get 

higher quality and lower cost. I am concerned about third-party 

payers, and institutions, in essence, try to set fees. When an individual consumer is given the information and the access probably 

is a better system. 

The GME issue is just one sliver of what you are doing, but I 

understand it is a very important aspect to you. We have hospitals 

that have too many GME slots. We have places in this country 

with not enough slots. And in the moving of the—I want more slots 

is what I want. Is there, in the calculation of the payments, is the 


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payment, say for a GME slot in New York City, is the payment the 

same as it would be in Springfield, Illinois, for a teaching hospital? 

Or is there a cost of where the education is going? Is there a percentage ratio there? 

Mr. HACKBARTH. Well, we have got, as I said to Chairman Pallone, we have got two different types of GME payments. We have 

got the direct payments for salaries and the like, and then we have 

the indirect add-on. The direct payments are set at a hospital specific amount. So there is a base year, based on the actual costs incurred for salaries and direct expenses in that year, and then that 

has been inflated by the CPI since. 

The indirect piece is a percentage add-on to whatever they get 

paid for Medicare admission. So that does reflect different wage indices and different costs of care. 

Mr. SHIMKUS. So I will end on this, and I appreciate the chairman’s permission to just finish with the statement. We need more, 

in this environment, with doctors talking about leaving the profession, we need more doctors. We need more GME slots. And I believe in supply and demand, and the higher supply you have, the 

lower; more supply you have, the lower cost, but we have got to get 

them out. And they have got to get trained in educational institutions. 

Mr. HACKBARTH. Chairman Pallone. 

Mr. PALLONE. Yes, please respond. 

Mr. HACKBARTH. May I make a brief comment about the number 

of slots? It may well be true that we need more slots, more physicians being trained. That is not an issue that we have looked specifically at. There are certainly a lot of people who believe that. 

What we have said, though, is that before Medicare decides to 

fund more slots, we think we would do well to step back and do 

a careful assessment of what our long-term needs are likely to be. 

We shouldn’t just extrapolate from the past, but look at the mix of 

physicians and other health professionals that we will need for a 

more efficient system in the future and then base our decisions 

about GME funding on that analysis. 

Mr. SHIMKUS. Thank you. 

Mr. PALLONE. Thank you. 

The gentlewoman from Florida, Ms. Castor. 

Ms. CASTOR. Thank you very much. 

And I want to stay on this topic. I think you are generally on the 

right track when it comes to the GME, to say we have got to look 

at these trends and specialization. I can’t tell you how many young 

residents or med students I meet, med students who are gung ho; 

they are going into family practice or general practice or pediatrics. 

And then I see them a few years later, and their loans have taken 

the toll, and they are going to go into plastic surgery or some other 

specialization. And so I think it is very wise to plan ahead and 

begin to look at how we create those incentives. So I appreciate 

that very much. 

And the diversity mix, MedPAC has done a good job focusing in 

on kind of the lack of how the medical field oftentimes does not reflect our population. We need to improve that because that means 

better care, although women now are going gangbusters in our colleges of medicine. 


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I had really hoped that MedPAC would also address this issue 

of the static nature of the cap and what that has done to States 

that have grown in population since 1996 when that cap was put 

on because it has created such a harmful dynamic in my State that 

has been a high-growth State in other areas. 

We have got three major GME-related issues. One, our residentto-population ratio is in very bad shape. Two, we don’t have nearly 

enough slots to account for all of our medical school graduates. We 

have nine med schools, but at least two-thirds of all students leave 

the State to practice. 

And then we have hospitals operating above their caps. They are 

struggling to pay for those additional residents and fear that they 

may not be able to keep up with those extra, the extra costs that 

those slots require. 

So, in the big picture, we can generally say that more slots 

doesn’t necessarily ensure better care or overall better training, as 

asserted in your report. However, there is this other issue that I 

know we, in our health care reform law, we said we are going to 

do a workforce study. And you mentioned that here, and in fact, 

Secretary Sebelius announced new residency positions just this 

past week for primary care, so that is very positive. 

Could you please address, why didn’t MedPAC consider the geographical inequities here in this report that are so fundamental? It 

is really underlying the workforce issue and the diversity issue. 

Can you address that and the impact of cutting the limited GME 

funds that some States already receive? 

Mr. HACKBARTH. We did not make specific recommendations 

about either increasing the caps or reallocation of them. 

However, we did suggest that we needed to take steps; Medicare 

needs to take steps to increase the diversity of the physician workforce of the future in and make sure that we are bringing into medicine people who are inclined to practice in rural areas, practice in 

inner cities that may be underserved. Recent research shows that 

an important element in that decision where to practice is where 

the student comes from to begin with. And so there are programs 

in the public health service, authorized by this committee, that are 

targeted at trying to change the mix of physicians being trained, 

increase the diversity, we think those programs that directionally 

make a lot of sense. 

Again, on the specific issue of how many physicians Medicare 

ought to support, we didn’t look at that issue specifically just for 

a matter of time and resources, but we do think that it needs to 

be guided, a decision needs to be guided by careful analysis of future needs, whether they be geographic, diversity, specialty. The 

beacon that we aim for is a high-performance delivery system. If 

we just doubled the number of physicians with the current specialty mix, we may well not make our problems better; we could 

end up making them worse. And so we need to think first before 

we increase the funding. 

Ms. CASTOR. We have got to harmonize what was in the health 

care reform law that says States that have these low resident-topopulation ratios are going to get a little bit of help. And I was 

hoping in your report you would reference that. 


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I know you mentioned in the report that you weren’t sure when 

the law would be finalized. But there needs to be some harmonization of those. 

And quickly, on the IME payments, many hospitals feel that redirecting the IME payments, since the needed level of IME funding 

is difficult to quantify, leaves them in a position to come up with 

dollars for indirect costs on their own, and for some States, that 

are looking at DSH payments changing over time and the fact that 

we may still be serving many folks in this country that show up 

in the ER but will not be covered in the health care bill; it is very 

troubling to see another challenge on the horizon. 

So if MedPAC recommends that we not make decisions about 

Medicare funding for new residency positions until an independent 

analysis of our health care workforce is conducted, is it premature 

to recommend that IME funds be redirected before the study is concluded? 

Mr. PALLONE. I am going to have to—I am sorry, Ms. Castor, I 

have been not paying enough attention to the time. You are like 

1 minute, 20 seconds. Why don’t we send that in writing? 

Ms. CASTOR. Thank you, Mr. Chairman, because, you know, I 

care about that. 

Mr. PALLONE. I know. I appreciate it. We will send that in writing. 

The next is the gentleman from Georgia, Mr. Gingrey. 

Mr. GINGREY. Thank you, Mr. Chairman. 

Mr. Hackbarth, physician reimbursements under Medicare were 

cut back 21 percent last Friday. Many physicians in my district 

have told me they will stop seeing Medicare seniors because of 

these cuts. And indeed, some in the more rural areas have said, 

well, they will just move to an urban setting where the Medicare 

case mix is not quite as high. 

Today, this mitigation, which has passed the Senate, that bill is 

being delayed by Speaker Pelosi, the bill that would restore these 

cuts, the cuts that may mean our seniors have a Medicare card but 

no physician to accept them. 

Given our current physician shortage and the access problems 

that Medicare seniors are currently encountering, do you believe 

that Speaker Pelosi’s decision to allow these 21 percent cuts to go 

forward will make it harder for new Medicare seniors, especially 

those in rural areas, to find a physician who would be willing to 

take them? 

Mr. HACKBARTH. Well, it is obviously not my place to comment 

on Speaker Pelosi’s position. 

But let me just describe our position on this. 

Each year, we do a large survey of Medicare beneficiaries to ask 

them about their access to physician services. We survey about 

4,000 Medicare beneficiaries each summer, and we survey a like 

number, roughly 4,000, of privately insured patients that are just 

under the Medicare eligibility age, so we have a reference point. 

Our survey done last summer, the summer of 2009, found that 

generally Medicare beneficiaries have access as good as or even 

better than privately insured patients in the 50 to 64 age group. 

The area of concern within that generally good picture is around 

primary care. 


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Part of the survey that we do is we ask Medicare beneficiaries 

who are looking for a new physician whether they have any problem in finding a new physician. That is the most vulnerable group. 

And what we find is roughly one quarter of Medicare beneficiaries say they have difficulty finding a new primary care physician. Again, this was 2009. 

The number for privately insured patients in 2009 was actually 

a little bit higher; a higher percentage of privately insured patients 

said they were having difficulty finding a new primary care physician. 

The lesson that we draw from that is the country has a growing 

problem with access to primary care. It is not unique to Medicare. 

It is a broader systemic issue. So that was 2009. 

We are in the process now of doing our 2010 survey. I don’t know 

what those results will be. 

I would say, though, that the uncertainty and even anxiety 

caused by the annual, now more frequently than annual, debate 

over SGR can only be undermining the confidence of physicians 

and patients in the Medicare program. And so I don’t know what 

the new survey results will be, but we are concerned that the repeated threat of very large cuts could impede access. 

Mr. GINGREY. Well, Chairman Hackbarth, I appreciate you bringing that information to the committee. That is extremely important. And if I understood you correctly in last year, 2009, before 

ObamaCare patient protection affordable care act, one-fourth of 

Medicare patients seeking new physicians had difficulty finding 

one. And now we are in the situation where fully 10 million people, 

Medicare patients on Medicare Advantage, that program is being 

cut; I think Mr. Shimkus said the number was $130 billion over 

10 years, so maybe 6 or 8 million of those 10 million will lose their 

coverage under Medicare Advantage. And then you compound that 

problem with a 21 percent cut. So we have put to put a Band-Aid 

on it now, and so those many physicians are going to say, I am 

outta here. And then you are going to get this deluge of new patients trying to find a doctor to cover them under Medicare. I just 

hate to think what your numbers are going to show when you survey those 4,000 in June, July of 2010. 

Mr. HACKBARTH. I just want to be very clear, because this is such 

an important issue, about what the 2009 survey results were. 

So we said that the most problematic area was Medicare beneficiaries looking for a new primary care physician. So that represents about, the number of Medicare beneficiaries seeking a new 

physician is about 6 percent, and it is one-quarter of that 6 percent 

that report experiencing a problem. 

Now we have got 45 million Medicare beneficiaries. So even if we 

are only talking 1.5 or 2 percent, we are talking 900,000 Medicare 

beneficiaries. That is a lot of people and reason for concern. But it 

does represent 2 percent of the Medicare population. 

And it is also important to emphasize, again, that this is not 

unique to Medicare. The privately insured patients were also reporting problems in finding a new primary care physician. 

Mr. GINGREY. Thank you for your indulgence, Mr. Chairman. I 

am a minute over, and I yield back. 

Mr. PALLONE. Thank you. 


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The gentlewoman from California, Ms. Eshoo. 

Ms. ESHOO. That you, again, Mr. Chairman for having this hearing. 

Chairman Hackbarth, I have two questions. The first one has to 

do with the report’s inclusion of a proposal that some of the graduate medical education funding provided to hospitals by Medicare 

be made contingent on practice-based learning to encourage medical residents to spend more time in community health clinic settings. Now some teaching hospitals in my district and elsewhere 

don’t have the emphasis on outreach with ambulatory care settings 

right now. What does the commission think the impact on the current GME system will be under this proposal? 

And what is the commission advising the Congress relative to the 

transition in order to incorporate what you have discussed in the 

proposal? 

And my second question is, on self-referral. Experts across the 

board, of course, agree that physicians self-referral, where doctors 

refer patients for medical services in which they have a financial 

interest, is a costly drain on the Medicare system. I agree with 

that. The report goes into quite a bit of detail to demonstrate that 

self-referral under the Stark Law ancillary services exemption continues to grow, but noticeably absent from the report are any concrete recommendations about how to address this. 

So can you address it? 

Mr. HACKBARTH. Yes. 

Ms. ESHOO. Those are my two questions. Thank you. 

Mr. HACKBARTH. Thank you. 

First, on the nonhospital-based training, training in community 

practice, a few points there. First of all, that is particularly important for some specialties. Obviously—— 

Ms. ESHOO. I am not arguing whether it is important or not, but 

since you make the recommendation about it and there are many 

that have brought up GME in their opening statements and some 

in their questions, my question was, what is the impact and how 

are you going to—what are you—what is the commission recommending in terms of the transition in order to accomplish this? 

Mr. HACKBARTH. Well, the first step is to remove some of the 

barriers. In the current Medicare rules, there are rules about how 

the time of residents is counted that impede people from doing nonhospital training. The teaching hospitals have asked for those rules 

to be changed. A number of those changes were included in the affordable care act. And so that is something that the teaching institutions themselves have asked for, take down one of the barriers. 

The second step is to make sure that those opportunities for nonhospital training are good experiences, rich experiences, because 

that is the experience that primary care physicians, for example, 

need in particular. That is the environment where they will be 

practicing. 

And one of the reasons that young physicians in training don’t 

go into primary care is they have that experience, ambulatory experience, and it is not a good one. It is in a clinic that is not well 

managed. They don’t have time to deal with their patients, and so 

they are turned off by primary care. Fixing that problem, as you 


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say, is not something that is going to happen overnight; finding 

new settings, rich settings for people to train in. 

So we recognize that there will be a period of time. 

Our recommendation, as I said earlier, is that the new standards 

wouldn’t go into effect for 3 years. But if, on this particular issue, 

the Secretary were to decide, oh, even more than 3 years is required to allow ample ramp up, then we wouldn’t object to that. 

But we do think we need to be moving in that direction. 

Ms. ESHOO. Good. And on the self referral issue? The report really does go into quite a bit a detail. It is really short on any recommendations. 

Mr. HACKBARTH. We lay out I think about a half dozen options 

that might be considered. 

For example, limiting self-referral to services provided on the 

same day as the basic visit, packaging certain imaging services, for 

example, with the visit payment, subjecting some types of high-end 

expensive imaging to prior authorization. There are I think a half 

dozen different options there. 

What we have done, each of those has pros and cons. And we 

have laid them out so that now we can get people outside MedPAC 

to react to those options, help us deepen our understanding of their 

implications, and we would expect next year, with that additional 

information, we will come back and look at those six options or 

maybe some new ones. 

Ms. ESHOO. Will it take you a year for you to gather that information before you make the recommendation to Congress? 

Mr. HACKBARTH. I don’t know exactly when we will take it up in 

our fall schedule, but it will be in the fall. It wouldn’t be next June. 

Ms. ESHOO. I see. I thought you said it would take a year to get 

them. 

Mr. HACKBARTH. Next annual cycle is what I am referring to. 

Ms. ESHOO. Thank you very much for your work and your testimony. 

Mr. PALLONE. Thank you, Ms. Eshoo. 

The gentleman from Texas, Mr. Burgess. 

Mr. BURGESS. Thanks, Mr. Chairman. 

Again, Mr. Hackbarth, we are pleased to have you here. Let me 

just be sure I heard you correctly when you gave your statement 

because we heard some discussion from the dais about Medicare 

Advantage, and I thought I heard you say that we need a robust 

Medicare Advantage. And that is something I have heard before in 

some of the Commonwealth on things. We heard that from the 

head of Scott—the physician from Scott and White last January 

who also happened to be a head of the AMA who endorsed the 

health care bill but with the cuts to Medicare Advantage. So why 

the dichotomy here? 

Mr. HACKBARTH. I am sorry—— 

Mr. BURGESS. We cut Medicare Advantage, and we said that is 

that was a good thing in the health care bill, but you are telling 

us we need Medicare Advantage. 

Mr. HACKBARTH. Yes. If I could, I would like to refer back to 

something Mr. Shimkus said. I believe strongly in the market and 

market signals. And how much you pay for something influences 

the product that you get. 


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I believe very strongly that having the option of enrolling in a 

private plan is a good thing for Medicare beneficiaries. But if we 

set the price too high, we get private plans that are not properly 

focused on increasing value for Medicare beneficiaries. We make it 

too easy. And the evidence that I would cite for that is that when 

the prices went way up, when we vastly increased the benchmarks 

on Medicare Advantage, we got a huge influx of private fee-forservice plans which added very little value. 

Mr. BURGESS. I do have to interrupt you there because some of 

the data we have heard and we never got in this committee because we never have had advantage, but some of the information 

that we have gotten, again from the Commonwealth Fund, that are 

not just bastions of conservative thought, that Medicare Advantage 

did hold the promise, they did the care coordination, the disease 

management, the ancillary providers, the electronic medical 

records; all the things you want your care system of the future to 

do, they were able to provide. So I heard it at a roundtable dealing 

with the Physician Group Practice Demonstration Project that if 

you don’t have Medicare Advantage, we can’t do these things that 

you have asked us to do. And we believe we are on the right track. 

I am going to have to leave that in the interest of time because 

I have things I just have to ask you. Appendix A of your report suggests that in addition to the 21 percent cut that went into effect 

June 1st, there is an additional 6.1 percent that will be shaved off 

physician reimbursement based on your calculations that will kick 

in January 1st. Is that correct? So an aggregate cut from last 

month of 26 percent by January 1st. 

Is there any way to prevent or to create the delink, you say that 

goes into effect, say there is nothing anyone can do to stop that, 

is there any way to delink private insurance reimbursement from 

what Medicare is reimbursing? Because as you know, many of the 

private contracts pay at a percentage of Medicare. 

Mr. HACKBARTH. Well, it is often the case, as you say, Mr. Burgess that private insurers use the Medicare relative value system. 

But typically they will use their own conversion factor. So the actual price paid is not Medicare. In some cases, it could be higher; 

in some cases, it could be lower. 

Mr. BURGESS. Correct. And in the interest of time, it is generally 

like 110 percent of Medicare. But you cut Medicare 26.1 percent, 

Blue Cross Blue Shield, that pays 110 percent of Medicare, guess 

what? They get a big windfall for their stockholders, and the doctors end up holding the bag on that. I do think that is something 

I would like to see your group look at. 

Let me just talk about a couple of things because they are terribly important. 

In the health care bill that passed, we got the creation of the 

Independent Payment Advisory Board will that render the Sustainable Growth Rate Formula obsolete or are the physicians perhaps 

facing the specter of both the SGR and cuts in the Independent 

Payment Advisory Board? 

Mr. HACKBARTH. Well, my understanding of the legislation is 

that the targets established for the Independent Payment Advisory 

Board are separate from SGR. 

Mr. BURGESS. So the answer is, yes, they could be hit with both? 


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Mr. HACKBARTH. Right. And the difference, of course, is that the 

Independent Payment targets are program-wide. They are not just 

focused on physicians. 

Mr. BURGESS. Right. But, again, that is one of the things that I 

think needs to be looked at with a great deal more scrutiny because 

I am getting these questions, and I have got to believe that doctors 

who are looking down the road at what we have done to them are 

going to be taking this quite seriously, and you may find your numbers of people who can find a Medicare physician actually dropping 

off more significantly beyond what you anticipated. 

The last thing, the chairman has such a quick gavel, you brought 

up on the prior authorization on imaging, why is it, and I hated 

prior authorization, I hated calling 1–800 to get a procedure approved, but why doesn’t Medicare look at a little bit of that type 

of activity? It is always a pay and chase; you pay something, and 

then wonder if it was advisable to do so and then try to chase 

someone down. In the private world, you end up having to get everything preauthorized, which is a pain and sometimes overdone, 

but why not incorporate some of the lessons that have been learned 

in the private sector to hold down the cost in Medicare? 

Mr. PALLONE. That has got to be the last question. 

Mr. BURGESS. See, I told you he is quick with that gavel. 

Mr. HACKBARTH. As you know, increasingly, prior authorization 

is used to for expensive imaging services. There are companies that 

specialize in that business, running those prior authorization programs. 

And it is an option that we will look at. 

Obviously, the concern is the intrusiveness of it, the hassle of it 

for physicians. But it is something that has some advantages, so 

I don’t know where we will come down, but we will look at it. 

Mr. PALLONE. Mrs. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. 

And again, thank you for being here, Dr. Hackbarth. 

I had to step out when my colleague, Dr. Burgess, was speaking, 

but I just have to get this off my chest because I really think that 

MedPAC has the whole provider reimbursement issue backwards, 

and therefore, the remedies are not really directed as they should. 

And I just wondered if MedPAC has ever considered providers are 

paid so very low reimbursement that they just have to see more patients to be able to keep their lights on, pay their staff, keep their 

doors open, as well as take care of their families. 

All of the remedies are based, seem to be based, on the assessment that fee-for-service is the source of the problem, but I really 

think that it is the low fees. Doctors are really forced into a position where they have to see more patients, and CMS has never 

really paid us to sit down and talk or listen to our patients. 

So I just wanted to get that off my chest. 

Mr. HACKBARTH. In fact, we would agree that there are some 

physicians who are paid too little and paid, being paid fee-for-service may not even be the best method for paying a primary care 

physician. 

But on the other hand, we think that there are other physicians 

who may be paid too much. 


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And so, rather than saying, oh, we think all fees should be cut, 

our view is more nuanced. We think that there is plenty of money 

in the Medicare physician payment pool in the aggregate, but it 

needs to be redistributed to support a high value care, more for 

some, less for others. 

Mrs. CHRISTENSEN. And as a primary care physician, I appreciate the fact that primary care is going to be given more attention 

and have perhaps some higher reimbursement, but I don’t see that 

that should be at the expense of the specialists. When you need a 

specialist, the situation is generally critical, and they have a specialized, by definition, service to provide. 

Mr. HACKBARTH. Before I started doing this job, I was a CEO of 

a 500 physician multispecialty group practice in Boston. And our 

physicians were all paid on the salary. We were largely at that 

point a prepaid group practice. But if you looked at the difference 

between a primary care physician and a cardiologist or some specialist within a group like mine or you do the same at Kaiser 

Permanente today, the range is much narrower than existing feefor-service. Yes, the specialists get paid more, but it isn’t the huge 

gap that exists in fee-for-service Medicare. And so what we are suggesting is not that specialists not be paid appropriately for their 

additional training and the like, but we do think that that gap 

needs to be smaller. 

Mrs. CHRISTENSEN. Thank you. 

Let me try to get one other question in, and my time is fast escaping. 

When CMS institutes a least-costly-alternative policy or codebundling determination, providers face a financial loss each time 

they prescribe a product that is not the least costly product subject 

to the LCA policy or a product that is more costly than the blended 

reimbursement rate under a code-bundling decision. To the extent 

that Congress grants CMS’s explicit authority to institute LCA 

policies or expanded code-bundling authority for drugs or biologics, 

what safeguards does MedPAC recommend including in such authorities to ensure you that patient access to important therapies 

is appropriately preserved? 

And what kind of clinical evidence should CMS be required to 

consider before instituting that policy or bundling determination? 

And what exceptions should Congress include to make sure that 

patients can get Medicare coverage for the more costly products 

when they are medically necessary? 

Mr. HACKBARTH. Yes. Well, the decisions in executing least-costly-alternative reference pricing options of that nature need to be informed by the best available clinical evidence. And the process 

needs to be a transparent one, whereby all interested parties have 

an opportunity to present their information to CMS. As we say in 

the report, we think in some areas like this, it would be good to 

give CMS and the Secretary more flexibility than they have under 

the current law to execute these policies. But that doesn’t necessarily mean abdication by the Congress either. 

You can imagine ways that the Congress would reserve the right 

to override particular policies and the like. So we would like to see 

the needle shifted some towards more discretion but only based on 


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evidence, transparency, and there could be some residual congressional control. 

Mrs. CHRISTENSEN. I am over my time. 

Thank you. 

Mr. PALLONE. Thank you. 

The gentleman from Kentucky, Mr. Whitfield, who has 8 minutes. 

Mr. WHITFIELD. Thank you, Mr. Chairman. 

And Mr. Hackbarth, thanks very much for being with us today. 

We appreciate your presence. 

I am going to revisit this one issue that Dr. Burgess mentioned, 

and that is Medicare Advantage. I want to do so because there are 

13,000 seniors on Medicare Advantage in my congressional district. 

And my understanding is that there will be $200 billion taken out 

of the Medicare Advantage program. And in your testimony, you 

talked about the need for a robust Medicare Advantage program. 

And it seems to me that taking $200 billion away is the exact opposite thing that we would need to do in order to have a robust Medicare Advantage program. And I would just like your comments on 

that, and I have not had the opportunity to read all of this report, 

but what do you say about that in this report, if anything? 

Mr. HACKBARTH. Yes. For many years now, going back to 2001, 

MedPAC had recommended reducing the Medicare Advantage 

rates. We believed that reducing them would leave, still leave 

ample resources for a well run, high-value Medicare Advantage 

plan to do very well in serving the Medicare population. 

I have been a senior executive in such a plan. I have run a medical group that has had a lot of Medicare. It was back then Medicare Plus Choice; this was pre-Medicare Advantage. But I know a 

little bit about such programs from the delivery side. 

Just increasing the rates, as was done in a series of steps by the 

Congress, does not assure a robust Medicare Advantage plan. In 

fact, in crucial ways, it undermines it by allowing signaling to 

plans you can do very well while doing very little. And again, the 

evidence that that was occurring is, as the rates got very, very high 

relative to fee-for-service Medicare, we had a large influx of private 

fee-for-service plans that were adding very little, if any, value to 

the Medicare program but doing very well. 

That was not in the interest of the Medicare Advantage program, 

to allow low-value performers to do very well. 

If you reduce the rates, yes, you make it more difficult in the 

first instance, but it is also the spur to finding ways to do things 

better that is needed. That is what drives markets. It is that spur, 

that pressure to find new innovative ways to produce a high-value 

product. 

That had gone out of the Medicare Advantage program due to 

overpayment. 

And so there is a lot of waste in traditional Medicare. We fill 

books each year documenting the waste in traditional Medicare. An 

innovative private plan, well managed and really focused, can find 

ways to provide Medicare benefits, plus more, to the Medicare population for less money than fee-for-service Medicare. I believe that. 


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Mr. WHITFIELD. So it is your position that you can maintain a 

strong, viable Medicare Advantage program even though you take 

that much money out of it? 

Mr. HACKBARTH. Initially, you are likely to see a reduction in the 

number of plans and a reduction in benefits, higher premiums, 

fewer enrollees. 

That is the short term. The long term, though, is that it will 

begin to change the nature of the plans that participate, and I believe towards a higher value, more worthwhile option for Medicare 

beneficiaries. 

Mr. WHITFIELD. And over the long term, would you guess that 

there would be more Medicare Advantage programs available? 

Mr. HACKBARTH. More individual plans offered? Again, it is going 

to depend on what your time horizon is. The first couple years, I 

would expect that you will see fewer. The easy money is gone, and 

people will say, oh, the easy money is gone, I will move on to something else. But over time, I think that you could see those numbers 

start to increase again. 

Mr. WHITFIELD. Also, I notice, on page 3 of the report in chapter 

1, and I told you I hadn’t read it, but I read the first page already. 

But it says in this report that you describe the least-costly-alternative policy as one way that CMS can apply the results of comparative effectiveness research in order to help contain Medicare 

spending. 

And yet when we were having the debate on the health care reform legislation, many people, including the President, were stating 

in no uncertain terms that comparative effectiveness research is 

providing patients and doctors with the information they need to 

make the best medical decisions. And there was never any reference to being a mechanism for cutting costs. So this report basically does say that that is one of the purposes of it. And in your 

mind, is there any inconsistency there? 

Mr. HACKBARTH. I won’t try to represent what President Obama 

or anybody else said. 

Let me say what I believe. I believe that it is in the interests of 

patients and physicians and the broader population to have more 

information about what works. That information, as it is developed, 

can be applied in many different ways. One would be to inform 

policies like least-costly-alternative. Another would be to build into 

shared decision-making programs where Medicare beneficiaries and 

other patients can be more actively engaged in making choices over 

their own health care. Still another way might be to identify potential areas to reward through pay-for-performance programs. Still 

another way might be to inform coverage decisions. There are a lot 

of different ways to use that information. 

You add them all together, having better information is good for 

patients and good for physicians. 

Mr. WHITFIELD. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

Mr. WHITFIELD. Can I yield Dr. Burgess 30 seconds? 

Mr. BURGESS. One follow-up question on the Medicare Advantage, you referenced Medicare Plus Choice. Far before my time 

here, but that kind of went away because it was underfunded, did 

it not? 


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Mr. HACKBARTH. The enrollment did increase. We went through 

a similar cycle—— 

Mr. BURGESS. The short answer to the question is yes. 

Let me ask you something else before the small amount of time 

I have goes away. Wouldn’t it have been better, if we stipulate that 

you are accurate about your statements about Medicare Advantage 

and there is more money going into Medicare Advantage than 

needs to go into it and if we have these additional dollars of Medicare, wouldn’t it have been better use of those funds to keep them 

in Medicare and deal with the number one problem that is going 

to affect access for Medicare patients in the future and that is offsetting the cost of fixing the SGR formula? 

Mr. HACKBARTH. How to allocate funds is really above my pay 

grade. Those are choices for the Congress to make. 

Mr. BURGESS. We have a whole book here about allocating funds. 

Mr. PALLONE. All right. We have to move on here. 

Next is Mr. Green. 

Mr. GREEN. Thank you, Mr. Chairman. 

I heard there were questions earlier on graduate medical education. In Congress, we call it GME. Because I want to make a 

point on it. I was a sponsor of the provision in the health care bill 

that on a residency training in our FUHCs because we have a 

great example in the Houston area of the Denver Harbor Clinic 

with an agreement with the Baylor College of Medicine. Greater accountability in GME isn’t a bad idea, though, and we need to debate exactly how we are going to go about doing that because we 

don’t want to hurt our hospitals or our resident programs, but we 

also like to make sure those physicians, those medical students 

know they can make a good living by practicing in FUHCs and 

hopefully will grow them. 

Mr. Hackbarth, again, I want to thank you, like all the committee members, for your being here today and the report. Your 

testimony and the report discussed demonstration projects at CMS 

and certain hurdles that these projects face, including low levels of 

funds and constraints on CMS in conducting these demo projects. 

Can you discuss these issues? And I know many of us in Congress, 

I like having CMS conduct a demonstration before implementing a 

broad policy on everyone, simply because it is a test model, to see 

how it works and if it is successful. Can you just address that? 

Mr. HACKBARTH. Yes. Well, as you well know, Mr. Green, the 

health reform law took a major step in terms of increasing funding 

in giving the Secretary a broader authority in doing, testing new 

ideas for Medicare. And we think that is a significant step in the 

right direction. 

In order to meet the challenges that Medicare faces, of slowing 

the rate of increasing costs while preserving or even increasing the 

quality of care, we are going to need to change how Medicare pays 

for services. And the problem that we have had historically is that 

that process for testing new ideas is painfully slow. From conception to completion, we are often talking 7, 8, 9, 10 years. 

At that rate, we will never get the job done. 

The steps taken in the affordable care act we think have the potential to accelerate that process somewhat. We think that is very 

important. 


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I would add, however, one of my biggest concerns is that let’s assume, as I think we all hope, that we can run some successful demonstrations and develop new ideas that work, those ideas need to 

then be operationalized by CMS. And I worry that even though we 

have given more funding, more funding for the research and demonstration, we are still chronically underfunding CMS operations. 

And if we continue in that pattern—we can have all the great 

ideas in the world—they won’t get implemented, or it will get implemented poorly, and we won’t be any better off than we are 

today. 

Mr. GREEN. That brings up the next question. You also mentioned that newly created Center for Medicare Innovation, which 

was authorized under the health care—health reform law. Mr. 

Whitfield and I have been working on a demonstration project we 

think that meets the criteria for a CMI demo, and the health reform law provides CMI with $10 billion in funding to carry out 

these new demonstration projects, which, in my opinion, is a sizeable amount of money. It may not be enough, because hopefully we 

will see lots of ideas that can deliver a more effective and even a 

more reasonable cost delivery of medicine. Yet your testimony indicates that there may not be enough funding four CMS to carry out 

all the demo projects, even though none have been taken up yet because, frankly, it has only been the law for a very short time. 

And what are the issues that may cause CMS—even though none 

of it has been taken up, this may cause issues within CMS with 

the fee-for-service models. Can you discuss your statements on the 

Center for Medicare Innovation and the CMI? 

Mr. HACKBARTH. I would agree, Mr. Green. The $10 billion funding is substantial, a huge increase compared to what CMS has had 

historically for this activity. So I don’t mean to be critical of that 

at all. I think it is a big step forward. 

I do think it is important for Congress to be sensitive to the complex task that CMS now faces. There are a lot of potential candidates for new projects, and these new projects are still going to 

take time to set up, operationalize, get running. And then it is 

going to take time to get results. So even with $10 billion, this isn’t 

going to happen with the snap of a finger. 

And then there is, as I said a minute ago, still the issue of about 

let us assume the best case, that we have successful demos; we still 

need resources in CMS to operationalize. It is a good step, but we 

need to be realistic. We have got problems still to solve. 

Mr. GREEN. Mr. Chairman, I have other questions. I know I have 

run out of time, even without giving an opening statement. So if 

we could submit questions later and get responses back. 

My next question. In your report, you state about half of the imaging studies were performed the same day in the office visit. You 

state that this is a reason to reevaluate the in-office ancillary exemption, and I assume because you feel that is a low number. However, this number of 50 percent seems to be quite—that quite a few 

evaluations of patients’ conditions were helped by being able to 

quickly diagnose an issue by performing an imaging study in the 

office. 

And I would imagine that clinically valid reasons when a physician may not want a patient to—may want a patient to rest and 


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then revisit if the condition doesn’t improve would lead to an imaging study done on a different day. If half are performed on the 

same day, it would appear that we are meeting a test for the need 

for the self-referral exemption of timeliness, convenience and coordinated care that same-day diagnosis allows for. Do you feel that 

this is a low number, the 50 percent? Or is it unrealistic to expect 

that this would be considerably higher? 

Mr. HACKBARTH. What we were trying to do is provide some data 

on what was one of the original reasons for having an in-office ancillary exception to the self-referral, and that was to allow sameday treatment in imaging. So what we did was look, in fact, at 

whether that is the case, and what we found was that for some 

services covered under the exception, therapy services, it was rarely the case that they were provided the same day. For advanced 

imaging, MRIs, CT and the like, it was provided same day less frequently than in half the visits. And then for the standard imaging, 

standard X-ray and the like, that was about half the time. And so 

there is variability depending on the particular service. 

But I would emphasize that this is an area where we need to 

tread carefully. There are some legitimate rationales for allowing 

physicians to do these services, including potentially accelerating 

diagnosis and treatment, making sure that the patients get the 

needed tests and the like. In other contexts we sing the praises of 

integrated practice. So it is not so much the integration that is a 

bad thing. It is not so much the physician ownership that is a bad 

thing. It is the combination of physician ownership with fee for 

service and often mispriced services. It is that combination that can 

be toxic and lead to overutilization of services. So we are trying to 

figure out ways to solve the problem without throwing the baby out 

with the bathwater. 

Mr. GREEN. Because I understand you have an endocrinologist, 

its ability to give a bone density test literally in the office there, 

it saves the time for another office visit for them to go get a test 

somewhere else. 

Mr. Chairman, I know I have run out of time, and I would like 

to submit the remaining questions. Thank you. 

Mr. PALLONE. And I will mention that any Member can submit 

questions in writing, and we will ask that you get back to us as 

soon as you can. 

The gentlewoman from Wisconsin, Ms. Baldwin. 

Ms. BALDWIN. Thank you, Mr. Chairman. 

Thank you, Mr. Hackbarth, for being here. 

You spent a chapter of the report discussing shared decisionmaking and its implications in Medicare. And I found it interesting 

that there was no explicit discussion of shared decisionmaking 

around care provided at the end of life. And especially given my 

sense that there is a fairly profound amount of end-of-life care that 

is provided that is not necessarily aligned with a patient’s wishes 

or values, I wonder if this omission is because you see these issues 

as being distinct. Or, in fact, could you share—could you share with 

us your thoughts on shared decisionmaking between physician and 

patients to improve care at the end of life? 

Mr. HACKBARTH. What we did in the chapter is our staff went 

out and looked at some of the existing programs for shared deciVerDate Mar 15 2010 13:53 Mar 06, 2013 Jkt 077916 PO 00000 Frm 00072 Fmt 6633 Sfmt 6602 E:\HR\OC\A916.XXX A916

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sionmaking. It wasn’t the whole universe of programs where a representative sample—we went to a number of them. And the programs that we looked at, they did not tend to be focused on endof-life issues; they tended to be more focused on treatment for 

breast cancer or prostate cancer or some of those examples. 

The potentially rich opportunity for shared decisionmaking is in 

what some people call preference-sensitive care, where the right 

care is not something the physician can decide, it depends on how 

the patient assesses various risks, benefits, different potential outcomes. So shared decisionmaking is a way of helping the patient 

express their preferences. Given that as the underlying logic, it 

would seem that it could be applied to end-of-life issues. But as we 

looked at the programs that we describe in the report, that was not 

their principal focus. 

Ms. BALDWIN. In the report I commend you for spending as much 

time and energy as you did looking at models to serve dual-eligible 

beneficiaries. These are folks who suffer not only from debilitating 

health conditions, but also from a system that leaves them with 

often poorly coordinated care. 

In your report you mention special needs plans, and specifically 

you profile a successful program that we have in my home State 

of Wisconsin. Yet there is also notation that these programs vary 

significantly across the country. So I am wondering if it is your expectation that the new requirements that special needs plans establish State contracts will improve the quality and consistent—I 

have a follow-up question about the National Committee For Quality Assurance and their role in this. 

Mr. HACKBARTH. Yes. A couple of years ago—I am not going to 

be able to remember the exact date—we did a chapter focused on 

SNPs, on this special needs plans, and made a series of recommendations there. And one was that—for the plans focused on 

the dual eligibles, that it was very important for there to be a contract with the State that specifies a lot of important operational details. And so we think that the requirement in the Affordable Care 

Act that there be contracts is a step in the right direction. 

Not just any old contract will do. It is important that the content 

be right, to be sufficiently detailed and the like. But we do think 

that is a step in the proper direction. 

Ms. BALDWIN. Then you focus again in this chapter on the importance of measuring outcomes, yet I think we lack information both 

on the best quality measures and the actual outcome data from the 

plans. So I understand that the National Committee For Quality 

Assurance is developing some additional reporting, but whose responsibility should it be to collect and analyze this data? Does 

there need to be congressional action to require this, or is it already within the powers of the agency and part of their obligation 

under the law? 

Mr. HACKBARTH. Let me just begin first with full disclosure. 

Until very recently, a month or 6 weeks ago, I was a Board member at NCQA. So I just wanted to put that in the record. 

Ms. BALDWIN. Thank you. 

Mr. HACKBARTH. In terms of who does the actual development of 

the standards and measuring of performance, typically in an NCQA 

accreditation program, they are specifying the data required and 


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evaluating the performance against that data. And then CMS basically piggybacks on that. So I would think that is the way the process is working. 

Am I misunderstanding your question? 

Ms. BALDWIN. I am just wondering whether there needs to be additional congressional authority at this point in time. Is it already 

within the powers of the agency and part of their obligation under 

law to do this analysis? 

Mr. HACKBARTH. Well, rather than risk an erroneous answer, can 

I respond to that request in writing? 

Ms. BALDWIN. Absolutely. And since I have already expired my 

available time, that would probably be preferred by all. So thank 

you. 

Mr. HACKBARTH. Thanks. 

Mr. PALLONE. Thank you. 

The gentleman from New York, Mr. Weiner. 

Mr. WEINER. Dr. Hackbarth, thank you for being here. 

I think that there is broad agreement that we need some kind 

of a model to go take a hard look at Medicare, try to figure out 

ways to save money. But when there was a proposal to expand 

MedPAC, a lot of us during the deliberation on the health care reform were very much against it because there is a general sense 

that there is a bias against big cities, there is a bias against graduate medical education. And unfortunately, the report—the most 

recent report kind of reenforces a certain tone deafness on some of 

this stuff. 

And I think that the report does some remarkable things, but 

when it talks about a 31⁄2 billion cut to IME funding in the exact 

same document where it points out that many teaching hospitals 

have negative margins presently, and further ignores the idea that 

we are in this movement, as you have testified to, of trying to move 

away from more and more people going into emergency rooms and 

more and more people seeing primary care physicians, it just seems 

to me that it is wildly counterintuitive. And it is not a question, 

but I would be glad to hear your response. 

Mr. HACKBARTH. First of all, I just want to be clear that we are not recommending a $31⁄2 billion cut. What we are recommending 

is that at a point in the future, at least 3 years in the future, that 

teaching institutions be held accountable for their performance, 

and that money, that 31⁄2 billion, be contingent on performance. 

The 3-year period would be used to engage both the teaching hospitals, people in academic medicine, patient representatives, purchasers, health care delivery organizations in the development of 

those standards. 

Our fondest hope is that every cent of the $31⁄2 billion would be 

paid out, because that would mean that good standards have been 

developed, and the programs are performing well against those 

standards. 

Mr. WEINER. So on page 102, recommendation 4–1 does not suggest the cost savings. 

Mr. HACKBARTH. Our goal—as I said, our hope would be there 

would be no reduction in Medicare expenditures. That would signify that the programs are achieving the job, they are being accountable for—— 


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Mr. WEINER. Right. Let me spend a moment on self-reform. You 

identified—I mean, there are various numbers in the report, but it 

is something like 104 percent overpayments, we think, for self-referral, and there was some consideration and the consideration of 

the health care reform bill again to basically ban wide swaths of 

the self-referral, include them under the START. 

You have shown in your report that an overwhelming number— 

the costs go up overwhelmingly for second- and third-day referrals. 

Can you tell us, is there any reason we should still permit physicians who clearly are conflicted from doing radiology, from doing 

MRI, from doing these various things? I mean, the evidence 

seems—it seems so clear that it is not that doctors are being venal, 

but they have got this giant machine sitting in their office, they 

have got to make payments on it, it just seems like too great a 

temptation. Isn’t there a much more bright-line recommendation 

we can make here to simply say just don’t permit those self-referrals anymore? I mean, this is no longer the type of thing where 

maybe you say only if it has to be in an emergency, where someone 

walks in with a sprained ankle where you want to do an X-ray— 

which, by the way, as you know, is the reason any exemption exists 

in the first place. I think—I mean, it just seems to me that we are 

past points of dancing around this, and I think that that type of 

prohibition is in order. 

Mr. HACKBARTH. As I was saying earlier, before I took this job, 

I was the CEO of a very large physician practice in Boston, 500 

physicians, all sorts of—— 

Mr. WEINER. Your career is not taking the best projectile so far. 

Mr. HACKBARTH. We all make choices. 

We, my group, brought high-end imaging MRIs, CT, in house. We 

thought it improved our ability to effectively manage the care, coordinate the care, assure the quality of the imaging and the like. 

A lot of notions of where the health care system needs to go in 

the future is towards more integration; not having all these separate, independent providers, but more organized systems. If we 

want to move in that direction, we don’t want to discourage ownership. 

The problem isn’t the ownership per se; It is the combination of 

ownership with fee-for-service payment and mispricing of services. 

So there is easy profit opportunities. That is the toxic combination. 

It is not one; It is the three of them together. So what we are trying to do is identify options that allow us to preserve the good part 

of integration while doing away with the bad part. 

Mr. WEINER. I have to say in my remaining—actually my time 

has expired. Let me just say that if we are going to get—if we are 

going to get your organization to a place that we really see it as 

a tool to start to do more of these savings and reenforce some of 

the good work you are doing in the report, you do have this institutional sense—and Mr. Pallone talked about it during the debate on 

health care—this institutional sense that you don’t get it when it 

comes to teaching hospitals, but more than a few Members have 

mentioned that. 

But I yield back the balance of my time. 

Mr. PALLONE. Thank you, Mr. Weiner. 

The gentleman from Ohio, Mr. Space. 


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Mr. SPACE. Thank you, Mr. Chairman. 

And thank you for your testimony today. 

I come from a very rural area of Ohio. It is a large district in 

southeastern Ohio, exclusively rural. The largest town we have is 

about 27,000 people. And we have historically suffered from an inadequacy of physician workforce, and I think that is something 

that is probably true for most rural areas around the country, especially those that are relatively indigent or poor. 

Can you talk about why this deficit is problematic in the context 

of its impact on creating a rural workforce? 

Mr. HACKBARTH. Mr. Space, which deficit are you referring to? 

Mr. SPACE. The deficit pertaining to access—not just family physicians, but physicians generally. And we have a difficult time recruiting subspecialists. We have a very difficult time recruiting primary care physicians. And I am curious as to your thoughts as to 

how that impacts creating the rule on workforce. 

Mr. HACKBARTH. Clearly recruiting physicians is essential to provide quality care, and there certainly are documented problems in 

recruiting physicians in particular to rural areas, but also some 

inner city areas as well. 

In our report, in the chapter on graduate medical education, we 

note that there are a number of programs authorized through this 

committee in the Public Health Service that are focused in particular on recruiting people into medicine that come from rural 

areas or inner cities or are drawn for certain minorities or ethnic 

groups. Although the research literature on the effect of those programs is not as robust as we would like to see it, that makes a lot 

of sense to us, because there is pretty good research that a physician who comes from a rural area is more likely to go back there. 

Mr. SPACE. I think you could probably add to that—and maybe 

you have research that would corroborate this—but a physician 

who trains in a rural area is more likely to stay there. In fact, I 

read that in your report. 

While we are on this subject, on page 117, figure 4–1 of the report, there is a graph that kind of outlines, I guess, third-year internal medical residents becoming subspecialists, or hospitalists. 

And it is actually quite remarkable. From 1998, we saw a predominance of general internal medicine somewhere in the neighborhood 

of 54 percent. That has shrunk to a 2007 level, it looks like around 

25 percent, while subspecialties and hospitalists have experienced 

a marked increase. I have kind of a subquestion about that phenomenon. And I think your report quite correctly points out that 

we need to do something about that. 

Mr. HACKBARTH. We do. 

Mr. SPACE. It seems to me that in the end it is about money. It 

is about compensation or the lack thereof that drives folks into 

those fields. I think the same thing would apply to family medicine, 

family physicians, primary care. Short of increasing the compensation for, in this case, general internal medicine practitioners or decreasing the compensation paid subspecialists or hospitalists, what 

avenues are available for Congress to rectify what is a growing and 

increasingly large discrepancy for those who are training to become 

physicians? 


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Mr. HACKBARTH. Actually one of our Commissioners, Dr. Karen 

Borman, has published on this topic of why physicians choose various specialties. She is a program director in general surgery. And 

money is certainly one of the factors. But it isn’t the only factor. 

Another important factor, in some cases even more important than 

money, is lifestyle, and do they envision living this job, and often 

that is a drawback about primary care. Physicians in training, they 

experience primary care while in training in an ambulatory clinic 

as way too many patients, way too few resources, and they say, 

this lifestyle is just not for me, this job is not doable. 

So we do think that increasing payments for primary care relative to subspecialty care is a step in the right direction, but it may 

also be necessary to change how we pay for primary care. And as 

you know, that is part of the idea behind the medical home. Let 

us in addition to paying fee for service, pay per patient amounts 

that allow a primary care physician to build some infrastructure, 

hire some staff, to make the job more doable. So even if that money 

is not take-home pay, if it allows them to have a more robust practice, it can make primary care a lot more appealing. 

And then there is the recruitment issues. Again, if you recruit 

people from rural areas into medical school and train them in rural 

areas, they are much more likely to do family practice in your part 

of Ohio than somebody who is trained in New York City. 

Mr. SPACE. Are there tools available for the medical schools or 

even at the college level where I assume some of this recruitment 

is happening that would channel people early to take an interest 

in and begin pursuing a career in primary care rather than waiting 

until they are out of medical school and then throwing them into 

the GME program where they might be more inclined to focus on 

financial issues? 

Mr. HACKBARTH. There are a number of programs in the Public 

Health Service that are designed to intervene earlier in the decisionmaking process and recruit people into medicine from diverse 

populations, and then encourage careers in primary care, because 

they are outside of Medicare. Frankly I don’t consider myself real 

expert in all of the details, but generally speaking, we think that 

sort of earlier intervention effort holds a lot of promise and would 

urge a careful evaluation of those programs, the PHS, to see how 

we can build on them and make them as effective as possible. 

Mr. SPACE. Thank you very much. 

I yield back the balance of my time. 

Mr. PALLONE. Thank you. 

We have about—I don’t know—7 or 8 minutes left. So we are 

going to conclude with Mr. Engel. When I say that, I mean, there 

are votes. I don’t know if the Members realize we have 3 minutes. 

Mr. ENGEL. Thank you. Thank you, Mr. Chairman. I won’t take 

the 7 or 8 minutes. 

I just want to pile on Mr. Hackbarth because—about the IME, 

the indirect medical education. It is a major concern to my area, 

New York, New York City. And I echo everything that Mr. Weiner 

said. We are very, very concerned. There are many, many teaching 

hospitals in New York City. They have been devastated by cuts on 

the Federal and State level, whether it is DSH payments or in the 

health care bill that we passed. We had a whole fight over do-goodVerDate Mar 15 2010 13:53 Mar 06, 2013 Jkt 077916 PO 00000 Frm 00077 Fmt 6633 Sfmt 6602 E:\HR\OC\A916.XXX A916

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er State provisions and things like that, And they have just been 

decimated back and forth. 

And New York has 15 percent of the teaching hospitals. We train 

15 percent of the doctors across the country. This is a really big 

thing for us. And I know you said that it wasn’t a $3.5 billion cut 

per se, and that cut supposedly would fund a new incentive grant 

program under which these teaching hospitals would still see funding if they show they are furthering goals. But there are yet to be 

established goals by the Secretary of HHS, and the New York City 

teaching hospitals are very worried that they would lose up to $450 

million annually. And that is just really untenable. 

So I really—I understand that, but—what you just said before 

about you want to make sure there is quality. Of course you want 

to make sure there is quality, but at some point you can’t get blood 

from a stone. And I think that these hospitals are just about at 

that point, and they are some of the best hospitals in the country, 

and every time we look for money or every time we look to so-called 

reform something, we hit them again and again and again. And at 

some point it obviously is going to affect the quality of care, or 

what they can provide, or how many nurses they can hire or things 

like that. 

So I just want to echo what so many of my colleagues have said, 

and I really wish you would look again at that point, because our 

teaching hospitals just cannot afford even the whisper of cuts. It 

can have a very negative and debilitating thing that could happen 

to them. 

Mr. HACKBARTH. Well, I certainly understand the anxiety about 

it, Mr. Engel, but, you know, that uncertainty often accompanies 

needed change. I don’t think that in any sense whatsoever we are 

anti-teaching hospital, as Mr. Weiner suggested. The vote on this 

recommendation was unanimous. Two of the members of the Commission are deeply involved in medical education and graduate 

medical education training. 

I have referred a couple of times now to my group in Boston. It 

was Harvard Vanguard Medical Associates. Our principal hospitals 

were the Brigham Women’s Hospital and Children’s Hospital. 

I have no antipathy whatsoever towards teaching institutions, 

but we do think that the taxpayer, the health care system, the 

Medicare beneficiaries deserve some accountability in the use of 

the resources put into GME. 

Mr. ENGEL. But you see, I am not going to argue with that statement, but I question whether the way you propose to go about it 

is the best way in going about it. Obviously we need to train tomorrow’s doctors to have the appropriate skills to provide care in a 

modern health care system, but I just think slashing funds to 

teaching hospitals with no guarantee that they will be recouped, I 

don’t think that is the best way to prepare future physicians. I 

think it causes a lot of angst, and I think it is negative. 

And the reports that we have, I think that MedPAC reports that 

teaching hospitals now have negative Medicare margins, which obviously means Medicare is not covering the cost of caring for Medicare patients. You know, what could be the justification of everyone 

a whiff of cutting funding to teaching hospitals so that Medicare 

pays even less? It makes no sense to me. 


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Mr. HACKBARTH. I certainly do understand your perspective on 

it and take it really seriously. I do. At the same time, I hear from 

a lot of colleagues involved in academic medicine who believe the 

system needs to be reformed, believe that the teaching hospitals 

can do a better job of training physicians for the future, that Medicare is their last hope. 

There is too much inertia in the system. Too many people do real 

well with the status quo. They need a catalyst for change. They 

need somebody to boost the prospects for reform in medical education. And these are people engaged in the system and say we 

need Medicare to be the lever that moves the system off the dot. 

Mr. PALLONE. We are out of time. We have votes. I apologize, but 

I think we only have a minute and a half before we finish votes 

on the floor. So let me thank Mr. Engel and thank you also. 

As you have heard, many Members want to submit written questions. We ask them to submit them within 10 days and then have 

you respond to them as quickly as you can. 

But thank you so much for all that you are doing. 

Without objection, the meeting of the subcommittee is adjourned. 

[Whereupon, at 4:31 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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