```

[Senate Hearing 114-860]
[From the U.S. Government Publishing Office]

                                                       S. Hrg. 114-860

                  CELEBRATING MEDICARE: STRENGTHENING
                   THE PROGRAM FOR THE NEXT 50 YEARS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                          ST. LOUIS, MISSOURI

                               __________

                             JULY 31, 2015

                               __________

                           Serial No. 114-11

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         

        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-877 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------   
                      SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois                  BILL NELSON, Florida
JEFF FLAKE, Arizona                  ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee                KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada                  RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                 JOE DONNELLY, Indiana
DAVID PERDUE, Georgia                ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina          TIM KAINE, Virginia
BEN SASSE, Nebraska
                              ----------                              
               Priscilla Hanley, Majority Staff Director
                 Derron Parks, Minority Staff Director
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Claire McCaskill, Ranking Member....     1

                           PANEL OF WITNESSES

Stuart Guterman, Senior Scholar in Residence, AcademyHealth, 
  Washington, D.C................................................     4
Brit Pim, General Manager of Federal Programs, Express Scripts, 
  Inc., St. Louis, Missouri......................................     7
Sandra Van Trease, Group President, BJC Healthcare, St. Louis, 
  Missouri.......................................................     9
Max Richtman, President and Chief Executive Officer, National 
  Committee to Preserve Social Security and Medicare, Washington, 
  D.C............................................................    13
Ron Sergent, Former AARP Executive Council Member, and Medicare 
  Issue Volunteer Lead, AARP Missouri, Columbia, Missouri........    15

                                APPENDIX
                      Prepared Witness Statements

Stuart Guterman, Senior Scholar in Residence, AcademyHealth, 
  Washington, D.C................................................    35
Brit Pim, General Manager of Federal Programs, Express Scripts, 
  Inc., St. Louis, Missouri......................................    58
Sandra Van Trease, Group President, BJC Healthcare, St. Louis, 
  Missouri.......................................................    65
Max Richtman, President and Chief Executive Officer, National 
  Committee to Preserve Social Security and Medicare, Washington, 
  D.C............................................................    70
Ron Sergent, Former AARP Executive Council Member, and Medicare 
  Issue Volunteer Lead, AARP Missouri, Columbia, Missouri........    78

 
                  CELEBRATING MEDICARE: STRENGTHENING
                   THE PROGRAM FOR THE NEXT 50 YEARS

                              ----------                              

                         FRIDAY, JULY 31, 2015

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 1 p.m., at the 
Five Star Senior Center, 2832 Arsenal Street, St. Louis, 
Missouri, Hon. Claire McCaskill, Ranking Member, presiding.
    Present: Senator McCaskill.

                 OPENING STATEMENT OF SENATOR 
                CLAIRE McCASKILL, RANKING MEMBER

    Senator McCaskill. The Senate Committee on Aging will come 
to order. This is a hearing of the United States Senate Special 
Committee on Aging that we are having here in St. Louis today.
    Yesterday was Medicare's 50th birthday, and I think all of 
us can celebrate that Medicare has given a sense of security 
and quality health care to seniors in this country since its 
inception, and I think now it is time for us to look at how we 
can strengthen the program and make sure we preserve the 
program for the next 50 years, so that someone 50 years from 
now can be here saying Medicare just had its 100th birthday.
    I want to begin by thanking all of you who have come out 
today for this hearing. I am so proud to be able to bring 
another Senate Aging Committee hearing to Missouri. I would 
like to especially thank my friend and Chairman of this 
Committee, Susan Collins, who unfortunately could not be here 
today, but was fully supportive of this hearing and having it 
in St. Louis. She is a Republican. I am a Democrat, but that 
does not stop us from working so closely together on a whole 
lot of issues. I am particularly proud of the bipartisan work 
that we do together on the Aging Committee.
    Let me also thank the witnesses, who I will introduce 
shortly.
    Saving the best for last, let me thank the excellent and 
gracious staff of the Five Star Senior Center. Mike Howard, the 
Director, and Laura Haney, the Assistant Director, have been 
amazing, and I truly appreciate them sharing this wonderful 
facility with us today.
    It is clear that 1965 was one of the most successful years 
for Congress in modern history. That summer saw the passage of 
the Older Americans Act, the Voting Rights Act, Medicaid, and 
Medicare. Upon signing Medicare into law, President Lyndon 
Johnson handed the first Medicare card to President Harry 
Truman, and that occurred right here in Missouri, in 
Independence.
    Medicare really is about Missouri. Only seven months into 
his Presidency, Harry S. Truman sent a Presidential message to 
the U.S. Congress proposing a new national health care program. 
In his message, Truman argued that the Federal Government 
should play a role in health care, saying the health of 
American children, like their education, should be recognized 
as a definite public responsibility.
    One of the chief aims of President Truman's plan was to 
ensure that all communities, regardless of their size or income 
level, had access to doctors and hospitals. He was particularly 
concerned with the lack of health professionals and hospitals 
in many rural or otherwise lower-income areas of United States.
    President Truman proposed a national health insurance 
program that would be open to all Americans. However, when his 
proposal went to Congress, it was attacked as socialized 
medicine. Sound familiar? Ultimately, President Truman was not 
successful in his push for national health insurance, but on 
July 30, 1965, President Lyndon B. Johnson signed the Medicare 
bill into law at the Harry S. Truman Library and Museum. He 
said that it all really started with the man from Independence.
    The Medicare program has grown into a beloved part of the 
American fabric. It is an essential commitment that we as a 
society have made to Americans in their senior years. Through 
Medicare, our government provides high-quality medical care to 
seniors at an affordable cost as long as they need it.
    That does not mean that it is without its challenges or 
threats. There are various proposals being floated to change 
the Medicare program. Some would make the program better and 
more efficient. Others would add additional benefits, like 
dental and vision, but some would completely change the nature 
of Medicare as we know it, turning it from a guaranteed benefit 
into a voucher program. I do not support that proposal and have 
fought hard against it during my time in the Senate.
    Let me be clear. The fundamentals of the Medicare program 
are strong. In 1965, only half of our Nation's seniors were 
insured. Today, over 98 percent are. Poverty among seniors has 
been cut by two-thirds since the early 1960's, in part because 
seniors now have a reliable and secure method of paying for 
their medical bills, in addition to their Social Security. 
Medicare helped desegregate hospitals and health facilities. It 
helps keep the doors of rural and urban hospitals open to serve 
the needs of all citizens.
    The Affordable Care Act, known as Obamacare, made the 
program even stronger by providing seniors with no-cost annual 
physicals and preventative care, closing the dreaded 
prescription drug doughnut hole, and giving us new tools to 
fight and prevent fraud when criminals try to take advantage of 
the program, and by the way, the life of the Medicare Trust 
Fund has been extended by at least twelve years as a result of 
the Affordable Health Care Act, so Obamacare actually 
strengthened Medicare. It did not weaken it. That provides not 
just savings to you, the taxpayer, but also to you, the 
beneficiary, through lower premiums and co-insurance.
    I look forward to hearing from our panel of witnesses as 
they describe ways to make the Medicare program stronger for 
the next 50 years.
    First, we have Sandra Van Trease. Ms. Van Trease is the 
Group President of BJC HealthCare here in St. Louis. She 
provides strategic leadership and direction to the BJC 
Collaborative LLC, an association of St. Luke's Health System, 
Kansas City, Missouri; Cox Health, Springfield, Missouri; and 
BJC HealthCare here in St. Louis; and Memorial Health System in 
Springfield, Illinois. She is also responsible for overall 
business and growth strategies for a select group of BJC's 
community hospitals, including Boone Hospital Center, Missouri 
Baptist Sullivan Hospital, and Parkland Health Center in 
Missouri, and the BJC Medical Group, to ensure outstanding 
clinical quality, operating efficiencies, and financial 
stability.
    In 2012, she was appointed President of BJC HealthCare's 
Accountable Care Organization and leads BJC's overall efforts 
in population health. She also serves as a member of the Senior 
Management Team at BJC HealthCare, one of the largest nonprofit 
health care organizations in the United States.
    She will discuss BJC's experience with and commitment to 
the ACO model to improve quality and reduce costs for Medicare 
beneficiaries and taxpayers.
    Next is Brit Pim. He is Vice President and General Manager 
of the Government Programs Division and CEO of the Express 
Scripts Medicare Prescription Drug Plan. He manages and 
oversees Express Scripts' Medicare and Medicaid businesses, 
leadership of the Express Scripts Medicare Prescription Drug 
Plan, and oversight of the development and implementation of 
Express Scripts health care reform strategies.
    Brit has nearly twenty years of industry, management, and 
consulting experience. He joined Express Scripts in 2004 and 
was responsible for leading the company's preparations for the 
initiation of the Medicare Part D benefit in 2006.
    Mr. Pim will discuss how through Medicare Part D Express 
Scripts is delivering a high-quality, affordable, and 
meaningful benefit for millions of Americans while reducing 
costs for Medicare.
    Ron Sergent is a former Missouri AARP Executive Council 
Member and the current Medicare Issue Volunteer Lead for AARP 
Missouri. He has been a dedicated volunteer, helping health 
cares understand Medicare and how it was positively impacted by 
the changes in the Affordable Care Act, known as Obamacare.
    Now over 65 himself, Ron is a Medicare beneficiary. He is 
retired from the Columbia Public Schools, where he taught 
American government and history. He still lives in Columbia, 
Missouri.
    He will discuss what Medicare means to health cares and 
how, from a beneficiary's perspective, the program can be 
improved and strengthened.
    Max Richtman is the President and CEO of the National 
Committee to Preserve Social Security and Medicare. The 
National Committee is a grassroots advocacy and education 
organization dedicated to preserving and strengthening safety 
net programs, including Social Security, Medicare, and 
Medicaid.
    He is very familiar with this Committee, as he is a former 
Staff Director of this very Committee, the Senate Special 
Committee on Aging.
    He will discuss steps that have already been taken to 
improve the program and ways to strengthen it in the future 
with additional benefits, such as hearing, dental, and vision 
services.
    Stuart Guterman is a Senior Scholar in Residence at 
AcademyHealth, an organization that works to improve health and 
the performance of the health system by supporting the 
production and use of evidence to inform policy and practice. 
Until June, he was Vice President for Medicare and Cost Control 
at the Commonwealth Fund, leading the Fund's special 
initiatives on advancing Medicare, supporting the analysis of 
data and development of policies to improve Medicare as a 
source of coverage for the aged and disabled Americans. He also 
analyzes the program as a platform for implementation and 
testing of new approaches to payment and health care delivery.
    His testimony will discuss the opportunity to continue to 
improve the program and its ability to serve its beneficiaries 
over the next 50 years.
    Thank you all so much for joining us, and with that, why do 
we not begin with Mr. Guterman.

          STATEMENT OF STUART GUTERMAN, SENIOR SCHOLAR
         IN RESIDENCE, ACADEMYHEALTH, WASHINGTON, D.C.

    Mr. Guterman. Thank you, Senator McCaskill, and also thanks 
to Chairman Collins.
    Senator McCaskill. Excuse me, can you all hear in the back? 
You need to get it right----
    Mr. Guterman. Right up, okay.
    Senator McCaskill. Get really close to your mouth, and then 
it will work.
    Mr. Guterman. Okay. How is this? Is this better?
    Senator McCaskill. Better? Thumbs up in the back? Thumbs up 
in the back.
    Mr. Guterman. Okay. Thank you, Senator McCaskill, and also 
thanks to Chairman Collins and the members of the Committee, 
for this invitation to testify on the current State of Medicare 
and the challenges it faces as it enters its next 50 years.
    I am speaking today as an individual who has been working 
on Medicare issues for a long time, as you mentioned, at the 
Commonwealth Fund from 2005 until recently, before that, for 
the last 30 years, actually, at the Centers for Medicare and 
Medicaid Services and at the Medicare Payment Advisory 
Commission, among others. I have seen and had the privilege of 
participating in many of the innovative changes that the 
program has implemented over the years and also been aware of 
the challenges faced by the program.
    In addition, I have got a mother and stepfather who are 
both 93 years old and who have been helped tremendously by 
Medicare's coverage and the access to care it provides, but 
also hindered by the program's shortcomings and the fragmented 
nature of health care provided in this country, so I have known 
Medicare since I was a teenager, I guess, now as it celebrates 
its 50th birthday.
    The program, as you said, has been a tremendous success in 
accomplishing its main goal, which is assuring the health and 
economic security of the Nation's elderly and disabled. It is 
very popular with its beneficiaries and has been influential in 
shaping the U.S. health system, improving the quality of care, 
and contributing to medical progress.
    At the same time, it faces considerable challenges as it 
enters its second 50 years. I will talk about some of those 
challenges and maybe some ways to approach dealing with them as 
we move on into the coming years.
    One, of course, is spending growth. Medicare spending 
growth per beneficiary has actually slowed dramatically over 
the last few years, but an increasing number of beneficiaries, 
projected to increase from about 54 million in 2015 to about 82 
million by 2030, has been pushing total spending, and Medicare, 
although the Affordable Care Act changed the insolvency date 
for the Medicare Hospital Insurance Trust Fund from 2016 to 
2030, still, 2030 can come upon us before we know it.
    The question is, is this a problem and how do we deal with 
it? It is a problem in the sense that the Trustees' Report that 
came out last week holds up a warning sign. It says, we have 
still got to work on this program to be able to address its 
issues, particularly the cost and also the effectiveness with 
which Medicare spends its money.
    We do have to understand one thing, that all of this is 
coming because we are living longer. That is not a bad thing. 
Having more elderly people means that people--comes about 
because people are living longer and that is something we want 
to see happen.
    In addition, I would point out that most of Europe is older 
than the U.S. is and they have been dealing with this issue for 
a number of years, but they actually spend much less on health 
care than we do, so there are things to learn from how others 
are doing--handling health care and how we spend money on it.
    How do we address these issues? Well, the main thing is 
that we need to make health care more efficient and more 
effective, and there are policies in place, thanks to Congress 
and thanks to the folks who work on the Medicare program, that 
are being tested and developed and implemented, including the 
ACO program and many other innovations that are being put in 
place, that are succeeding in slowing health care costs and 
improving quality of care.
    We also have to recognize that if we are going to have more 
seniors, that means we need to devote a higher proportion of 
our resources to seniors, and so we need to be able to live 
with that, as well.
    In addition, we need to align incentives better within the 
program and also throughout the health care system. There has 
been a disconnect historically, not only between Medicare and 
the private sector, between Medicare and Medicaid, in fact, and 
we have to present a set of incentives that the health care 
system can respond to consistently so that we do not drive 
doctors crazy and also give a clear message as to what we want 
from our health care system.
    The benefit design of the Medicare program, as you 
mentioned, can be improved. We have very fragmented coverage. A 
typical Medicare beneficiary now gets hospital coverage from 
Part A, they get doctor coverage from Part B, they get drug 
coverage from Part D, and then most of them also have 
supplemental coverage, a Medigap policy or an employer-
sponsored policy, and that leads to fragmented health care 
delivery and it also hinders the coordination of care across 
settings and between providers, and Medicare beneficiaries 
would benefit from an improved coordination across all of these 
programs, so one approach might be to develop a Medicare 
benefit package that is more coordinated rather than having 
these differing coverages with different rules and different 
copays and expenses.
    Medicare also has a lack of stop loss protection. Unlike 
most employer-sponsored care, Medicare beneficiaries are not 
protected once their out-of-pocket costs hit a certain level, 
and that is something that has been talked about. It clearly 
involves figuring out where you want to spend your money, but 
it is something that would align Medicare better with the 
private coverage that we all have before we hit 65.
    Now, some colleagues of mine and I, when I worked at the 
Commonwealth Fund, put out a proposal that called Medicare 
essential, which would, in fact, combine Medicare into one 
program and also incorporate positive incentives for Medicare 
beneficiaries who use high-value providers to align the 
incentives that Medicare is trying to develop for providers and 
bring that home to beneficiaries, too, so that the two sets of 
incentives can be consistent and Medicare beneficiaries can be 
rewarded for seeking care from providers who are doing so in a 
coordinated way, in addition to having better outcomes.
    We also are facing an increasing problem with beneficiaries 
with complex conditions. Medicare beneficiaries--37 percent of 
Medicare beneficiaries have four or more complex conditions, 
and those beneficiaries account for 74 percent of Medicare 
spending each year, so how do we address that? Well, improving 
coordination of care helps people get the appropriate care 
without bouncing around from one setting to another, from one 
provider to another.
    The provision of services that enhance--some of them non-
medical--that enhance the Medicare beneficiary's ability to 
manage his or her conditions without having to go into the 
hospital or into the doctor and do so on a day-to-day basis, 
some of this is happening in the private sector, because the 
case in point, I guess, is taking people with chronic asthma 
conditions, and people have realized that if you buy them an 
air conditioner, that helps keep the air quality in their house 
better and it keeps them from having to go into the emergency 
room with an asthma attack.
    There are many situations like that that Medicare 
beneficiaries face that could be enhanced by a broader notion 
of what Medicare can provide. One example of that is the 
Independence at Home Demonstration that has shown some pretty 
positive results recently that the Centers for Medicare and 
Medicaid Services is testing right now, and there have been 
proposals by Senator Wyden and his colleagues and others to 
enhance the at-home care that is available to beneficiaries so 
they do not have to go into the hospital.
    A fourth issue that I will raise here is the desire or the 
need to balance the traditional Medicare program with Medicare 
Advantage, through which Medicare beneficiaries can obtain 
their coverage through private plans. Right now, they are 
really two separate things. Medicare Advantage now has over 30 
percent of Medicare beneficiaries, so it is a growing but still 
a minority of Medicare beneficiaries, and the incentives 
provided to Medicare Advantage plans versus the incentives 
provided under traditional Medicare are really inconsistent.
    The Congress has been working on that. There were 
provisions in the Affordable Care Act to do that, to deal with 
that partially, but we need to keep working on trying to make 
sure that both the public traditional Medicare program and the 
private Medicare Advantage programs can bring out the best in 
what the program has to offer its beneficiaries.
    In conclusion, I will say again, Medicare has been very 
successful in achieving its basic mission, but as the country's 
largest purchaser of health services, it can do more to improve 
quality, promote more coordinated care, and control costs, both 
its own costs and throughout the health care system, because of 
its unique position, it can be an important testing ground for 
costs and quality innovations, and policies have already been 
put in place that encourage such development, but including 
expanding the power of the Secretary of Health and Human 
Services to put payment pilot programs on a fast track through 
the Center for Medicare and Medicaid Innovation created in the 
Affordable Care Act, and to work with private payers and 
providers to establish multi-payer initiatives that address 
these issues.
    It is a program that has been extremely successful, 
popular, and important to its beneficiaries, but it can be 
improved in several ways, and we have an imperative over the 
second 50 years of Medicare to continue to work on improving 
that program. Thanks.
    Senator McCaskill. Thank you so much.
    Mr. Pim.

             STATEMENT OF BRIT PIM, GENERAL MANAGER

          OF FEDERAL PROGRAMS, EXPRESS SCRIPTS, INC.,

                      ST. LOUIS, MISSOURI

    Mr. Pim. Thank you.
    Senator McCaskill. You are going to need to pull the 
microphone over and get close to it.
    Mr. Pim. I am. Thank you.
    Senator McCaskill. There you go.
    Mr. Pim. Senator, thank you for the opportunity to share 
our perspective with you today. As the General Manager of the 
Government Programs Division for Express Scripts, I am 
responsible for Medicare, Medicaid, public exchanges, 
Accountable Care Organizations, and the like.
    When I joined the organization almost a little more than a 
decade ago, the Medicare Modernization Act had just been passed 
and we were just beginning to prepare for Medicare Part D. 
Today, it accounts for a growing third of our business. We are 
happy to serve almost seven million Americans that participate 
in the Medicare Part D program.
    We look at the program and we think it has been 
phenomenally successful. Seniors have saved money on their 
prescription drugs, almost $7 billion. Taxpayers have saved 
money. The program's costs are 45 percent below the original 
projections, and seniors are happy, largely, with their 
prescription drug coverage. Ninety-four percent of them report 
being satisfied, and 95 percent believe the coverage meets 
their needs.
    We believe, in part, the reason why the program has been so 
successful is because Congress, working with CMS, designed a 
program that allowed commercial insurance companies to 
implement and take advantage of common business processes, and 
one example that I will share with you are preferred networks.
    There are more than 60,000 pharmacies in the country. We 
are able to leverage our size in the business that we represent 
and negotiate discounts with some of those pharmacies and to 
provide Medicare beneficiaries with tens of thousands of 
pharmacies that they can go get their prescriptions filled at, 
but we recognize tremendous value from that, so today, more 
than 80 percent of the Medicare beneficiaries are enrolled in a 
Part D program that has a preferred network.
    We think it is innovations like these, practices that have 
ported from the commercial business into Medicare Part D, that 
are really one of the reasons why we think the program has been 
so successful, and for that reason, we think it is important 
that the non-interference clause that today is in the Medicare 
Modernization Act be preserved.
    I would like to take a couple of minutes and talk about 
just a few things briefly where we think there are 
opportunities to improve the program, and I will start first 
with specialty drugs. To be fair, these are drugs that are 
being developed to treat conditions where otherwise they might 
be untreatable, and they are doing some pretty remarkable 
things.
    They are extraordinarily expensive. They can be from 
$10,000 to $100,000 a year, and in the commercial business, we 
have the opportunity to control the utilization of those drugs 
and make sure they are only being used when appropriate, but in 
Medicare, we do not have the same ability to provide some of 
those--to enable or implement some of those same controls, so I 
will give you a brief example.
    I mentioned that we support about seven million Medicare 
beneficiaries. In one of the programs that we support, we had a 
thousand Hepatitis patients, and for those thousand Hepatitis 
patients, we spent more than $100 million last year on drugs to 
treat those patients.
    Senator McCaskill. For a thousand?
    Mr. Pim. For a thousand.
    Senator McCaskill. And you spent how much?
    Mr. Pim. A hundred million dollars. It is fantastic that 
those patients now have a treatment to cure the disease, but it 
is not sustainable. I cannot afford to continue to pay those 
kind of prices and preserve the benefit the way we know it 
today.
    In particular, what I would tell you is that we are not 
able to make mid-year drug coverage changes in Medicare Part D, 
so if I am a manufacturer, I have a strong incentive for 
introducing a drug in the middle of a plan year, and it almost 
guarantees that I have 18 months of coverage for that drug, 
because I am in the middle of a plan year and I have likely 
already submitted my formulary for the next year and cannot 
make changes. We would like to encourage CMS to create some 
flexibility where there are these particularly high-cost drugs 
where we can make formulary changes where we think it makes 
sense.
    Another example is fraud, waste, and abuse. Prescription 
drug abuse kills nearly 15,000 Americans and drives 1.2 million 
emergency room visits a year. In our commercial business, we 
have invested heavily to develop fraud, waste, and abuse 
programs. I would like to give you an example of just one 
patient.
    It is a 49-year-old patient who is taking 43 controlled 
substance prescriptions, from 17 prescribers, from five 
pharmacies. In just over a year, this person was able to obtain 
825 days' worth of drugs. It is a commercial patient, so we 
were able to pair that person with a nurse case manager. We 
were able to have that patient go through a rehabilitation 
program, and now, today, they are seeing one pain management 
physician. They are getting their prescriptions filled from one 
pharmacy. We have saved their plan sponsor $40,000, and we 
believe we have likely saved that patient's life.
    We would not be able to implement that program in Medicare 
Part D and we would like to see CMS allow us to implement those 
kind of controls in Medicare Part D. We think it would benefit 
the beneficiaries and it would save the program money.
    In closing, as we reflect on the success of Medicare, 
Express Scripts is looking ahead to the next 50 years. We 
remain acutely focused on the challenge of high-cost 
medications and an aging population and the need to 
continuously innovate. We are proud to be part of an important 
American legacy and believe our contributions to help keep 
medicine affordable will help ensure these programs celebrate 
more milestone anniversaries and are here for our children and 
grandchildren. Thank you.
    Senator McCaskill. Thank you very much.
    Ms. Van Trease.

             STATEMENT OF SANDRA VAN TREASE, GROUP 
         PRESIDENT, BJC HEALTHCARE, ST. LOUIS, MISSOURI

    Ms. Van Trease. Thank you, Senator. I appreciate the 
opportunity that you and the Committee have provided me to be 
here and to speak with you today on behalf of BJC HealthCare. 
We are----
    Audience Member. You are going to have to talk into the 
microphone.
    Ms. Van Trease. How is that? Does that sound better?
    Audience Member. Yes.
    Ms. Van Trease. Okay.
    Senator McCaskill. Thank you, sir.
    Ms. Van Trease. Thank you so much. As I said, I am 
appreciative of the opportunities to be here before you today, 
and as you mentioned, my role is as a--I serve as Group 
President for BJC HealthCare. I also have the honor and 
distinction to serve as the President of our Accountable Care 
Organization, which really will be the focus of my comments 
today, and we did submit, as requested, the written 
documentation or the testimony, but I am just going to focus on 
a few key points in that testimony, if I may.
    I would like to share with you, though, just a little bit 
of background about BJC's Accountable Care Organization. Back 
in July 2012, BJC was the first health care provider in the St. 
Louis area, and really one of only 89 across the country at 
that time, to actually form an Accountable Care Organization 
and enter into the contract with CMS for the Medicare Shared 
Savings Program, and our Accountable Care Organization includes 
ten of the BJC hospitals. It includes our Home Health Division. 
It includes the three long-term care facilities in BJC, the 
medical group in BJC, which employs over 260 physicians and 
over 75 advanced care practitioners, and our ACO, importantly, 
also includes over 200 independent community physicians.
    We serve nearly 40,000 beneficiaries. The majority of those 
beneficiaries actually are here. They reside in the St. Louis 
metro area, but we have a substantial portion of these 
beneficiaries that also reside in more rural communities--
Sullivan, Farmington, and in the Columbia, Missouri, area.
    The ACO program has really provided us a platform that did 
not exist before, and it has allowed us to do a couple of 
things that both of the previous witnesses have mentioned, in 
part, in their remarks. It is allowing us to focus care in a 
much different way than we have been able to in the past, and 
our focus has been around clinical care management, 
specifically around identifying those patients that have these 
multiple comorbid conditions, which are very significant.
    It has also allowed us the opportunity to focus more 
directly on what we call transitional care, and that is the 
care that needs to happen when a patient leaves the hospital 
and goes to the next setting, be that in a skilled nursing 
facility or home or other places, but interesting, the third 
component of our focus that we have found that we have needed 
is actually--are in other types of support services, services 
like telehealth, services like medication adherence programs, 
services like transportation, that heretofore you might not 
necessarily have encapsulated in the body and the term 
providing health care.
    We in the program, under the Shared Savings Program, we 
have not yet met the targets established by CMS as it relates 
to being able to share in the value creation that we have had 
inside the ACO, but that said, we have successfully bent the 
total cost of care curve for Medicare, and we have excelled in 
both the clinical quality and the patient satisfaction 
performance metrics, and we are very, very proud of that, as 
well as the feedback we are getting directly from our 
beneficiaries.
    For a moment, I would like to focus on some of our key 
lessons learned, because we are living this and we are on the 
journey every day. What we have found is that we must focus on 
identifying and then reducing clinical care variation that is 
not necessary. That means gaining efficiencies in workflow, in 
the physicians' offices, in all of our care settings. I wanted 
to give a couple of examples of what we are talking about.
    As a result of this work we have done over the last couple 
of years, we decided to establish what we are calling a patient 
access. It is a centralized patient access center. This, among 
other things, opens things like phone lines for patients and 
their families to really gain access when they are seeking 
appointments with a variety of their caregivers, or, frankly, 
they just need someone to answer some questions, and we believe 
by opening up this access center, we are avoiding unnecessary 
emergency room visits and our beneficiaries are able to access 
their physicians or their primary care health provider in a way 
and on a timely basis that had been a little bit more difficult 
for them in the past. We have extended physician office hours. 
We focused our physicians on blocking out enough time annually, 
at least once a year, for our doctors to sit down with the 
beneficiary and conduct a very comprehensive care plan on their 
behalf.
    Other things we have learned that we needed to do, clinical 
data integration and aggregation has been extremely important 
so that we can provide actionable information to our caregivers 
for their patients, so reorganizing technology infrastructure 
and the data sets that we do now get from our own electronic 
data sources as well as what CMS provides us, we are now able 
to provide more information in a seamless way in patient 
charts, for physician notes.
    We are using data experts to actually help us identify 
patients that our clinicians would deem at high risk, and 
importantly, also those patients that are deemed to be rising 
risk, and we have to do that systematically, because if we do 
not do that on a systematic basis, we cannot scale our efforts 
and make sure that we get interventional care delivered on the 
most timely basis to prevent something negative happening to 
one of our beneficiaries.
    Care manager dedication, so clinical care managers has also 
been something we have had to invest in, to focus and help our 
physicians and their offices focus on these high and rising 
risks, so we are embedding care managers in local physician 
offices or in their geographies to actually provide additional 
support, not only to the doctors and the office staff, but also 
to the patients and their families as they are working on 
access issues, getting appointments, medication adherence, and, 
again, even basic things like transportation.
    I wanted to give an anecdote to you as an example of impact 
in the real world, the life of one of our beneficiaries. In 
April of this year, one of our patients--I am going to call her 
Mrs. Green, that is not her real name--Mrs. Green was admitted 
to the hospital for a very serious GI issue, and she then had a 
multitude of other issues that quickly manifested, including 
renal failure, and for the next three months, so April and May 
and a good part of--well, it actually started in March, April 
and May--she spent a total of 38 days in the hospital and ten 
in rehab.
    This team of ours worked with her and her physician, and we 
learned things that were exacerbating Mrs. Green's situation 
and was putting her at very high risk for readmission into the 
hospital. Something very basic as the fact that her physician's 
office was a fair distance away from her home. Mrs. Green had 
virtually no reliable means of transportation, and she had 
virtually no family support.
    Between the care manager and our staff social worker, we 
worked with her and her physician to educate Mrs. Green about 
early warning signs if something in her health started to 
deteriorate, and most importantly, what to do about that in her 
home and how she should take care of it and what she should do.
    By virtue of spending that kind of quality time with Mrs. 
Green, I am very happy to let you know she is doing quite well 
at home. She has not had an ED visit. She has not been back in 
the hospital, and what we learned here is that this delivery of 
health care is now encompassing a body of work that before we 
did not really have the programmatic infrastructure to execute 
on.
    We have had a lot of successes, and there are many to name, 
but I wanted to share with you, notwithstanding that progress, 
I wanted to share a few challenges, as well.
    Some of my colleagues and I actually had an opportunity to 
visit with some of the CMS leadership earlier this year, and we 
shared with them some of the challenges and some of the 
observations that we had in order to help make the program 
better under the--the ACO program better. I thought I would 
share a few of those with you today.
    One is around something called the homebound status. Now, 
currently, Medicare requires patients to qualify for this 
homebound status in order for the clinicians to receive 
reimbursement for their services, and that is when the home 
health nurse goes out to visit, and there are criteria that 
must be established, but the way the regulations are currently 
written, it creates a bit of an arduous process for the 
physician and, frankly, for the patient, because the assessment 
has to be done only by the physician and it has to be done face 
to face, and given many of our seniors are dealing with things 
like this transportation issue, we would and have requested 
that CMS take another look at those regulations to see if we 
cannot streamline them to make sure that we are getting the 
right care at the right time by the right person available in 
this particular situation and help streamline that care 
coordination.
    Another area of focus that we have shared with CMS revolves 
around the very real and increasing opportunities provided by 
telehealth. Telehealth offers a lot of benefits, a lot of 
potential benefits to our seniors. That includes increasing the 
access to specialists. Again, this is a transportation issue, 
but because of the way the rules are written today, there is 
minimal reimbursement for telehealth services, and when you are 
dealing with a lot of folks in rural communities, that can be 
particularly difficult.
    Again, we would ask that CMS consider taking a look at 
providing waivers to certain restrictions that allow us to 
recognize and then benefit from the developing opportunities in 
telehealth.
    Last, I do want to applaud CMS for actually approving a 
waiver related to a rule that is called the 3-day inpatient 
rule. This allows us to coordinate directly with skilled 
nursing facilities in a way, again, we had not been able to do 
that before. The regulations came out. We are going to be able 
to get the waiver. Unfortunately, we do not get the waiver 
until January 2017, so we will have a little bit of a time lag, 
about a year and a half or so, before we are able to take 
benefit of that, but really, to summarize, you know, in 
participating with this ACO over the last three and a half, 
three years, soon to be three and a half years, when we are 
successful, what we believe, when we are successful in this 
ACO, our patients will, in fact, experience better health. Our 
communities will have better health care, and we will provide 
even better value, and that is about achieving the triple aim.
    I wanted to thank you and the Committee for the opportunity 
to be here today. On behalf of BJC HealthCare, we are very 
privileged and proud to be able to participate in this event 
today commemorating the 50th anniversary of Medicare, and for 
the next 50 years, we will strive to be a leading partner with 
Medicare as we continue to evolve new innovative programs to 
serve our seniors.
    Thank you very much.
    Senator McCaskill. Thank you.
    Mr. Richtman.

              STATEMENT OF MAX RICHTMAN, PRESIDENT

             AND CHIEF EXECUTIVE OFFICER, NATIONAL

             COMMITTEE TO PRESERVE SOCIAL SECURITY

                 AND MEDICARE, WASHINGTON, D.C.

    Mr. Richtman. Thank you, Senator McCaskill, for inviting me 
to testify here today. As a former Staff Director of the Senate 
Special Committee on Aging, I am very proud to have been part 
of that Committee's long history of highlighting the needs of 
the aging community, and I commend you, Senator, for continuing 
that tradition in your service on the Committee and as the 
Ranking Member.
    Also, thank you, Senator, for co-hosting the party last 
night at the Kennedy Caucus Room celebrating the 50th 
anniversary. We had a beautiful cake. I am Chairman--besides 
being the head of the National Committee to Preserve Social 
Security and Medicare, I chair the Leadership Council of Aging 
Organizations, 72 groups that work together regularly, and they 
were all there, and they all want to thank you for the terrific 
food and beverages. Thank you very much.
    I am testifying today to share the National Committee's 
views on how to strengthen and improve Medicare for the next 50 
years. Before Medicare, as you said in your opening statement, 
half of seniors did not have health insurance, and 35 percent 
lived in poverty, and today, more than 55 million Americans 
receive guaranteed health care benefits through Medicare, 
regardless of preexisting conditions, regardless of income.
    Together with Social Security and Medicaid, Medicare forms 
the bedrock of economic health security for seniors and people 
with disabilities. As I mentioned last night, these are great 
programs, Medicare, Medicaid, and Social Security, but they are 
beyond programs at this point. They are really values, American 
values, part of our fabric of America.
    While Medicare has been a blessing, the current and future 
needs of seniors demand that the program's coverage become more 
comprehensive. Today, in addition to premiums, deductibles, co-
insurance, many seniors have to pay out of pocket for gaps in 
Medicare coverage.
    The financial burden of these coverage gaps will only grow 
over time as retirement savings and income continue to shrink. 
We have seen that happen for quite a few years now. Seniors 
have less income in retirement because employers have scaled 
back or eliminated defined benefit pensions. The loss of 
retirement benefits is even worse, as you know, for communities 
of color, because those folks have the highest poverty rates 
and have the least amount of wealth.
    In addition, stagnant wages are grinding away at the middle 
class's ability to save for retirement. In other words, you 
cannot save what you do not earn. What little disposable income 
middle-class Americans have is often used to take care of 
children, grandchildren, aging parents, and so forth, and that 
is why millions of Americans reach retirement age without 
enough private savings to live on.
    That is why 40 percent of Social Security beneficiaries 
depend on Social Security for 90 percent of their income in 
retirement, and that is why Medicare households, even with 
Medicare, spend three times more than the average household on 
out-of-pocket health care costs, and as a result, any future 
for Medicare must, we feel, must fill these coverage gaps that 
will become increasingly unaffordable.
    Making Medicare coverage more comprehensive is not without 
precedent. It is a dynamic program. All of these programs are 
dynamic and have changed over time, for the most part, in 
better ways.
    In 1972, Medicare added coverage for individuals with 
disabilities and end-stage renal disease. In 1982, Medicare 
added coverage for hospice care, and as we all know, a 
prescription drug benefit was added in 2003, and mental health 
benefits were significantly improved in 2008.
    As you pointed out, the Affordable Care Act, despite all of 
those awful ads that we saw in many election cycles about 
Medicare cutting, cutting, cutting--or, the Affordable Care Act 
cutting Medicare by $767 billion--I know this is polite company 
here, but those were lies. Medicare--there were savings of $716 
billion in the Medicare program. Most of those savings went to 
improve the program. For the first time ever, Medicare under 
the Affordable Care Act provides a lot of preventative care--
colonoscopies, mammograms, diabetes screening, that awful 
doughnut hole that you talked about is going to be eliminated 
completely. It is being reduced and will be eliminated 
completely in a couple more years.
    Again, as you noted, the solvency of the Medicare program, 
the Affordable Care Act added 13 years to the solvency of the 
program, and the Trustees just told us a few weeks ago it is 
now solvent until the year 2030.
    The National Committee strongly believes Congress should 
equip Medicare for the economic and health challenges facing 
seniors in the 21st century. I am talking about creating a 
catastrophic out-of-pocket limit, which we advocate. We talked 
about the hospital observation status. I do not think we can 
wait until 2017. There is legislation in the Congress that 
would count those three days toward the availability of skilled 
nursing care. A lot of people leave the hospital and all of a 
sudden face enormous bills, and that is not right, and vision, 
dental, hearing. You know how important those are to everybody, 
but particularly to seniors.
    Last week, I participated in a press conference in the U.S. 
Capitol to promote your colleague, Congressman Debbie Dingell's 
bill to expand Medicare to include hearing testing and hearing 
aids, and that legislation, I hope, will get some momentum this 
year. It recognizes that hearing loss goes untreated because 
many older Americans cannot afford to pay for hearing aids, and 
if seniors cannot hear, they get confused, embarrassed, 
frustrated, withdraw from normal activities.
    We had--you will find this interesting, I think. We had at 
the press conference a highly regarded doctor at Johns Hopkins, 
a researcher named Franklin Lynn and he has developed some 
groundbreaking research that draws a connection between hearing 
loss and dementia, not just the isolation part, but changes in 
the brain that have an impact on dementia and Alzheimer's, so 
we are going to be pushing hard to try to get Congressman 
Dingell's bill passed into law, and I think it is important 
that we get out that information about the link to dementia.
    In closing, again, thank you for inviting me. Seniors 
understand Medicare is vital to living in dignity throughout 
their retirement years. They understand Medicare, as I said, is 
not just a Federal program, it is an American value, and the 
dream, the American dream of livable retirement is being 
threatened by the economic realities the middle class faces. We 
have had enough of proposals to cut benefits, raise the age, 
privatize the program, and we are going to spend the next 
couple of years trying to improve the program, and this 50th 
anniversary, I think, is a good point to begin working to 
expand those coverages and make them more comprehensive.
    Finally, I do not want to embarrass you, but we have a 
scorecard, like other groups have, and I want to thank you for 
your consistent votes on behalf of seniors. We have 47,191--I 
checked this morning--members and supporters in the State of 
Missouri, and they ought to know that in the last Congress, you 
had--you can have a score of zero, you can have a score of 100. 
You had 100. In the Congress before that, you had 100 percent, 
so as far as we are concerned, you are voting the right way day 
in and day out, and I thank you for that.
    Senator McCaskill. Thank you very much, Mr. Richtman. I 
wish I had 100 on everything.
    Mr. Richtman. So do I.
    Senator McCaskill. Mr. Sergent. We need to move the 
microphone. Thank you.

        STATEMENT OF RON SERGENT, FORMER AARP EXECUTIVE

          COUNCIL MEMBER, AND MEDICARE ISSUE VOLUNTEER

            LEAD, AARP MISSOURI, COLUMBIA, MISSOURI

    Mr. Sergent. Thank you, Senator McCaskill, for including 
AARP and myself in this hearing. We consider it a real 
privilege, and I am happy to represent the approximately 
750,000 members of AARP from Missouri. About 45 percent of 
those are Medicare eligible, I being but one of those, so----
    Senator McCaskill. You need to get right up on the 
microphone. They are having trouble hearing you. It almost 
feels like it is too close if you are close enough.
    Mr. Sergent. As I was saying, I am happy to represent the 
almost 750,000 members of AARP in Missouri. About 40 to 45 
percent of those are Medicare-eligible, and, of course, those 
under 65 will at some point become eligible.
    I am a volunteer. I have great respect for the 
professionals to my right. I hope to talk to you just a bit as 
a beneficiary on behalf of the beneficiaries.
    As we commemorate Medicare's 50th anniversary, it is 
essential that we not only celebrate what it has meant to so 
many people, but we must also be honest about what Medicare 
means today, what it covers and what it does not cover, as we 
have heard. We must recommit ourselves to keep this vital 
lifeline strong for current and future generations.
    From the beginning, AARP's founder, Dr. Ethel Percy Andrus, 
supported the creation of a Federal health insurance program 
for all older Americans tied to Social Security. The essence 
later became, as we know, Medicare.
    As we have already heard, back in 1965, three out of four 
Americans under the age of 65 had adequate private hospital 
insurance, but according to AARP's research, only one in four--
not half, but only one in four over age 65 were as fortunate. 
If you were an older person, getting sick meant you risked not 
only losing your health, but your financial independence.
    Today, 50 years later, Medicare provides guaranteed 
affordable coverage for roughly 45 million Americans 65 and 
older and about nine million people with disabilities. Medicare 
is largely responsible for the poverty rate among older 
Americans dropping to less than one of every ten.
    Just anecdotally, I would like to share with you, after 
friends learned that I was going to be here to testify, one of 
them mentioned that last year, she and her husband had $27,000 
out-of-pocket expenses, and without Medicare, they would have 
been bankrupt.
    The program has transformed the lives of millions by 
helping them to pay for many vital health care services, 
including hospitalizations and physician visits and 
prescription drugs, and, has been mentioned more than once, 
most recently, essential preventative services have been added 
to Medicare by the Affordable Care Act, and as a volunteer in 
charge of educating seniors about the Affordable Care Act, I 
have found that that is a very glaring omission in information 
that seniors have. I think we really need to do a better job of 
educating them about what is available to them under the Act.
    I would also like to point out to my friend that too many 
seniors look at the Affordable Care Act in a negative fashion. 
It is hard for me to understand, but I try my best to educate 
them. I think most of it has to do with lack of knowledge.
    While Medicare offers important benefits, Medicare is not a 
free ride. It is not a Cadillac plan, more like maybe a 
reliable Chevy. There are premiums, deductibles, copays which 
people have to pay, and there is a lot that Medicare simply 
does not cover. I speak to you now as a beneficiary. It does 
not cover the cost of dental, vision, or hearing problems. 
Myself, I have a hearing loss and I have spent over $15,000 on 
hearing aids over the last 12 years. The need for eyeglasses 
and hearing aids is particularly common among older people. 
Moreover, Medicare does not cover long-term nursing care and 
home care.
    It is important to remember that half of all Medicare 
beneficiaries live on incomes of less than $23,500 a year. The 
average out-of-pocket cost for beneficiaries and for cost 
sharing of services is about $4,500. For the typical 
beneficiary, this represents over 17 percent of their income. 
Some of those numbers may not seem so great to those of us who 
are still earning a reasonable income, but when you consider 17 
percent of your income goes to out-of-pocket expenses, that is 
a significant amount.
    Medicare's golden anniversary is a time to think ahead 
about how we can ensure that the program continues to fulfill 
its essential role. Medicare today faces a number of 
challenges, including the rising cost of health care and a 
growing aging population. Some say the answer to these 
challenges is simply to cut benefits or force seniors to pay 
more.
    AARP believes that there is a better way than that. We 
think there are responsible solutions that can and will 
stabilize the system, and we have heard some of them today. We 
can start to put Medicare on a stable ground by clamping down 
on drug companies' high prices, improving coordination of care, 
using technology to make care more accessible and efficient.
    Looking forward, we must recognize that the way people 
receive care is changing. For instance, more people are 
receiving care from non-physician providers and are using 
telemedicine to access care more conveniently.
    Additionally, I do not know that we have had this addressed 
yet--we find that almost nine in ten seniors say they want to 
remain in their home as they age. We should do everything we 
can to let that happen. Aging in place helps maintain a better 
quality of life and is less costly than institutional settings. 
This means funding community-based services, such as Meals on 
Wheels, which help older Americans live independently. It also 
means supporting family caregivers through better tax policies 
and workplace programs which recognize the economic 
contribution made by individuals who take care of loved ones.
    AARP stands ready to help keep Medicare strong for the next 
50 years, and I thank you very much for the invitation.
    Senator McCaskill. Thank you so much.
    Let me start with the Accountable Care Organizations with 
Ms. Van Trease, and let me just explain, so everyone 
understands. The idea here--we use the letters ACO. The idea is 
a simple idea. The idea is that--let me use my mother as an 
example.
    Near the end of her life, she was an insulin-dependent 
diabetic. She had serious arthritis. She had a heart condition 
and a pacemaker, so she had a number of chronic problems, and 
this--she is not an unusual American near the end of their 
lives. She was seeing a different doctor for each one, and I 
could not get her to say to the doctor, ``I am not going to 
draw a blood sample for you because I drew one for the doctor 
yesterday. Use his.'' Each one of those doctors was replicating 
some of the work that the other doctors needed and there was no 
sharing.
    As a result, the costs to Medicare were much more expensive 
and, frankly, I was the one that was trying to ride roughshod 
over the list of prescriptions because the doctors were not 
doing a good job--so, this brings you in, Mr. Pim, too--because 
the doctors were not doing a good job of really checking to 
make sure that all of her prescriptions made sense together.
    The idea behind an Accountable Care Organization was that 
there would be a primary doctor that would be like a gatekeeper 
or the sheriff that would be paying attention to what everyone 
else is doing, and with that, a team of providers that would be 
giving the level of care that was needed, but not more.
    Instead of my mom going to the emergency room, what she 
really needed, perhaps, was to have her blood sugar checked by 
telemedicine, or maybe she needed a home visit, and that is 
what the ACO is about, so with that in mind on the ACO, I am 
curious if we are incentivizing enough on Accountable Care 
Organizations, and by that I mean when my mom had a nurse--we 
hired a nurse to come to the house and see her. We were blessed 
that we could afford that, and this nurse knew that we were 
looking to keep Mom out of the hospital. Mom did not want to go 
to the hospital. Mom was not happy in the hospital. Mom did not 
get better in the hospital, so we wanted to keep her home. This 
nurse knew her goal was to keep Mom at home and she worked 
really hard at it, because she knew if she did, she was going 
to get compensated more--not that she did not want to anyway, 
because she cared. She was a good nurse, but are we 
experimenting enough with incentivizing that? I think the fear 
about home health care is runaway costs. Could we not combine 
home health care with, you are not going to get paid a lot of 
money unless you are successful at what your goal is, which is, 
overall, bringing down the number of incidents that require 
emergency room or hospitalization?
    Ms. Van Trease. Yes. A lot of components to that question, 
Senator. Yes. I think that one of the things that we are doing 
and others are doing is, in fact, within the structure of the 
Accountable Care Organization, because we have certain waiver 
protections. We, from BJC's standpoint as a primarily acute-
based organization with our medical group and our affiliated 
physicians, we can now work together in ways that, legally, we 
could not work together before.
    That allows us to explore different ways to create 
incentives as we do things, not only within the construct of 
something known as the patient-centered medical home, which we 
are, and that puts that primary care physician, whoever he or 
she might be, fully in charge of the team and really leveraging 
their expertise across care managers, social workers, 
pharmacists, other health coaches, dietary, behavioral health. 
We create a team and that team has its own set of goals and 
objectives to work together in a way that, again, they had not 
been able to do that before.
    As we focus on this, there continues to be a clear need to 
continue alignment, economic alignment as well as just people 
who are good professionals who want to take the best possible 
care of patients.
    Having these constructs like the ACO, having constructs 
that are coming out of CMMI, the innovation division of CMS, 
bundled payment concepts, these are all experiments that try to 
tie all of this together so that we get out of our silos from a 
health care perspective and look at the totality of the entire 
person across his or her multiple conditions, not individual 
conditions. I think you are exactly right that there are some 
continuing opportunities in that area.
    Senator McCaskill. How close are you from--you said that 
you are bending the cost curve----
    Ms. Van Trease. Yes.
    Senator McCaskill [continuing]. but at a certain point, the 
idea is you do this so well, you get compensated more for it--
--
    Ms. Van Trease. That----
    Senator McCaskill [continuing]. kind of like my nurse 
example.
    Ms. Van Trease. That would be--yes----
    Senator McCaskill. How close are you to actually getting 
more compensation for having succeeded in bringing down costs?
    Ms. Van Trease. In our first contract year, the first 
contract year that it was in existence, we were, as a 
participant in the Medicare Shared Savings Program, Medicare 
sets a corridor around some of the economics, and so what we 
have seen over the quarters that we have been doing this---and 
we have been in it for three years now--we have seen a nice 
steady decline in the trend line, the health care cost trend 
line. We are bending it downward.
    That is really great news as a taxpayer and as Medicare, 
because that means we have lowered the total cost of care----
    Senator McCaskill. Right.
    Ms. Van Trease.--and, simultaneously, actually improved our 
quality scores and our patient satisfaction scores, but we have 
not gotten outside what Medicare has set as the savings 
corridor, so right now, all of this is on BJC P&L, so we really 
have not received any of that compensation.
    Senator McCaskill. Do you think you are going to get there?
    Ms. Van Trease. We are working aggressively to get there. 
It is our intention, and to do that, then, when we are 
successful, allows us the flexibility to share in some of that 
with our physicians and our other caregiver partners, and that 
is an objective we have, as well.
    Senator McCaskill. How quickly are the lessons that you 
have learned being adopted systemwide?
    Ms. Van Trease. Yes----
    Senator McCaskill. What I worry about is we have done these 
wonderful little oasis of sanity in terms of how we are 
delivering health care, which I think is what the ACOs 
represent----
    Ms. Van Trease. Right.
    Senator McCaskill [continuing]. but it is still the 
exception and not the rule. What steps do you think are being 
taken to make sure that what you are learning about Mrs. Green 
and what you are learning about the other patients in terms of 
this system--how is CMS doing? What do I need to do to crack 
the whip at CMS about adopting these lessons systemwide?
    Ms. Van Trease. Mm-hmm. Well, I think from a CMS 
perspective, the great news, I do think, is that they are 
listening to these concerns and they are inviting organizations 
like ours, large Accountable Care Organizations that take care 
of significant population, to explore ways to make things 
better. Some of this is about dealing with waivers and 
regulations and the restrictions that are in the testimony. 
That is probably the fastest thing that they can do.
    There is a lot of behavioral change across our systems. We 
have trained our patients well to go to the ED as opposed to go 
to their primary care physician. We have trained them well that 
perhaps they do not need a primary care physician, so there is 
a lot of behavioral change----
    Senator McCaskill. Yes.
    Ms. Van Trease.--that has to happen on the part of 
beneficiaries. It has to happen on the part of physicians, 
because we are asking them perhaps to practice in ways that 
they did not train for and to develop skill sets in other ways, 
so part of this is going to be progression, evidence of 
success, celebrating success, communicating what works and what 
does not, alignment of the economics, and then providing health 
care organizations like ours with the capability legally to do 
the things that we are now after, with the right kind of 
protections, obviously, around things that we do not want to 
run amok, clearly.
    Senator McCaskill. I learned something today, Mr. Pim, 
about--I have learned a lot from all of you, but one of the 
things that struck me with your testimony, speaking of 
regulations, was the notion that when you see 825 days' worth 
of pain medication in one year to one patient, you have the 
ability outside of Medicare to take steps, as somebody who is 
filling these prescriptions, but you cannot do that with 
Medicare.
    Mr. Pim. That is true. I think it is an unintended 
consequence of the regulation, to be fair, but it----
    Senator McCaskill. That is what I specialize in fixing----
    Mr. Pim. Yes----
    Senator McCaskill [continuing]. is stupid regulations.
    Mr. Pim. And that is----
    Senator McCaskill. That is my job, is to fix a stupid 
regulation.
    Mr. Pim. That is where we would like help, the details of 
which we put in our written testimony.
    Senator McCaskill. Right now, if you see--and, by the way, 
just so everyone understands, one of the biggest health threats 
in the Midwest right now is heroin, and that is a direct 
consequence of opioids being prescribed. When I was growing up, 
you did not get Vicodin when you went to the dentist. You 
certainly did not get 30 of them, and there is so much pain 
medicine being prescribed that kids are getting a hold of it, 
they are getting addicted, and then heroin is cheaper and not 
regulated, so they are taking amounts that are deadly.
    Mr. Pim. Absolutely.
    Senator McCaskill. We are now losing more young people to 
heroin addiction than we are to car crashes, and that is a 
serious problem, not just in Missouri, but throughout the 
country, and by the way, a lot of that medicine starts 
sometimes by grandmother having the medication, or aunt having 
the medication, not that it was prescribed for the young 
person, but in my own household, I saw opioids stolen from my 
mother by family members who were up to no good.
    Is the regulation because they do not want pharmacies to 
see what--what is the rationale behind the regulation that you 
cannot reach out and stop this kind of abuse in the Medicare 
population?
    Mr. Pim. The regulation prevents us from restricting who 
can write a prescription for that patient and restricts our 
ability from putting some constraints around what pharmacies 
that patient can go to.
    We are not trying--in the commercial setting, what we say 
is, similar to the ACOs, we want a provider, a single provider, 
to coordinate your care and make sure that you are not taking 
competing therapies or more than you should, and that is done 
best if one person is responsible for your care, and it is done 
best if you are getting that care from one setting, ideally. 
The Medicare requirements today do not allow us to put those 
kinds of restrictions around a beneficiary.
    Senator McCaskill. Are there conversations ongoing with CMS 
now----
    Mr. Pim. We have been trying----
    Senator McCaskill [continuing]. about those restrictions?
    Mr. Pim. We have been talking to CMS about it, but we would 
like to see more progress more quickly.
    Senator McCaskill. This is for any of you to speak up, and 
maybe, Mr. Sergent, you could talk about this. I think one of 
the things that was most--there were a lot of things that were 
upsetting about the Affordable Care Act, and one of them is 
what you said, Mr. Sergent. There is a lot of misunderstanding 
about what it did and what it did not do.
    One of the things that I was so depressed about was the 
whole death panel controversy, and maybe one of you have the 
number. What percentage of the Medicare payments go out for the 
last 30 days of someone's life? Does anybody know off the top 
of their head?
    Mr. Sergent. Well, I will defer to the experts. I have a 
number that has been repeated to me, that something like 40 
percent of the total cost of Medicare is in the last five 
years.
    Senator McCaskill. Forty percent of all the costs of 
Medicare come in the last six months of someone's life, and so 
what we--what was an amendment to the health care bill in the 
Committee by Republican Chuck Grassley from Iowa was the idea 
that we would reimburse Medicare doctors for the time they took 
to talk to their patients about end-of-life nutrition and 
hydration.
    I know--once again, I will call on my mother. She is in 
heaven, watching, smiling. She is so glad all of you are here, 
by the way. She thinks you should all come out and see your 
elected officials.
    My mother was adamant with us about what she wanted at the 
end of her life. It was very clear to us. She had it in 
writing. She would yell at us about it at least once a month. 
Now, this is what I want at the end of my life, so when the 
time came, we knew when it was time to take Mom out of the 
hospital and bring her home, get hospice, and my mother died in 
my living room with all of us around her, laughing, smiling, 
and that is what she wanted. She did not want more at the 
hospital. She wanted less when that time came.
    It was easy for us, because we had clear instructions, but 
most families do not have that, and so at the end of life, they 
do not know what mom or dad really wants, and if they do not 
know what mom or dad really wants, they are in the most 
emotional and conflicted place they will ever be in their life, 
because your emotion is, I want to hold on to mom. I want to 
hold on to dad.
    I had an ICU doctor at your hospital tell me that someone 
was kept on a machine, was brain dead, had no valuable life 
left, because the family wanted to wait until the son graduated 
from college in a month to come say goodbye. That is an 
incredibly expensive month. I understand you want to hold on 
for a month, but that is one of many examples that ICU doctors 
can talk about in terms of end of life.
    Let me ask you, Mr. Sergent, what can we do about getting 
Medicare beneficiaries to understand about directives for their 
end-of-life, and I believe there has now been a rule--am I 
correct about this--that doctors can begin to be reimbursed for 
this?
    Panel Member. Yes. Yes.
    Panel Member. This just happened a couple of weeks ago.
    Mr. Sergent. I do not know exactly where to start with that 
answer. I am so frustrated by that complication. I talk to a 
lot of seniors in the role that I serve, and there has been so 
much noise, so much false news about that particular 
conversation, that one of the things that I have discovered is 
that when seniors have made up their mind about death panel 
discussions, you cannot get them to see--it is almost like a 
cognitive dissonance.
    You cannot get them to understand that that is, number one, 
not true, never was true, could not possibly be true, in my 
opinion; and number two, the opposite is true, that you get a 
good conversation designed to inform you and your primary care 
physician what your hopes and intentions would be.
    That does not mean that you have to be on the verge or edge 
of death. This should be a conversation--I have already had 
this conversation with my physician, who I think is a 
remarkable man. We also have it in writing, but my point is, 
you do not have to have that at the end-of-life conversation.
    I wish I could tell you that there was something that I 
could suggest, that if you could support, we could get it done. 
All I can tell you is that I wish proponents of what is so good 
in the Act were more willing to speak out, because as you very 
well know in your position, sometimes when you speak out 
against this noise or false news, if you know where I am going 
with that, it can result in a vicious counterattack.
    Senator McCaskill. Yes. Mr. Guterman.
    Mr. Guterman. Senator, I wanted to add that the whole issue 
of palliative care and the kinds of services that can help 
people at the end of life is not just an end-of-life issue and 
is not just the cost issue. I mean, the fact is that a lot of 
costs in Medicare are concentrated at the end of life because 
many of these people are sick. It is not surprising that people 
are very sick----
    Senator McCaskill. Of course.
    Mr. Guterman [continuing]. right, in the last year of life.
    Senator McCaskill. Of course.
    Mr. Guterman. What is more important is not the decision 
about when to pull the plug but providing services that help 
people live a reasonable life at the end of their life, to help 
provide them with services to make them comfortable and not 
plug them into machines and pump them full of drugs to try to, 
you know, squeeze every last moment out of that duration of 
life.
    The quality of life is really important, and it is really, 
if we look at it as a quality of care issue, you know, rather 
than just a cost issue or a pulling the plug issue, I think 
people would be able to really reconcile themselves to this 
thought, that, you know, you are not going to live forever. 
Grandpa Joe is not going to live forever, and plugging them 
into machines actually ends their life prematurely because it 
sours the end of that whole lifelong experience.
    Senator McCaskill. I think you are exactly right. I mean, 
what you are saying is what we ought to be focused on is a 
quality of life, and how can we form the Medicare program so 
that you get the most quality out of life for the longest 
period of time, but then, hopefully, have decisions made at the 
end.
    Ms. Van Trease. Senator, I might just--might build on that 
thought, because the data also tell us that, appropriately 
used, palliative care in pre-hospice actually extends a 
person's life, and I think palliative care and hospice care are 
significantly----
    Senator McCaskill. Why do you not define palliative care 
for everyone.
    Ms. Van Trease. Palliative care is really--think of it as 
comfort. You are making someone comfortable. It is not intended 
for curative. It is unlikely the person will recover, and it is 
comfort in nature, so that the quality of a person's life is at 
the highest level is possibly can be. They are not in pain and 
they are not confused about what is happening, and we under-
utilize both that and hospice care.
    Unfortunately, many people--hospice care is actually the 
transition between life and death care, but many people are not 
able to take advantage, perhaps because they are not having 
these crucial conversations with their physicians and their 
families, and hospice care, oftentimes, people are only in 
hospice for a few days. That is probably under-utilizing 
hospice. They are staying in the ICU, which is probably not 
where most people would like to spend----
    Senator McCaskill. Right.
    Ms. Van Trease.--most of their last days.
    Senator McCaskill. Right.
    Ms. Van Trease. I do think those kinds of things that 
continue to educate and appropriately compensate the physicians 
to have these very significant conversations with the patients 
are going to be beneficial in the long run.
    Senator McCaskill. Which is more expensive, a R.N. going to 
someone's home or someone coming to the ER?
    Ms. Van Trease. The ER.
    Senator McCaskill. I am trying to figure out--we have done 
all of this regulation around whether or not you can get home 
care, but we have no regulation about whether or not you can 
come to the ER, right?
    Ms. Van Trease. That is correct.
    Senator McCaskill. So, you know----
    Ms. Van Trease. In fact, we do have regulation, which says 
anyone must be seen.
    Senator McCaskill. Right. What we are saying is we have got 
to make sure that you really deserve a nurse at home, but we do 
not need to make sure you can walk in any ER in America, 
insured, not insured, under-insured, and we are required to 
give you medical care. That seems backward to me, I mean, not 
that we want to ever have anybody have to qualify for the 
emergency room----
    Ms. Van Trease. Right.
    Senator McCaskill. The point I am trying to make is it 
seems backwards that we are doing so much regulation around the 
ability to get home care. Where did that come from?
    Ms. Van Trease. Well, again, I think most regulations come 
with good intentions, and sometimes they just have negative 
consequences, particularly as we think about the new models of 
care that we need in order to protect the solvency and increase 
high-quality care.
    I do not know--I could not answer exactly where the origins 
are. I think, though, the point is we are recognizing that 
there are these barriers. There is going to continue to be a 
challenge in providing enough doctors in order for the growing 
number, the 10,000 Medicare beneficiaries coming on a day are 
going to need more and more care, not less, as we all age, and 
let us keep in mind that we have a whole lot of doctors that 
are falling into the retirement age, as well.
    We need different types of models that allow nurses to work 
at the top of their license. That can be home care nurses, it 
can be care managers who facilitate the physicians' office 
work, but our regulations are set up for the old way and we 
need to identify which ones specifically. Either get waivers 
quickly and then rewrite the regulations to facilitate.
    Senator McCaskill. Do we not have a critical shortage of 
gerontologists?
    Ms. Van Trease. We do, indeed.
    Senator McCaskill. Is that because they are not making as 
much money as other kinds of doctors?
    Ms. Van Trease. Well, you know, I think economics play into 
a physician's decision as to what to do with his or her skill 
set. The fact of the matter also is, though, again, we are 
aging faster than we are producing doctors with, frankly, any 
of the specialized skills, so this is just going to be a 
fundamental challenge for us, which is, again, why we are 
advocating with our physicians learning better ways to do team-
based care so that certain things that a doctor might have 
historically done which could be done through licensing of 
pharmacists, advanced care practitioners, paramedics, nurse 
practitioners, we need to distribute the care model.
    Senator McCaskill. Yes, Mr. Guterman.
    Mr. Guterman. Also, I would add--let me point out that the 
solution to this is not more regulation, but actually less 
regulation and more--I mean, the restriction on home health 
comes from the fact that Medicare was originally designed as an 
acute care program and it was designed under a fee-for-service 
system, so people get paid more for doing more, and in a system 
like that, if you open up more services and if you do not 
regulate them, you are going to end up with people abusing the 
use of those extra services.
    If you align payment, instead of rewarding people more for 
doing more and doing more complex things, to rewarding people 
for getting better outcomes and providing better care to their 
patients and providing better patient satisfaction, better 
patient experiences from that care, then you can expand the 
services that you can allow people to do, because then they are 
doing those things from a broader perspective.
    That is true for drug coverage, too. I mean, rather than, 
you know, giving the drug plans the power to restrict what 
individual beneficiaries can use, there is a medication therapy 
management provision in the Part D law, and if you plug--and it 
is an artifact of--this disconnect is an artifact between--of 
different Part A, Part B, Part D coverage, and so people do not 
have any opportunity and certainly no incentive to talk to each 
other to help manage the patient more broadly, and then a lot 
of these problems can be eliminated.
    Senator McCaskill. That goes to your point you made in your 
testimony, that if we kind of blurred the lines between A, B, 
and D and had this be a more holistic program as opposed to the 
silos of A, B, and D, it would make a lot more sense, which--
and that brings into play the 3-day observation, because it is 
the separation of those three that end up having these 
anomalies in classification, whether it is observation or 
treatment, because it has direct impact on whether you get 
reimbursed, because if you are not admitted into the hospital, 
you do not get A and it goes to B, right?
    Ms. Van Trease. Right.
    Mr. Guterman. Absolutely.
    Senator McCaskill. I am getting my alphabet right, am I 
not?
    Panel Member. It is not just that you do not get 
reimbursed, you may not even get the care. You may not be able 
to get the care in a skilled nursing facility----
    Senator McCaskill. Then you cannot go to a nursing home.
    Panel Member. That is right.
    Senator McCaskill. Because you have not been admitted.
    Panel Member. Yes.
    Senator McCaskill. Because under the rules, you cannot go 
to a nursing home if you have not been admitted to a hospital, 
so----
    Panel Member. For three days.
    Senator McCaskill. For three days. If you are in for 
observation, which sometimes--which is, you know, I mean, we 
have put all these artificial regulations in that have these 
unintended consequences.
    What I am going to do after this hearing--I have got, like, 
four or five already that we need to, like, really focus on 
getting these regulations so that they are more holistic in the 
way they are being applied, with keeping an eye on costs.
    Yes, Mr. Pim.
    Mr. Pim. I would like to add two more, if I could, and you 
touched on this, as well, but first of all, we would like to 
see drugs included in the ACO. Right now, they are not, and 
they are going to become an increasingly bigger part of driving 
costs for the program----
    Senator McCaskill. Drugs are not part of the Accountable 
Care Organizations?
    Mr. Pim. No.
    Senator McCaskill. Wow.
    Mr. Pim. Then the other thing is----
    Senator McCaskill. How did we miss that? Is that pharma?
    Mr. Pim. I do not know what to say.
    Senator McCaskill. Is it pharma? They did not want it?
    Panel Member. It is because it is a separate program, and 
because they did not have the wherewithal to combine the data 
at the time to be able to track. I mean, data is really key to 
the operation of an ACO, and the drug data are on a separate 
track and it is hard to combine all the data together to get 
the total cost.
    The incentives are terrible, because if you have got--you 
know, for a Part D plan, they want to try to maximize the 
efficiency of your use of drugs, but if the use of drugs to 
manage a chronic condition can save money on visits to the 
doctor and hospital admissions, then you end up with Medicare 
saving money on Part A and B, but the Part D plan losing money 
because they have to spend more on the prescription drugs.
    Senator McCaskill. Which goes again to the, let us take the 
lines away. That makes sense.
    Yes.
    Panel Member. On that, though, I would say we have been 
talking actively with CMS around some pilots where we would try 
to do some innovative programs in Part D and measure the impact 
that we saw in A and B costs, so movement in the right 
direction, but, again, we would like to see more, and then the 
other thing I just wanted to touch on quickly, and you had 
mentioned this in your testimony, but telemedicine, I believe, 
would help, as well, in terms of trying to balance the supply 
and demand of providers.
    Senator McCaskill. In terms of the availability and the 
reimbursable----
    Panel Member. Specifically, the reimbursement of it.
    Senator McCaskill. Yes. Yes. I am trying to look and see if 
there is anything I have missed.
    I was struck by your testimony, Mr. Pim, about the thousand 
Hepatitis patients costing $10 million.
    Mr. Pim. A hundred million.
    Senator McCaskill. A hundred million, I mean.
    Mr. Pim. Sorry.
    Senator McCaskill. A hundred grand a piece.
    Mr. Pim. Yes.
    Senator McCaskill. Who paid for that?
    Mr. Pim. Medicare did. Taxpayers.
    Senator McCaskill. And why is it so expensive?
    Mr. Pim. Uh----
    Senator McCaskill. I mean, that is just the medicine?
    Mr. Pim. That is the medicine. It was an extraordinarily 
expensive drug----
    Senator McCaskill. Why is it extraordinarily expensive?
    Mr. Pim. We can follow-up with some information. We can 
provide more information to your office. It is a point that we 
have been trying to make for some time now. The drug does treat 
a condition that beforehand really did not have an effective 
treatment, but we just believe that the price was exorbitant 
and unsustainable from a program perspective.
    Senator McCaskill. Is it just certain kinds of Hepatitis 
that need this drug, or----
    Mr. Pim. Hepatitis C.
    Senator McCaskill. Hepatitis C. Are there a lot more people 
that have this drug? I mean, you said you treated a thousand. 
Is that because very few people have Hepatitis C, or just these 
are the only ones that----
    Mr. Pim. The drug came on the market last year, and so we 
were limited in our ability to put some controls in place, and 
so, thus, a thousand patients consumed approximately $100,000 
worth of drugs each.
    Senator McCaskill. That is how much per dose? I mean, that 
is ten grand a month, almost.
    Mr. Pim. Well, it is, depending on the genotype, it is an 
eight-or a twelve-week course of treatment, so it is actually 
even more expensive than that on a monthly basis.
    Senator McCaskill. I see. I see.
    Panel Member. Yes, Senator. I may have this wrong, but I 
think I remember hearing a CMS official announce that they had 
spent $4.6 billion on Hepatitis C drugs last year, and it is a 
good question how much it costs, but again, one of the 
ramifications of separating the program into different parts 
is, for all we know, that hundred thousand dollars apiece in 
drugs, since it appears to be very effective in addressing 
Hepatitis C, may be saving more money than that, but that 
savings does not accrue to the Part D plan. It accrues to A and 
B, and in any case, I think we need more study as to what the 
appropriate, you know, what the tradeoff is between the 
spending and the savings overall.
    Senator McCaskill. Well, we are going to----
    Panel Member. I would argue that it is going to be hard to 
save a hundred million dollars on those patients. I believe my 
colleague was mentioning to you right before we started that 
this drug was going to be approximately $30,000 for each 
patient, and then through a transaction, the price ultimately 
went up to almost $100,000.
    Senator McCaskill. Yes, and that is one thing we are going 
to do an investigation on, both in the Aging Committee and the 
Permanent Subcommittee on Investigations, looking at mergers 
and acquisitions in the pharmaceutical area and what that has 
done to the price of escalating drugs, because we see the same 
drugs, and when one company gets acquired by the other, all of 
a sudden, it doubles. Then it gets acquired by another, and all 
of a sudden it quadruples, and all they have done is change the 
label. Something is up there, and I want to try to track that 
and get to the bottom of it and expose it, because I have a 
feeling the taxpayers are the ones paying those bills.
    Why is your waiver so far away on--why 2017? If they have 
agreed to give you a waiver, why do you have to wait so long to 
get it?
    Ms. Van Trease. As we understand it, there is an 
implementation challenge as it applies to getting that waiver 
fully vetted through the process. We are very happy to have the 
waiver, and----
    Senator McCaskill. You do not want me to complain, because 
you are afraid they will take your waiver away.
    Ms. Van Trease. I am very happy to have the waiver.
    Senator McCaskill. By the way--too late.
    Ms. Van Trease. I would love to have the waiver sooner----
    Senator McCaskill. I will complain, and if they try to take 
your waiver away then, then I will really complain.
    Ms. Van Trease. There you go. There you go.
    Senator McCaskill. That does not make sense to me. If they 
have made the determination that this is appropriate, then it 
sounds to me that that is gobbledygook that would delay it for 
a year and a half before you would actually get it.
    Ms. Van Trease. Right. The waiver would be effective, as I 
said, January 2017. The contract period, the contract year to 
which I am referring actually begins January 2016, so perhaps 
one could argue, since the new contract period does not start, 
that is why the waiver would not start.
    Senator McCaskill. Dumb.
    Ms. Van Trease. However, I would more than welcome an early 
application.
    Senator McCaskill. Yes. I will look into that. We are 
getting--believe me, we are taking notes today, so I have got a 
list of things to do.
    I know some of you have obligations that you have to go, so 
many of the questions I had, you covered in your testimony. Is 
there anything else that we have not talked about that you 
believe needs to be brought up as we look at the next 50 years 
of Medicare and how people see Medicare?
    I do think that we still have a lot to do in terms of 
educating people about what their benefits are that sometimes 
things that feel free are not free, and sometimes benefits that 
are badly needed are not available, and if we could get those 
two things reconciled and stop the over-utilization of some 
things that are not necessary versus adding dental, or adding 
certainly hearing.
    I think that discoveries that have been made--and I might 
also bring out that there is going to be a National Geographic 
program. We have got to keep investing in NIH. It is important 
in St. Louis for Washington University, but it is important in 
the whole country. I had CEOs of multinational corporations 
talking about how important NIH is to America's security, 
because the strength of our country, the attractiveness of our 
country has to do with our innovation and our commitment to 
higher education and research.
    I was part of a program, because of my role on the Aging 
Committee, where some scientists have figured out that there is 
an available drug right now, and they just got an approval for 
the NIH testing, that you could take, and it does not prolong 
your life, but it delays the onset of some of the chronic 
illnesses that occur near the end of life. Incredibly exciting, 
and this is not a drug that has to be developed, this is a drug 
that is currently available, prescribed, obviously, for another 
purpose.
    It is going to--I was just in a room talking to them. I 
think they just wanted somebody that did not know all their 
jargon to ask them common sense questions, because when you 
leave these three doctors to talk to themselves, it is 
sometimes like, you guys--I am not sure that everybody knows 
what ACO or palliative care is, so I try to make sure everybody 
understands. It will be on the National Geographic channel, and 
this is--believe me, I am not any expert, I am just there kind 
of as a prop.
    These scientists are very impressive and it is very 
exciting, but it brings about the other issue that we talked 
about, and that is if, you know, the longer we live, the more 
expensive Medicare is, and so we have got to make sure that we 
continue to make sure we keep it strong and financially viable.
    Is there anything else any of you would like to add? Yes, 
Mr. Richtman.
    Mr. Richtman. You know, I want to just make a comment about 
the death panels. I think a lot of good Members of Congress 
lost their seats because of the scare tactic of death panels. 
You know, I do not know how it should have been addressed, but 
someone needed to confront Sarah Palin, because she really went 
to town on that, and I think it hurt the effort to improve 
these programs, health care programs, even more. I think you 
should be riding roughshod, to use your term, on those kinds of 
scare tactics, because you can counter that.
    Senator McCaskill. It is frustrating, because I spent a lot 
of time trying to correct information that was out in the 
public domain about what was and was not in the Affordable Care 
Act, and believe me, it is not perfect, and I am the first one 
that is anxious to get to the table and make some fixes that I 
think would be important. I have had a lot of talks with some 
of you about readmission, other things, the size of businesses, 
you know, the 50 versus 100, the 30-hour week versus the 40-
hour week.
    Unfortunately, we have not had any partners willing to make 
it better, because it has been a political two-by-four and it 
has been used very effectively, so they have had a tendency to 
focus on it being bad, not let us try to fix it and make it 
better.
    I joked one day that they have been saying, ``repeal and 
replace'' for five years. I am going to get some bloodhounds 
and I am going to go through the halls of Congress looking for 
replace, because I have never seen it. I do not know what it 
looks like. I would not know it if it walked up and shook my 
hand. ``Replace'' is the most often mentioned thing in 
Washington that has never, ever surfaced. There is not a 
replace, and so, what we ought to do is focus on fix, and in 
the process, maybe we could adopt some of the things we talked 
about today.
    The record for this hearing will remain open for another 
two weeks, which means there might be questions for the record 
for all of you, particularly from some of my colleagues that 
are not here today but are on the Committee. They were all very 
interested in this hearing.
    I once again want to thank my colleague, Susan Collins, who 
is the Chairman of the Committee. She and I work very closely 
together, as I said in the opening statement, and she was very 
enthusiastic about this hearing occurring.
    There will be questions for the record. If there is 
anything else you would like to put in the record, we welcome 
that, and I will make sure that all the members of the 
Committee have access to it.
    Thank you all very much for being here.
    [Whereupon, at 2:36 p.m., the Committee was adjourned.]     
=======================================================================

                                APPENDIX

=======================================================================

                      Prepared Witness Statements

=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                [all]
```