Lobbying Disclosure Act of 1995 (Section 5) - All Filers Are Required to Complete This Page

9. Check if this filing amends a previously filed version of this report

LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code BUD

16. Specific lobbying issues

Labor HHS Appropriations, Appropriations for Community Health Centers, and Increased Funding for Tele-health Activities. Funding for Dental programs in underserved areas.
Provisions of the American Recovery and Reinvestment Act (HR 1) including appropriations for:

HRSA - $500 M for community health centers; $500M for health professions training; and $200 M for primary care and dentistry programs.
Comparative effectiveness research at NIH $400 M, AHRQ $300M, and HHS $400M. The funding in the conference agreement shall be used to conduct or support research to evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition.
HHS ONCHIT $2 B, $300 M of which is for regional efforts for health information exchange; remaining funds can be used for: development of certified electronic health records software if HHS sees that the private market does not meet certain providers needs; training on best practices to integrate health I.T. systems; infrastructure and tools to provide telemedicine; promotion of technologies and best practices that enhance the protection of health information; promotion of the interoperability of clinical data repositories or registries; and improvement and expansion of the use of health I.T. by public health departments. Much of the funds could be distributed to states as planning and implementation grants.
HHS HIT Grants to facilitate the purchase, train personnel in use, and secure electronic exchange of health information; Medicare HIT incentive payments up to $44,000 for physicians who are meaningful users of certified EHR technology to improve quality, and who submit quality information (under PQRI - Rules for 2010 forthcoming in July) - with 10% additional in Health professional shortage areas; $11 million for hospitals; Penalties for those physician and providers who have not implemented EMRs begin in 2015. Medicaid incentive payments for non-hospital based physicians, nurse practitioners, nurse midwives, and physician assistants who are meaningful users, but not claiming Medicare incentives equal to 85% of net allowable technology costs not exceeding $63,750. Rural Health Clinics and FQHCs with at least 30% patient volume attributable to Medicaid will be eligible for payments not exceeding $63,750 for the cost of adoption and use of certified HER

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Centers For Medicare and Medicaid Services (CMS), Health Resources & Services Administration (HRSA), Health & Human Services - Dept of (HHS)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

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LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code MMM

16. Specific lobbying issues

The following bullet points summarize the objectives of the Marshfield Clinics Health Policy Agenda:
value-based purchasing of health services including bonus payments for high value Medicare Advantage programs;
establishment and funding of comparative effectiveness research;

promoting payment fairness in Medicare physician and practice expense payments;
new formulas for aligning Medicare reimbursement with value;
bonus payments for efficient providers;
bonus payments for primary care providers;
financing for the adoption and utilization of health information technology;
repeal and reform of the Medicare sustainable growth rate mechanism for updating physician payments;
improved reimbursement for the CMS Physician Group Practice (PGP) demonstration;
expansion of the PGP demonstration methodology into a national accountable care organization program to extend the physician group practice demonstration;
Adequate funding for CMS;
Adequate funding for community health centers;
Funding for after-school programs
Integration of Medical and dental care and records
Meaningful use of HIT;
Funding for medical simulation training
Personalized medicine
Healthy lifestyles programs

Value Based Purchasing

The concept of value-based health care purchasing is that buyers should hold providers of health care accountable for both cost and quality of care. Value-based purchasing brings together information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. It focuses on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. Recommendations:
Medicare and other payors must capture the data on performance measures utilizing available claims-based data, and/or data recoverable through enhanced IT functions, and validate performance improvement.
Implement quality/efficiency based payments for physician services as soon as possible.
Implement bundled payments for episodes of care.
Implement FFS reimbursement for the value added through care management and coordination of services.
Improve reimbursement for primary care services.

Comparative Effectiveness/Evidence Based Medical Informatics Research

Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for policy coverage decisions.

Payment Equity for Physician Work

Before MMA 03, Medicares payments were geographically adjusted based upon erroneous assumptions about the cost of hiring and retaining physicians. Congress established a floor payment mechanism for the physician work component of Medicare payment for 04 06 to assure that physicians in low payment localities were compensated for their work at least at the national average payment amount. The payment floor provision expired in 06, but has been extended in federal legislation every year since then. Currently CMS defines physician work as the amount of time, skill, and intensity a physician puts into a patient visit. There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis.

Payment Fairness for Practice Costs

The formulas by which Medicares payments are calculated are widely variable throughout Medicare localities, and are based upon outdated data assumptions regarding the cost and organization of medical practice. Medicares physician fee schedule, which specifies the amount that Medicare will pay for each physician service, includes adjustments that are ostensibly made to ensure that the fees paid reflect systematic and enduring variation in geographic practice-related costs.
Recommendation: Congress should require CMS to administratively revise its measurement of cost of practice to assure the validity and fairness of payments.

Medicare Advantage

The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. Corresponding mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. Performance bonuses should be provided for plans that:
Achieve predetermined quality performance targets;
Adopt health information technology;
Meet standards for care coordination; and
Provide data on comparative effectiveness.

Accountable Care Organizations

The current Medicare payment system is not a forward looking system. It reflects our past medical practices more that it reflects our future medical practices. However, since it is likely that the current system will be in place for the foreseeable future, there are strong reasons to correct its many deficiencies. We fully support those efforts. In the longer term we believe that it will be important to develop alternative payment systems that properly reflect the emerging realities of delivering health care in the US. Some of the emerging ideas in this regard, including the concepts for Accountable Care Organizations and Medical Home as examples, would seem to require fundamentally different payment arrangements and therefore fundamentally different data collection systems to ensure equity in payments for Medicare services and yet maintain some control over global Medicare expenditures One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary. The basic shared savings model outlined in the statute provides a bonus payment to ACOs that meet quality targets and keep spending for the population for whom the ACO is responsible below a target level. The amount of the bonus payment will depend on the amount of savings and the proportion of the savings allocated to the ACO and Medicare ACOs should report a focused set of quality indicators that reflect the outcomes ACOs are designed to achieve: keeping the population healthy, better care coordination to reduce unnecessary and sometimes harmful spending, and better patient experience.

Adequate Funding for CMS
The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. The federal government developed formulae to evaluate the cost of providing services in different practice settings and in different geographic locations. Those formulae measure resource inputs that have changed over the +40 year life of the program. To ensure affordable access to Medicare services throughout the country Medicare must take steps to refine its measures of the cost of providing services so that Medicares overwhelming financial dominance does not interfere with affordable access in markets that have changed very much since the program began. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs.

Community Health Centers Under Health Reform

The health reform legislation contained a number of key provisions relating to community health centers, including $11 billion in new funding for the community health center program over the next five years and $1.5 billion over the next five years to expand the National Health Service Corp. While these are mandatory funding levels, it is possible that the Congress might cut the base funding levels for community health centers and the National Health Service Corp effectively diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must contract with health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminates the outdated Medicare payment cap on FQHC payments. This will begin to modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries.

Dental Access and Integration with Traditional Medicine

The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records.

Meaningful Use of Health Information Technology

The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. As information technology has sparked this explosive growth in knowledge, only information technology can provide an adequate response. By using evidence-based knowledge embedded in clinical decision support deployed within a well-designed workflow, physicians can manage the ever changing and growing knowledge base critical to the delivery of effective and efficient healthcare. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.

Personalized Medicine

Personalized medicine is the concept that envisions an individually tailored approach to detecting, preventing, and treating disease based on a persons specific genetic profile. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit.



Medical Simulation Training
The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. Medical errors are highly preventable through the use of modeling and simulation in medical education. Simulation will enhance technical and communication skills of physicians and other medical providers in high fatality, low frequency skills, such as emergency cricothyroidotomy, and amniocentesis and physician re-entry skill verification, such as pelvic exam and central line placement. Simulation experiences also provide the opportunity to enhance team communication and patient to provider communication through the recreation of uncommon or stressful scenarios such as obtaining a sexual health history or abuse/neglect screening. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation

Afterschool Health Services Program
Improving the health of an entire community goes beyond doctor-patient visits, to population health efforts directed at vulnerable populations. Recognizing the complexity of health challenges facing young people and the strong intersection between community coalition efforts, afterschool approaches and improved health, Marshfield Clinic has developed a sustainable infrastructure to unite the efforts of its clinics with grassroots coalitions and afterschool programs. Marshfield Clinic will support legislation to implement quality services in afterschool settings that include case management of individual youth to promote academic success, personal/social development and health/wellness. This will include access to clinical services designed to meet the identified needs of enrolled youth i.e. early and periodic screening, well-child visits, immunizations, behavioral health appointments/treatment plan compliance, dental screening and sealants, asthma case management; Evidence-based programs, practices and policies targeting identified health priorities i.e. alcohol and other substance use and addiction, high-risk sexual behavior, intentional and unintentional injuries and violence, overweight, obesity and lack of physical activity, tobacco use and exposure; Release of information forms and written consents signed by parents prior to services.

Healthy Lifestyles Program
Marshfield Clinic will support legislation to implement policies that take a comprehensive approach to obesity prevention, addressing nutrition and physical activity in a broad variety of environments including communities, businesses and schools.

On March 20, 2010, HHS Secretary Sebelius wrote a letter to the House of Representatives Quality of Care Coalition stating that HHS would commission two studies by the Institute of Medicine to 1) evaluate hospital and physician geographic payment adjustments, the validity of the adjustment factors, and the sources of data used for such adjustments; and 2) examine the geographic variation in the volume and intensity of health care services ultimately recommending ways to incorporate quality and value metrics into the Medicare reimbursement system. Secretary Sebelius also convened a National Summit on Geographic Variation, cost, Access, and Value in Health Care on October 4.

Practice expense geographic practice cost index (GPCI) adjustment: Retroactively effective from Jan. 1, 2010, HHS is required to revise the calculation method of the practice expense (PE) portion of the GPCI. This revision results in increased PE GPCIs for certain rural areas. Implementation of this provision will likely require CMS to reprocess certain 2010 claims (Sec. 3102 of HR 3590 as modified by Sec. 1108 of HR 4872 Reconciliation).

CMS Physician Group Practice Demonstration Marshfield Clinic submitted a proposal for this demonstration and was selected by CMS to participate in the demonstration program, effective April 1, 2005. Marshfield Clinic supported CMS determination to extend this program, beyond its initial 3-year term, and transition these organizations into Accountable care Organizations. Section 1301 of the House bill HR 3962, the Affordable Health Care for America Act, and Section 3022 of the Senate bill HR 3590, the Patient Protections and Affordable Care Act. Marshfield Clinic Also supported efforts to eliminate the 2% threshold for payments and the 5% limitation on payments in the PGP demonstration.

HR 4213: The American Jobs and Closing Tax Loopholes Act introduced by rep. Charles Rangel included a 6-month ARRA FMAP extension that would provide much needed Medicaid relief for states ($305 Million for Wisconsin alone). HR 4213 also included provisions canceling the pending reductions in physician reimbursement under the SGR formula. Marshfield Clinic urged Wisconsin Senators to support the extension of federal funding

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Agency for Health Care Policy & Research, Centers For Medicare and Medicaid Services (CMS), Health & Human Services - Dept of (HHS), Health Resources & Services Administration (HRSA)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

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LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code HCR

16. Specific lobbying issues

Privacy and Security provisions of ARRA

The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about:
Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
Covered entities must comply with requests to restrict the disclosure of an individuals protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities.

Meaningful Use of health information technology

On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems.

Marshfield Clinic presented testimony to the Policy Committee of the HHS Office of the National coordinator discussing concerns about the timing and requirements imposed upon eligible providers to perform physician order entry into an electronic medical record of patients care. In particular Marshfield Clinic expressed concerns that order entry requirements may unnecessarily interfere with team oriented work processes.

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Centers For Medicare and Medicaid Services (CMS), Health & Human Services - Dept of (HHS)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

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Information Update Page - Complete ONLY where registration information has changed.

20. Client new address

21. Client new principal place of business (if different than line 20)

22. New General description of client’s business or activities

LOBBYIST UPDATE

23. Name of each previously reported individual who is no longer expected to act as a lobbyist for the client

ISSUE UPDATE

24. General lobbying issue that no longer pertains

AFFILIATED ORGANIZATIONS

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Internet Address:

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FOREIGN ENTITIES

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