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

AmeriCorps Funding: Afterschool Health Services Program
The primary focus is an Afterschool Health Services Program, which provides the infrastructure for communities to work collaboratively to improve health of youth in afterschool settings.
This approach recognizes afterschool programs as a credible venue for health improvement as our nation moves forward with health care reform. This approach also takes into account the research base that demonstrates that a quality education is a number one determinant to good health. 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.

AmeriCorps Funding: Healthy Lifestyles Program

There is a need for strategic action at the federal level to counter the obesity epidemic in our nation. Chronic diseases related to obesity such as diabetes, heart disease, high blood pressure and certain cancers are the leading causes of premature death and disability. Unless the obesity epidemic can be curbed, the life expectancy of future generations will be compromised. Programs, practices and policy approaches that have been effective in the adult population such as employee wellness and policies promoting physical activity must be implemented early in life to redirect obesity inducing habits and behaviors in children. 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.

Community Health Center Funding Dental Access

Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 10 dental clinics. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

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

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, 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 MMM

16. Specific lobbying issues

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic:
Extends health insurance to the uninsured
Establishes the Patient-Centered Outcomes Research Institute to support comparative effectiveness research

Imposes necessary regulations on Insurers banning rescissions and exclusions for pre-existing medical conditions limits
Expands Medicaid Eligibility to 133% of FPL
Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL)
Increases practice expense payments,
Calls for IOM study to Correct Geographic payment disparities
Calls for CMS to establish a Value Index to align payment with quality
Establishes Bonus payments for primary care, efficiency, quality
Calls for Value Based Purchasing for all providers
Calls for the establishment of Accountable Care Organizations
Establishes a Center for Medicare and Medicaid Innovation to test innovative payment and delivery models
The following are key elements of the health policy agenda of the Marshfield Clinic:

Medicares Sustainable Growth Rate -- We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use.

Medicare Pay for Value -- Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. Score-able savings might be achieved if Congress put a larger percentage of the value modifier at risk for participating physicians, and imposed penalties on inefficient practices.

Geographic Adjustment of Physician Payments - Recent findings by the Institute of Medicine and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.

CBO Scoring of Preventive Health -The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.

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.

Medicare Payment Inequities - In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities?

Payment Equity for Physician Work - 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.

Transparency -- Marshfield Clinic supports The Quality Data, Quality Healthcare Act, S. 1758, introduced by Senators Tammy Baldwin (D-WI) and John Thune (R-SD), and similar legislation the Expanding the Availability of Medicare Data Act, HR 4418, introduced by Reps. Ron Kind (D-WI) and Paul Ryan (R-WI). This legislation would provide for greater access to Medicare claims data by modernizing and reforming the Qualified Entity (QE) program, which permits organizations to access and analyze Medicare data.

Medicare Advantage Performance Measurement - The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that 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.

Medicare Advantage Improvements -H.R. 2753, THE SECURING CARE FOR SENIORS ACT, by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System. Marshfield Clinic supports this bill.

Accountable Care Organizations - The Affordable Care Act seeks to improve the quality of health care services and to lower health care costs by encouraging providers to create integrated health care delivery systems. These integrated systems will test new reimbursement methods intended to create incentives for health care providers to enhance health care quality and lower costs. 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. We recommend that CMS relax restrictions on the provision of services using telemedicine technologies to allow ACOs to increase the efficiency of services provided.

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. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act.

Telemedicine in Medicare -Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine.
Recommendations:
1.Amend the Medicare requirement for non-MSA geographic location of the patient to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation.
2.Alternative amend the Medicare requirement for non-MSA geographic location of the patient to allow accountable care organizations to be exempt from the MSA requirement.

Community Health Centers Under Health Reform -- The Affordable Care Act contained a number of key provisions relating to community health centers, including new funding for the community health center program and funding to expand the National Health Service Corp. While these are mandatory funding levels, the Congress did cut the base funding levels for community health centers. Americas Health Centers like Family Health Center of Marshfield, Inc. currently serve as the health care home for more than 22 million Americans, providing comprehensive primary and preventive care services. Americas Health Centers play an important role in delivering care to many Americans and could be the health care home for many more, but unless Congress and the Administration act, funding for the Health Center program will be cut by 70%. A cut of this size would force Health Centers to close their doors, lay off staff, and reduce the services they provide, leaving millions of Americans without access to the health care services they need. We ask the Congress to provide not only the funding to preserve ongoing Health Center services but to also expand this cost effective model of care to every community especially those that currently lack basic primary care services.

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. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. has been providing on-site dental services since the fall of 2002 and operates eight dental sites. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. 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.


Oral Health Coverage for the Medically Compromised and at Risk Populations

There is sufficient data that demonstrates oral health impacts the systemic health of the patient and in doing can reduce the cost of care. Linkages that encourage patient compliance, patient education, provider education, and bi-directional referral and surveillance should be incented and compensated. Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care.


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. Health IT on a broad basis is still in its infancy. 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, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. 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. 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.

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), Executive Office of the President (EOP), Medicare Payment Advisory Commission (MedPAC)

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

Federally Facilitated Exchange Policy Issues
Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013.

Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice. This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience.

Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies.

We opposed the absence of a complete regular order consideration of the Equitable Access to Care and Health Act, HR 1814, by Rep Aaron Schock, which would create a new religious exemption to the individual mandate. This bill was approved by the House under suspension of the Rules on
Community Engagement for Healthy Lifestyles Coalitions, Afterschool, AmeriCorps and Community Organizations

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, afterschool programs, tribal communities and other community stakeholders.

Marshfield clinic believes that high quality afterschool programs are a credible venue to improve the health and education of children and communities. Afterschool programs are poised to assist children to develop and reinforce lifelong healthy habits to stem the tide of chronic disease and to reduce the incidence of lifestyle related disease related to alcohol, tobacco and other substance abuse; high risk sexual behavior; intentional and unintentional injuries and violence; overweight, obesity and lack of physical activity; and, tobacco use and exposure.

There is a critical need for strategic action at the federal level to counter the obesity epidemic in our nation. Chronic diseases related to obesity such as diabetes, heart disease, high blood pressure and certain cancers are the leading causes of premature death and disability. 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, schools and afterschool programs.

To this end, Marshfield Clinic supports federal funding designed to improve the health and education outcomes of youth, children and families. Examples of funding streams that are of particular importance include: Corporation for National Service AmeriCorps Program; Department of Education 21st Century funding; and, the Department of Health and Human Services Child Care Development Block Grant; Center for Disease Control Childhood Obesity Prevention and Community Transformation grants; etc.
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. Rules issued by CMS outline provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. Final regulations issued by ONC set 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.

National Farm Safety

Support for occupational safety and health funding for Fiscal Year 2015. The National Institute for Occupational Safety and Health (NIOSH) is the primary federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury. NIOSH provides leadership to avert workplace illness, injury, disability, and death and supports programs to improve the health and safety of workers. NIOSH funds the National Childrens Center for Rural and Agricultural Health and Safety. Marshfield Clinic urges support for this important program.

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), Executive Office of the President (EOP), Health & Human Services - Dept of (HHS), Medicare Payment Advisory Commission (MedPAC)

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

25. Add the following affiliated organization(s)

Internet Address:

26. Name of each previously reported organization that is no longer affiliated with the registrant or client

FOREIGN ENTITIES

27. Add the following foreign entities:

28. Name of each previously reported foreign entity that no longer owns, or controls, or is affiliated with the registrant, client or affiliated organization