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

BUD (Budget and Appropriations)
Opposition to ICD 10 delay considered during consideration of Cromnibus budget negotiations

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

U.S. SENATE, U.S. HOUSE OF REPRESENTATIVES, Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP)

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

MMM (Medicare and Medicaid)
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
Creates state based Health Insurance Exchanges for individuals between 133% - 400% of Federal Poverty level (FPL)
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.

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.

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.

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.

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.

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

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

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.
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 population-based 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. SENATE, U.S. HOUSE OF REPRESENTATIVES, Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), 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

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