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 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
Calls for Value Based Purchasing for all providers
Calls for the establishment of Accountable Care Organizations
The following are key elements of the health policy agenda of the Marshfield Clinic Health System:

Medicare Access and CHIP Reauthorization Act
With passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress has put to rest the constant threat of massive cuts to Medicare physician fees. Going forward Medicare physician payments will transition to an incentive-based system based on value and accountability. Starting in 2019, Medicare physician payment will be based on the Merit-Based Incentive Payment System (MIPS). Physicians who perform well on quality, value and IT metrics will be rewarded with higher pay rates and those who perform poorly will face penalties. Participants in Alternative Payment Systems (APMs) such as accountable care organizations that assume financial risk will receive 5% bonuses between 2019 and 2024. Because the language of the statute is not specific, the Centers for Medicare and Medicaid Services (CMS) is developing metrics that will be used to determine the bonus payments and penalties that will start in 2019 in a public rulemaking currently underway. The proposed metrics simplify and consolidate the existing measurements employed under the Meaningful Use Incentive Program, the Physician Reporting System (PQRS), and the Value-Based Modifier (VBM) to streamline the reporting burden for physician practices. MIPS will then pay physicians based on four weighted performance categories: Quality (50% of total score in year 1), Advancing Care Information (25% of total score in year 1); Clinical Practice Improvement Activities (15% of total score in year 1): Resource Use (10% of total score in year 1, but growing to 30% in subsequent years). Having a source of credible data as the foundation of CMS metrics is critical both to fair payment and maintaining access to medical services in rural areas. CMS will be refining the metrics perpetually throughout the lifespan of this program. Challenges to fair reimbursement persist under the current Medicare fee schedule, which remains the foundation of the reimbursement system, particularly in regard to the valuation of primary care and the geographic adjustment of physician wages. These challenges must be addressed. Adequate funding for CMS to implement and maintain this new system is critical to patient care, provider education and acceptance of the new program and its long term success. 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 and MACRA.
MCHS also supported MACRA provisions that extended funding for the Childrens Health Insurance Program and provided $7.2 billion to community health centers over the next 2 years, postponed cuts in payments to hospitals that treat large numbers of low-income patients; and extended provisions that funded geographic adjustment of the physician work, therapy services and payments for rural hospitals.
Accountable Care Organizations

Marshfield Clinic has benefitted substantially from its 9 + years of experience with CMS in the development and implementation of the Physician Group Practice Demonstration, and the Medicare Shared Savings Program. The mission of the Clinic and the objectives of the PGP and MSSP programs are closely paralleled in that it is our mission and objective to make compassionate care more affordable, improve outcomes and enrich the care experience of our patients. It is in our organizational self-interest that these programs succeed, so we have committed substantial resources and energy to the understanding and improvement of the programs. By both objective and subjective criteria Marshfield Clinic has performed successfully. In a recent letter to CMS we focused on the CMS program objective of encouraging ACOs to transition into full risk arrangements. In the proposed regulations codifying the terms and definitions of the Medicare and CHIP Reauthorization Act of 2015, (MACRA) we find that we must become a risk-bearing MSSP ACO before 2017 to become a qualified Alternative Payment Model (APM). This is a primary strategic objective for MCHS. As Dr. Patrick Conway testified before the Energy and Commerce Health subcommittee on March 17th We (CMS) want to help (organizations) make the transition to become APMs. We believe that it is in our own and our patients best interests that we take whatever steps are necessary to move into risk-bearing arrangements, and we have requested support from CMS to make this necessary transition.

Graduate Medical Education -

MCHS is concerned about having a sufficient supply of primary care physicians to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in rural settings. Currently only about 10% of physicians practice in rural areas while 25% of the population resides there. While 36% allopathic residents and 50% osteopathic residents who are trained in a rural residency end up practicing in a rural area, only 4% of the residency training actually occurs in rural areas. Currently there are more US medical students graduating from medical school than there are GME slots. An increase in GME primary care training positions is essential to maintaining high-quality, accessible, and cost efficient care.

Teaching hospitals in rural locations provide an environment for residents to learn and faculty to serve as educators, providers and researchers. These roles advance the broad mission of preparing each generation of physicians, provide critical patient care and specialized services, often to the disadvantaged, facilitate the discovery of new therapies and treatments, and enable residents to acclimate to the rural setting. As new payment and delivery models emphasize primary care to improve patient outcomes and reduce costs, and as more care shifts to outpatient settings, teaching faculty and residency programs must increase access to ambulatory residency rotations to serve Americans who live in areas with an under-supply of primary care physicians including Psychiatry. The purpose and value of residency training in clinical settings and the financial support needed to sustain physician education will only increase as the U.S. population lives longer with more complex health conditions. To ensure GME can meet the future needs of the newly insured and aging population, Congress must commit to the consistent GME funding and lift Medicares limit on funded residency positions. We support the Teaching Health Center funding in MACRA for Community Health Centers but request you extend funding beyond 2017.


The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4)

The Medicare Advantage program provides a full risk, 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.

The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) By authorizing Quality Incentive Payments for MA plans with star ratings of 4 stars and above, Congress made a significant policy change towards value-based purchasing in the MA program. If a plan is eligible for a Quality Incentive Payment, it receives it in the form of a 5 percent increase to its benchmark. However, Congress also authorized a new methodology for calculating benchmarks, and mandated that benchmarks under the new methodology cannot be greater than what they would have been under the old benchmark methodology. This is the benchmark cap. The benchmark cap reduces or even eliminates Quality Incentive Payments. The policy issue is that the cap weakens the incentive for plans to attain higher star ratings and undermines the shift towards paying for performance in the MA program. We do not think that Congress intended to take away with one provision (the cap) the significant policy change towards paying for value that it enacted in the ACA. This change will have a significant negative impact on Medicare Advantage beneficiaries. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap.


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.


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. We recommend that the Medicare requirement for non-MSA geographic location of the patient be expanded to allow all Medicare certified organizations as originating sites regardless of rural or metropolitan statistical area designation.


In addition, MCHS supports the CONNECT for Health Act (S. 2484) and (H.R. 4442) that contains a provision which would permit Medicare Advantage plans to use telehealth or remote patient monitoring technologies to provide basic Medicare benefits, without the restrictions that limit originating sites, geographic locations, store-and-forward technologies, and types of health care provider. We believe that telehealth is a different way of delivering an already covered service, and that Medicare should treat remote access technologies as an alternative modality or complementary means of providing clinical services, and not a service itself. In other words, telehealth should not be seen as simply a supplement or complement to face-to-face encounters. Patients increasingly expect their health plans to provide the access to services and convenience that remote technologies facilitate. These technologies can increase communication between providers and patients, enhance care coordination, and help physicians and patients work together to treat illness and maintaining health.

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.

Part B Drug Payment Model

CMS proposed a new Medicare Part B Drug Payment Model in the Federal Register on March 11, 2016. This model proposes to test alternative payment methodologies for separately payable Part B drugs to determine whether alternative drug payment designs will lead to a reduction in Medicare expenditures while preserving or enhancing quality of care.

MCHS supports CMS efforts to address the rising cost of Medicare Part B drugs, but has concerns about the proposed demonstration of a new Average Sales Price (ASP) payment methodology. Specifically we believe that CMS should utilize its rule making authority to de-link physician payment entirely from the drugs they prescribe for patients.

MCHS believes that the major responsibility for unsustainable drug spending remains with pharmaceutical manufacturers. The rising costs of drugs and biologics is a system-wide concern. A major contributing factor to those costs is the price set by manufacturers. The fact that there are no regulations on pricing of new anticancer drugs is disturbing. Pharmaceutical companies have the freedom to price their drug liberally at whatever price they deem appropriate, on the basis of what they presume the market will bear. The fact that the largest purchaser of drugs, the US Government, via Medicare and VA, is obligated to purchase the drug at that price and is barred by law from negotiating price, is illogical, disturbing, and unfortunate for public beneficiaries throughout the country. We believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs. MCHS encourages CMS to work further with stakeholders to address the pricing side of the ledger with the expectation that this will enable it to move beyond shortsighted modifications in the Average Sales Price (ASP)-based payment methodology. To be very explicit we are not recommending that this proposal be withdrawn, but we do believe it is a long way from perfect policy. We believe that some necessary preconditions should be met before this program is implemented. The first of which must be to de-link physician payment entirely from the drugs they prescribe for patients. In addition, we believe manufacturers should be transparent about their research and development, marketing, advertising and other costs in getting a drug to market and setting prices that reasonably reflect the true costs.

Advance Care Planning

MCHS supports S. 1549 Care Planning Act of 2015, introduced by Senators Mark Warner, Johnny Isakson and Tammy Baldwin which Amends titles XVIII of Medicare) of the Social Security Act (SSAct) to cover advanced illness planning and coordination services furnished to an eligible individual with progressive illness, including Alzheimer's disease, by a hospice or other provider through an interdisciplinary team.

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

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

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 VET

16. Specific lobbying issues

We have asked for assistance to resolve administrative problems with Health Net Federal Services in the VA Choice program.

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

U.S. SENATE, U.S. HOUSE OF REPRESENTATIVES, Veterans Affairs - Dept of (VA)

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

​

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

The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4)

The Medicare Advantage program provides a full risk, 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.

The Medicare Advantage Benchmark Cap - ACA SEC. 3201. (b) (4) By authorizing Quality Incentive Payments for MA plans with star ratings of 4 stars and above, Congress made a significant policy change towards value-based purchasing in the MA program. If a plan is eligible for a Quality Incentive Payment, it receives it in the form of a 5 percent increase to its benchmark. However, Congress also authorized a new methodology for calculating benchmarks, and mandated that benchmarks under the new methodology cannot be greater than what they would have been under the old benchmark methodology. This is the benchmark cap. The benchmark cap reduces or even eliminates Quality Incentive Payments. The policy issue is that the cap weakens the incentive for plans to attain higher star ratings and undermines the shift towards paying for performance in the MA program. We do not think that Congress intended to take away with one provision (the cap) the significant policy change towards paying for value that it enacted in the ACA. This change will have a significant negative impact on Medicare Advantage beneficiaries. Medicare Advantage benchmark cap legislation was introduced in December. MCHS supports H.R. 4275, the Medicare Advantage Quality Payment Relief Act of 2015, introduced by Reps. Mike Kelly (R-PA), Ron Kind (D-WI), Brett Guthrie (R-KY) and Mike Doyle (D-PA) that would remove the quality incentive payments from the calculation of the benchmark cap.


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.

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)

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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