>> we need to set the polics up for success by providing

stability. moving toward a 3-5 year end date would better enable to committee to conduct proper oversight and consider changes over time. in addition, we look to make changes to some of the policies and more importantly we look to offset the cost associated with both extenders we must not cross on to patients who rely on the programs. i want to highlight some of the extenders and how they help the medicare and medicaid programs. this isn't a long list, but they are ones i would like to urge the committee to extend. one is the qualify for medicare that assists medicare beneficiary by covering the cost. it helps produce burdens and improve access to needed health

care access to low-income people who don't qualify for medicaid. in new jersey 49,000 people were able to get this assistance. another is the tma program that allows them to stay on medicare for a year once their income changes. it allows for consistent access to primary care. i wanted to highlight two policies in the aca. the low physician payment rates compared between the two. higher payments increase the probability of beneficiaries having care and one visit to the drr doctor. unfortunately we need time to under the impact of the program

in a meaningful way. and there are programs that are central to the program but not included in the bonus payment but should be. we included performance bonuses for stated rolling in children in medicare. new jersey received a bonus payment in 2013. minimizing enrolling make as difference in how many chinch are enrolled and whether they receive the medical care thaw need. and then the family-to-family health care centers. they assist youth with special needs which promotes better treatment. they provide a service in that

they are staffed by family members who have firsthand experience in navigating the system. that is why i have sponsored the bill to expand until 2018. these are just a few examples of the many extend provisions we must discuss. i have been pleased by the progress made on sgr. i stand ready to work on my committee and ways and means. and with the senate counter parts to repeal and replace the sgr and continue the important extender provisions. i don't know if ms. capps would like my last 30 seconds. all right. then i yield back. >> chair, thanks. >> gentlemen, our chair isn't here. so the chair recognize the ranking member of the committee

mr. waxman for an opening statement. >> thank you very much. my colleagues, they seem poised to eliminate the sgr and make it a program that is no longer in existence so we don't have to go through the torture of trying to make sure the harmful consequences of not extending it are averted. two in the house and one in the senate voted. our committee voted unanimous. it is served as a vehicle to address medicare, medicare, child care health and additional public health related programs that contain similar time limits. these provisions have been referred to as extenders or

extender policy. when we repeal the sgr policy we must address these associated extender policies. they seek to protect the vulnerable populations. so we cannot afford to leave them out in the cold in jeopardy of being terminated. in medicare, we have policies that need to be extended relating to therapy caps, special need plans, those have been discussed and they are well known. some have a long history of bi-partisan support. i want to note my reservations about extending the abstinath only program. i want to talk about the medicare and chip programs. they help stream line the

process for state. there is an express lane program that gives state the option of relaying on income data in use for other programs helping reduce the cost. this is indispensable for families and we must end the roller coaster and assure the coverage is successful. the chip program is getting new ways to get kids enrolled. 23 states half of states with republican governors qualified. and i have heard a great deal from the family doctors and pediatricians about the medicaid

primary care bonus. it will be comp prbl to medicar. we need make sure doctors, especially family care and pediatricians have the extra payment that will allow them to see the patients. i want to yield the balance of my time to my friend and colleague from california mrs. capps. >> thank you very much. i want to add my thanks to the chairman for holding this hearing. we have had discussions on how to move past the flawed system. i am shared views we cannot and must not ignore the health care

extenders. they go along with the patch legislation. small, technical but critical policies that make a world of difference for health care providers and their patients. i want to stand ready to work with colleagues on the issues. the medicare primary bump and the many critical medicaid and public health extenders we are considering today and again thank you for yielding your time and for holding the hearing today. yield back. >> that concludes the opening statements. i would like to thank all of the witnesses. we have mr. glenn hackbarth, chairman of the medicare payment advisory commission. we have diane rowland chair

medicare and chip payment access commission. we have dr. michael lu association of child health borough and health resources. and we have dr. naomi goldstein director of office of planning research and administration for children and family. your prepared testimony is made part of the record. you will have five minutes to summarize your testimony. and that will be placed in the record. at this point, i will recognize the first speaker. >> thank you very much ranking member and vice president. i appreciate the opportunity to talk about med packs recommendation on these issues. there is a long list of medicare provisions under discussion here

as noted. it is diverse list so i will not try to summarize our views on those provisions. i will describe the criteria we used. we looked at them in two batches. first the 2012 request focusing on the medicare extenders. all of the provision increase spending above the current baseline. in evaluating the provisions, what we did was ask the question whether there is evidence that the provision in question improves access to care, quality of care, or enhance movement toward new payment models. we had a 2011 request from the congress to evaluate special

payment provisions that apply to rural providers. there we used a similar test and asked whether a provision was targeted so it provided support to isolated providers necessary to provide access to care for medicare beneficiaries. what it provided was justified in whether it was designed to preserve some incentive for the efficient deliver of care. these are stringent test but they back up the recommendation to congress that will make sure they have high quality care. we think a stringent test is

needed in the current context. we have advocates of the repeal for well over a decade. we have hardened the progress made by the appeal and recognize the remaining part of the challenge financing the appeal. so a stringent test on the extenders is appropriate. i welcome questions from the committee. those are my summary comments. >> i recognize dr. roleland now. >> thank you members of the committee. i am pleased to be here to share mack pack's expertise as we talk about the provisions affecting

medicaid and chip. they began the work in 2010 to provide congress with analytical support on medicare and chip. the focus of the work is on how to improve the efficiency of medicaid and chip, to reduce complexity and improve the care for the over 60 million beneficiaries. we will look at the patient protection in the affordable care act and the coordination of medicare and chip and exchange coverage. children's coverage and the status of the chip program in the future. cost payments in the sism underway in the states for medicare. at issues for high cost-high need enrollees and on medicaid capacity. today i am focus on the issues up for reauthorization and

extension. transitional medicare assistance has been looked at. tma provides additional months to low-income parents and children who would lose the coverage due to increased earnings. it was limited to four months and has since 1990 been raise today a 6-12 month period through the extenders. this applies to the lowest income beneficiaries. this recommends eliminating the sunshine date that allows the

6-12 months covererage and provides states with the additional flexibility. we have recommended when states expand medicare to the new adult group they are allowed to opt out of the transitional medical assi assistance because there is no gap from the period or the coverage they would provide under the subsidies. with regard to express lane eligibility we see it provides children with enrollment under chip and medicaid with an expressed vehicle so it eliminates the duplication that goes on. 13 states have implmented this

and we will continue to monitor the use and effectiveness of the approach. we will in the process of reading the december report and will provide comments on the report to the congress. in terms of the program and outreach, we see the bonus payments have provided a strong incentive to the states to improve outreach and enrollment processes for children. many of the strategy will be used in 2014 so we will look at the restructured system. we strongly support developing systems that will help us measure the quality of care of children including the

requirement and extenders to develop the measures. there is no other way to compare the quality of care being provided or to aaccess it without substandardizatitandard methods use. we kn with regard to the individual qualifying program and the special needs program, we have been looking carefully at the importance medicare pays especially helping the lowest income afford premiums but get better care and will continue to work to assess ways we can improve the coordination of care for individuals who are dually eligible as very low income. so we will continue to keep congress informed of the progress, we look to try and find ways to reduce

administrative burden and streamline the programs as well as provide better care to the beneficiari beneficiaries. thank you very much for having us today. we look forward to continuing to share the work with you in the future. >> now i recommend dr. lu. >> thank you for the opportunity to testify today. the focus is on improving access to health care services to people who uninshurninsured and isolated. we work to improve health and health equity. i am pleased to provide an update on the maternal home

visiting program and the family to family program. the home visiting program is in close collaboration with the administration for children and families supports evidence-based house visit during pregnancy and up to age five. they work with parents to sign up to participate and help them build additional skills to care for children and family. low income family, teen parents, families with a history of abuse, families with development delays, and military families. evidence-based research shows that home visiting by a nurse, social worker or early educator during pregnancy and during the first years of live prevents child abuse and neglect,

positive parenting, and school readiness. the benefits continue into adolescence and adulthood. previous works shows among 19-year-old girls born to high-risk mothers nurse visits during the pregnancy and first two years of live reduced the arrest and con vision by 80%, teen pregnancy by 65% and medicare enrolling by 60%. home visiting programs have a return on investment. the most current one found that for every dollar invested in home visiting $9.50 is returned to society. early data collected found within the first nine months of

implementing the program, it provided more than 175,000 home visits to 35,000 parents. preliminary data in 2013 indicating more than 80,000 parents and children are receiving the program and it is available in 656 counties across the country which is 20% of all counties into the united states. states and communities are the driving force in terms of turning out the program. with our support, state and communities are building capacity in this area and are showing improvement in quality, efficiency and accountable of the programs. states can taylor programs to serve the needs of different communities and populations. states are able to chose from 14-evidence based models that best fit the risk community needs, capacity and resources. we have taken a number of steps

to provide accountability and success. we support learning across states, additionally we monitor the state's progress. it is collected on an annual bases and by 2014 they are expected to show improvement in had 4 of 6 bench areas. and we have the family to family support building and they provide support, resources and training to families with special needs children. they are staffed by the parents of other special needs. it connects people to families for information and resources. and provide training to professionals on how to better

support families with special health care needs and assisting the state in family-center and medical home and community system of care for the children. we monitor the effectiveness. it was shown between june 2010-june 2011, hundred thousand families received training from the centers. greater than 90% of the families reported being able to partner in decision making, better able to navigate through services and more confidant. i will be pleased to answer any questions you have. >> the chair recognizes naomi

goldstein. >> i plan to speak about three programs my agency oversees as well as the home visiting program just described. we have bringing about evalz -- evaluations -- we make them sound so they are relevant for policy makers. the health grant program provides training in high demand health care for professions for low income people. the program is funded 32 grantees including five tribal organizations. of the people completing the training program, 80% are

employed. nursing assistance or short correspondenc courses that are the first step. we published three reports. grantees are using a range of strategy. one in pennsylvania is using google hangouts for real time tutoring in a highly rural service area. we are seeing how it effects employment and earning. it is educating on contraception and for abstinath. all models must provide medically accurate information. we have a systematic review to identify immure -- areas of

impact and 32 of the programs have met that. we talk about how they define and reach target populations. further findings from the national evaluation will be released over the next four years. states are encouraged to use models that are evidence based in sex-education and they must provide accurate information. in 2007, hhs evaluated four local programs that found no effect on abstaining from sex or the likelihood of unprotected sex. three models are among the 31 prevention models that meet the criteria. it provides no funding for research and evaluatioevaluatio.

however, one virginia grantee is evaluating an abstanith program. the statue requires continually learning through national evaluation and other activities. so far, 14 home visiting models have met the review criteria. the committee reviewed and endorsed plans for the report due to congress in march of 2014. it used a random design to

assess to program and the home visit program. i hope this can give you an idea of the ongoing efforts to learn and improve. >> we will begin questions and i recognize myself five minutes for that purpose. glenn hackbarth, i believe we need to consider the policies carefully. many people are advocating for make the extenders permanent. you laid out a set of criteria to use when considering the extenders. using your criteria, did you

believe all or the majority were not extension? >> not all. we think many shouldn't be extended. >> in your opinion, based on your criteria, do you have a couple programs that congress needs to look at with a critical eye as we begin the review? >> let me focus on the rural payment provisions some of which are permanent and some are temporary and under consideration here. as i said in the opening comments, we did an extensive review of medicare rural health issues published in june of 2012, i believe. and part of that was to examine

the special payment provisions against the criteria i mentioned in the opening comments. are they justified and retain incentive for efficiency and we found a number of the provisions didn't. i will focus on one in particular. there was a temporary low volume adjustment in the medicare program, a hospital payment adjustment for providers are low volume. there are a couple serious problems with that adjustment. it is based only on medicare discharges. if the issue we're trying to address is small size and lack of economy of scale, the appropriate index of that total discharge is not medicare

discharge. it looks to us like the magnitude of the adjustment is too large. and finally it isn't directed only at isolated providers. so hospitals close to a critical hospital qualify for the low volume. soul community hospitals can double dip and get special payments as sole community and low volume as well. >> i want to commend you for putting together the criteria you put together. dr. diane rowland, do they have

separate ways of weighing the cost of medicare versus the benefit? if not how do you take into account issues of cost and other important consideration that med pack is advocatinadvocating? >> we are a newer body so med pack is trying to establish the criteria. one of the strongest would be e efficiency and reducing complexity. around transitional medical assistance is where we have made suggestions and we are continuing to look at the others in terms of cost and impacts on beneficiaries on federal dollars and spending. >> thank you. i understand the acf provides

technical assistance to grantees but little of the assistance encourages more teens to avoid sexual avoidance. please provide the technical assi assistance you provide on abstaining versus contraceptions. >> i am not prepared to answer that but i will take it back to the colleagues and bring it back on the record. >> the committee described 22 studies showing significant evidence of the positive impact of those programs. are you familiar with that? >> i am. >> and would you share it as technical assistance? >> i will provide that to my colleagues and come back for the

answer. >> i recognize the ranking member for questions now. >> thank you, mr. chairman. i had a number of documents on the extenders i wanted to ask unanimous consent to put it on the record. >> without objection it is order. >> i had a question of dr. lu. i have been a supporter of the family to family and it has helped many in my state and across the country manage special health care needs. that is why i introduced bill to extend the funding until 2016. the senate went further to extend until 2018 and included a million increase. i was wondering if you could talk more about the contribution

that the f2f program has made to the overall health care system. >> use the microphone there. please turn it on. >> you mentioned congressman, thes centers are unique in they help parents with special health care needs. the parents under the challenges, they know the system and they can connect other parents to a larger network of families and professionals for support. they can help the families find the best health care providers. they partner with providers and they can improve on the outcomes and the cost of care for vulnerable population of children. >> you kind of answered the

second question, but could you talk about how it is different than other programs and how the staff are uniquely qualified to help the families. >> it is unique in the sense it is staffed by parents themselves. in terms of the support, the information, the resources, the training that they can provide from their first-hand experience is irreplaceable. >> the work of the family to family centers is supported by members on both sides of the aisle, i wanted to ask diane rowland a question about the chip or bonus payments. chip enrollment performance benefits have encouraged the states to support them.

for the fiscal year 2009, ten states received $37 million. 2013, 23 states received for $303 million. in order to qualify the states have to implement five of the eight best practices. states haven't adopted all of them. express lane eligibility and others are important for enrollment. wouldn't you agree working to the courage the states to adopt the policies are critical? >> well, i think we have learned a great deal about the quality of these best practice and that

is why some are now required. i think to continue to look at ways to encourage states to do outreach of the eligible but not enrolled children. being able to look at other incentives to provide in the bonus payments that if the state choses to eliminate the waiting period for chip that might be another thing to add on for the incentives. it gives states incentive to find the children who are eligible but not enrolled. >> thank you. i wanted to mention to the chairman, the chip is authorized for 2015, but i think the bonus

programs should be extended for a lifetime. we want to retool and qualify the threshold but in the mean time it make sense to keep the program going. and more than half of the states that qualified are led by republicans. so it has success in red and blue states. >> i would like to do what you did and give you the list. i have a number of records to submit to the record. the chair recognizes the subcommittee members. >> dr. diane rowland let's stay on the tran -- transition.

is the tha necessary now we have the affordable care act? >> i think it depends on the option the state chose to pursue. the states that did opt in there is a way to eliminate but half of the states opted not to get the extension. in those states, transitional medical assistance is particularly important because it lets people get the ability to go in the workforce. >> if i understand you, the extension of transitional medical assistance should be for those states not participating in the medical program? >> this is existing for all

states and this is about extended for 12 months which provide states with additional flexibility to do premium assistance. it gives states the ability to move from medicare into private insurance and that is important. >> i think that was a flaw in the affordable care act. we can talk that. but really it seems for continuation, it is only necessary in the states that are not participating in the medicare expansion which was their right under the supreme court ruling. >> correct, but if you are concerned about the cost, there is a higher cost for the federal government to individuals in the states that do the transition to the affordable care act coverage because there it is a 100 federal financing as opposed to

the shared financing that is going on for transitional medical assistance. >> that is a temporary state. we know the f-map for the states participating is going to have to change. there is a limit to how much the chinese will loan us. you are going to have churning and people that continuously earn at different levels during the course of the year and 157% poverty level sound great in a committee or federal agency, but in real life, there are people whose income may go up and down wildly throughout the course of the year. when we had the hearing on the people effected by the deep

water horizon we heard from a fixer who earned a lot in may, but he is broke the rest of the year. so he is going from medicare into an exchange and back into medicare. it seemed not to be efficient. does your program prevent that? >> it would help maintain coverage so during the lapses you have continuous eligibility so it eliminates having to transition and helps manage care plans to provide continuous care. >> i don't think it is our role to help manage care plans. dr. lu, let me ask you because you talk about a study among 19-year-olds and the lifetime

risk of arrest was significantly lowered. what period of time did the study comprise? the study i believe was a follow up. these children and family are over a two decade period. >> you site a lifetime arrest risk as being deminished. most of us expect to live more than two decades so how else did you compile the figures? is there a way to project the

arrest at age 19? >> i can speak to that. the lifetime arrest record is as long as their life had been so far. it was through the age of 19. not beyond that. >> chair, thanks. recognize the member of the full committee for questions. >> i want to draw your attention to a provision that was enacted into law that i fear will have serious consequences for access to medicare and medicare. medicare shouldn't pay for care that someone else is libel for and states can recoop when others are liable. but for pediatric care, the law required states to pay promptly and chase other sources of payment later.

this is to ensure children, infants and pregnant woman get access to care promptly with no delay. the law was changing said to say states must delay for 90 days while they choice other potential sources. congress would be outraged if anyone proposed delaying the pay to medicare physicians for a service provide. i am afraid it will harm access to care for children and discourage thoses from participating in the program. can you com on this? >> we are looking at the barriers that prevent more primary care and specialist to participate in the program.

we learned that payment delays and inability to get payments processed is one of the issues doctors raise about why they are unwilling to participate. so one needs to look at a delay in payment and it it would affect the access to care that is so important giving medicaid's role in paying for 50% of all births in the country and a high share of the neonatal care. >> that seems logical we should expect that is going to happen if we delay payments just to delay them when we don't anywhere else and there is no reason should

stick to the aca reform and continue moving forward? or is there any justification for repealing? >> we have long advocatiadvocat the way of traditional medical care. the affordable care act moves in that direction and we would encourage congress to stick with that course. we expected that with fiscal

pressure resulting in the reduction of bench marks, plans would respond to lower cost. the bids have fallen with the tightening of the bench marks. so it is evolving as expected. >> there was an additional recommendation of changes to medicare payments and how plans offered by employers to retirees are priced. can you describe the recommendation? >> we will be voting next week for recommendations on the march report to congress. the issue here is that the bidding system used for employer sponsored plans is different. there is no inceptive for plans to bid low in the employer sponsored earlier so it results in higher payments for medicare.

we are looking at options for using market bids to set the payments for the employer-sponsored plans that would reduce the medicare outlay. >> thank you. now recognize the gentlemen from illino illinois. >> thank you. a great hearing and it is important to remember the extenders and tide with the sgr. let me go, i have a chart with the budget number for, i think, 2012. just to keep the debate in perspective. if you look at the budget is

$251 billion for medicare and medicare is $466 billion. those are 2012 numbers. my first question is to glenn hackbarth and diane rowland, we don't move any of the extenders and they lapse. what happens to the solvency debate. how much does it improve the program? >> i don't have the total spending impact of all of the various temporary provisions. we could get you that number. >> but you understand where i am headed with the question.

i am going to go back -- do you have a response? >> we have the congressional budget office is estimating making the assistance provision would save medicare spending dollar. >> in the billions, hundred billions. >> in the 1-5 billion. >> the point is these programs, and week debate the relevancy -- we can -- mand tory spending is required. >> they are not large relative to these numbers. another reference point, though, is how do they compare to the cost of repealing sgr?

how much do they add to the challenge of financing the repeal. that is a number where they look more significant. >> obviously proportional. >> these are prepared to total medicare spending. the overall debate, if we don't get a hand on the mand tory spending programs we will continue to have budget fights because the readid areas will

continue to grow. we are unwilling to make those tough choices to have a medicare program that is there for future generation. and i fear for the future. that is just the macro-debate. real numbers matter and this is giving me the opportunity to put them on the board. for our children, and our children's children and who is subsidizing our debt? foreign countries. and i represent about a third of the state of illinois, 33 countries, i would hope in the evaluations we understand distances and the importance of rural health care providers. in essence, the medicare dependent hospitals and the low volume hospitals understand the

reforms. but the importance for rural america is there is no place else to go. if they don't have the volumes to justify the existence we need to figure out how to make sure those doors stay open. >> we agree that we need to preserve access for medicare beneficiaries that live in rural areas. we need to target the assistance to the isolated areas. if we target it well, we can provide more effective assistance than if we spread the dollars loosely. >> if i could make this final statement, it sent a question,

but your the one that raised the ground extenders programs and there has to be a timeframe we can get the real data before we cut it off. >> now recognizing mr. dingell for five minutes of question. >> good morning, mr. chairman. thank you for your courtesy and holding this meeting today. it is very important. i want to thank the panel members for being here. i am not going to be asking questions because i want to make a few observations about needing to get this over the finish line. without it the whole problems of medicare and our taking care of

it and making the affordable care act is going to suffer as will the people. ... to move the alternative payment models forwarded in the long-term. it's really a shame that we weren't able to put this in. because of budget matters

without having to address the question of how we're going pay for it. because it solves the problem that was created by some very unwise actions as a congress. the legislation is going to make a significant contribution to the change. in our efforts to provide health care for our people. and reward doctors for their performance rather than for the quantity of the work and take steps away from the fee-for-service system parts which are so badly broken. the three bills passed by which committee, the ways & means committee, the center for finance committee, can be reconciled since the president's desk before march 31 deadline. there are still hurdles to be overcome. i want to commend the members of the committee, the leadership of the committee, and other committees in the house and

senate. because the leadership, which they gave in this matter and for the vision and for the hard work and for the decency with which they worked. this hearing is an important contribution to resolving the problem. and i want do you take my accommodations, mr. chairman, for your part. i want to observe it would be a terrible calamity if we don't carry this thing across the finish line. i want to make it very clear that medicare beneficiaries should not have their benefits reduced or cost increase to pay for the reform of sgr. both sides must be willing to comprise in all persons must understand that the resolution of this problem will probably not be perfect from anybody's view. but at least if we will make

progress and get rid of something that is causing vast difficulty in achieving our purposes. so our goals must be responsible comprise. formula patches are the focus of today's hearing. you have been perceptive in doing that, mr. president. -- mr. chairman. i thank you. i'm please that the committee included many of these critical extenders in their program sgr bill. in the extenders provide benefits to americans across the country. especially medicare and medicaid ben beneficiaries. people who have great need of these things. we must not forget about these

critical programs as congress moves forward with sgr reform. specifically the qualifying individual program. transitional medical and assistance express lane eligibility. and opponents famous programs must not be allowed to expire. it should be extended as part of the long-term sgr bill. congress should consider extending many of these programs on a permanent basis given the proven track record and the fact that the annual sgr batch will not be available in the future. further more, i hope the congress will consider reinstating section 508 expired in 2012. i believe that the medicare primary care program. in closing i hope we can build on the momentum we generated last year.

i look forward to continue working with you and all of my colleagues and the leadership on on the committee and the leadership in the house and senate. to get this bill to the president's desk before the march 31 dlt. mr. chairman, -- we have taken major steps to solve a terrible problem which has been inhibiting responsible consideration for the american people. >> thank you for the express.

i share those with you. the chair recognizes the gentleman from pennsylvania. dr. murphy five minutes for question. >> thank you. , mr. chairman. i thank the panel here. a number of you talk abouted a number of things with quality and that is the quantity and value of great concern to all of us. i want to -- deal with some of the measures. for example, reports have come out for medicare about readmission rates with heart attack, that mown ya. i don't do we look at readmission rates? on the medicare level when people have a chronic illness we know a small portion of folks on medicare make up a large portion of the cost particularly those with chronic illness. i think 90% of the cost is

chronic illness. when you have a lot of chronic illness you have 50% higher rate of depression. you have untreated depression and chronic illness you double the cost. along those lines they recommended payment. under the criteria recommendations, a facility with fewer 100 beds and approximately 60% of danger on medicare qualify for medicare dependentened hospital payments program. >> mr. murphy, we think that the medicare dependent hospital program suffers from some of the issues that i referred to earlier. for example, it is not targeted at isolated hospitals. and so a medicare dependent hospital can receive these

higher payments, the subsidies, if you will. even when it's close in proximity. >> i think some are in danger of being changed. one of my concern with medicare how does not pay for coordinated care. for example, southwest regional medical center in green county, pennsylvania. used the medicare dependent hospital funding to provide case management services for patients upon danger. so if you torp eliminate the payments, could not lead -- following danger orders? >> well, we absolutely share your concern about better care for complicated patients. many of whom have multiple assumes responsibility for a

full range of conditions -- way outside the 25 mile boin drink. what i look at is happening they talked about 500 patients in the state of maryland with strisk problems. i account for $36.9 million a year with regard to -- psychosis and have occurring symptoms which means they are not aware they have a problem. but also occurs in stroke victims who may have a right sided problem in a stroke. if the left side doesn't know they don't know it doesn't work. they may not realize the hallucinations are not real. what happens when they are dangered from the hospital they stop taking medication. it is essential in these cases there is someone who is working

with them. so i'm -- now that's in baltimore. the example i'm giving is hospital in a rural area. i want to make sure we have mechanism in place to look at coordinated care. the reason for that so long as we use measures such as readmission -- it can't be the criteria. it's a symptom of the disorder. we're not maintaining that coordination. so what advice do we go with this and improving this? >> again, i think the clinical problem that you're raising is a really important one. not just for the individual patient but for the program. our goal is to address the needs of the patient in the most effective way possible. we don't think that poorly targeted subsidies. if we have finite amount of

money to spend, which we do, we need to be very careful. so one thing that has been done recently in the post dischallenge care. that's a much more targeted response to the clinical problem as opposed to paying more for medicaid dependent hospital. >>let don't work on that together. >> the chair thanks the gentleman and recognizes the gentlelady from california. >> thank you, mr. chairman. thank you, witnesses for your testimony today.

i can start with the program as i mentioned that the programs built on decades of evidence on the effectivenesses and. it's two thirds of all the communities identified by the state to be in the highest for average control and help outcome

in the country. >> let me turn to you for one of the other praments, if you would. >> we mostly looked at way in which medicaid care can be coordinated and look at the fact that case management and -- especially for coordinating the care for people with behavioral and -- >> okay. >> okay. dr. lew was a long time visiting nurse. i know, the firsthand how it can be have pregnant women children and family helping them be healthy. make healthy choices. i'm referring to a program in my district the department of health delivers nurse family partnership model which is shown long-term improvement in child health and educational achievement as well as family economic self-efficiency.

what is at stake in the program is not continued? >> well, if the program is not continued, families will be losing service that improvement to improve the health outcomes and all the positive nemesis on positive parenting, children's cognitive socially emotional and language development as well as school readiness. also, the investments that states and communities have made

. the statute require medically accurate information. the prep ram also requires that services be evidence-based or substantially incorporate elements of evidence base programs. the it doesn't have a requirement. we have encouraged them to use evidence-based approaches. as i noted, there are evidence-based model for a range of approaches in teen pregnancy prevention including both comprehensive sex education and

ab stance education. >> thank you. i was involved with that for teen parents when i was in my community as a school nurse. >> i was 15 minutes ahead. anyway. oh my gosh. can i --

miami chair -- madam chair, can i defer and come back. i was thinking i had two more people ahead of me. >> that would be fine. want gentleman yield back for a later time. mr. griffith from virginia. five minutes. >> thank you. i appreciate that. as we prepare to permanently replace the sgr. we've talked about these previously in testimony today. the medicare dependent hospital and low volume which are critical in southwest virginia. if these programs are not extended va hospitals in total will lose about $10 million. most of the hospitals that qualify are in my district. and about $10 million in medicare reimbursement next year. a time being hit hard by new costs. deep cuts to medicare and other programs. and economic crisis, which is exacerbated by the

administration new regulations and many of us refer to on the casualty on the war. the combination of factors resulted in one of my rural hospitals closing in lee county. at least eight of the remaining hospitals in my district benefit from these two essential programs. they keep the doors open that pivotal to vie tam access to care. i have smith county, russell county, lonesome pine hospital. go see the movie. mountain view in norton,.

>> i'll have to check this, mr. griffith. i'm pretty sure it is road miles, and my recollection is that the regulations take in to account unique conditions like mountains and difficulties in certain time of the year. but i'll verify that. >> i appreciate that. oftentimes we see that in the area people say there's still no pharmacy just done the road. if one closes. >> well, coming from a mountainous area. >> it may be down the road but not easy to get to.

i can't address the circumstances of your district. i don't know if. but again our emphasis is on maintaining access for beneficiaries in remote areas. i think we're in complete agreement on that. and what we want to do what we urge the congress do is with that goal in mind focus the subsidies on institutions that are truly necessary to provide. right now we're concerned some of the provisions including the medicare dependent hospitals and the low volume adjustment are not well targeted. and i would emphasize, again, in particular the low volume adjustment is problematic. even if you accept the premise, which we do, that there are economies of scale in the

hospital business in small institutions may have difficulty keeping their cost down. the right measure of that is not just medicare dangers. it's the total danger. the adjustment is based on medicare discharge alone. so a hospital that has relatively few medicare discharge can get a big adjustment. wraz a smaller institution with an economic problem don't get their adjustment because it's a different mix of public and medicare discharges. that's not fair.

i don't want to lose anymore hospitals. the parent company of two the eight i mentioned as announced today they're looking for new ways to do things in the future and may be seeking out a strategic partner because they're having some difficulties dealing with the new environment we're in, with the new laws passed in health care. with the economic situation, and southwest virginia and east tennessee, and with lots of other things that are putting pressure on the hospitals and so anything that we can do as we find a better formula that is great. i just don't want to see us taking away one of the items that is helping these hospitals survive in the small communities. >> if i can make a suggestion, the low volume adjustment we're

discussing today is a temporary provision. there is a permanent low volume adjustment that already exists. we believe it's structured in a they is much better targeted and that's the foundation build on for the committee. >> i thank you. i yield back. >> the gentleman's time is expired. the chair recognizes mr. greene from texas. >> thank you, ma'am chairman. i appreciate our panel being here. i know, i worked worked with them on the commonwealth retreat you do every year. i would encourage my colleagues to consider that. it's at the end of february. it's not south of florida this here. it is in houston, texas. you will hear it's bipartisan, bicommittee. because we typically, in our committee, don't deal with ways & means or and work force. you have different members and question come and problem solve

in an informal setting. the affordable care act takes a number of important steps and broad access to health care. especially for people working in -- employer-response insurance. i want to followup on my -- transitional medical assistance. it's due to a small change in income and switched from medicare to being eligible for now subsidized coverage in exchanges. switching back and forth between insurance coverage can mean a change in benefits, participating providers, and out of pocket expenses. not to mention, the administrative paperwork for the state or insurance company or doctor's office. one of the programs to help reduce it is the transitional medical assistance. and as i understand it, they

recommended congress make it permanent in part of the because of the churn factor. can you elaborate? and i know i want to address this issues. is that the reason because the recommendation for it? >> well, we have tried to look at how to make transitions between coverage smoother and more streamlined. one of the ways clearly is to help the lowest income beneficiaries qualified for the 1931 provisions, which are the old welfare related categories.

could use transitional assistance. we believe it is critical in the states that have not extended coverage to keep people from going to uninsurance from one dollar up increase income. in the states that have elected to go forward with the expansion. the expansion will provide for a way to transition from medicaid coverage on the income side to enter the exchange or the new medicaid coverage options.

that's an issue we will be looking at in the future as well. >> i know one of the concerns a 12-month continuous eligible to make sure there's no a gap in coverage. and i know in states like texas who has a six months for medicaid but the congressman barton and i have legislation to make sure that continuous coverage would be 12 months. if you have people that are -- not coming in every six months and particularly if they're ill they have the lapse and coverage and cause more than having a continue use coverage. the medicaid primary care vote helps ensure that sufficient access to medicaid providers is enroll increases. the aca requires state to rise the medicaid feeds to medicare

levels at least are -- peed tries for primary care. can you comment on the lack of parents between the medicare and medicaid provider rates on participation paption. i know, particularly because in texas tricare spays the lowst. private sector pays more. but to have that medicaid and medicare would help us have more physicians accept more medicaid patients, i think. >> one of the thing the commission looked at in fact what are the incentives for them to participate in the medicaid program. what are the barriers.

we need to understand more about the payment levels wrch managed care plans. we pleaf that the primary care -- improving access to primary care is of course a critical part of the medicaid program. and one that it's very important to make sure we get full participation there. but the -- gentleman's time is expired. thank you. i know, we ran over time. i appreciate the committee having the hearing today. hopefully we'll come back and visit it again. >> thank you. i now -- the chair recognizes for five minutes. >> thank you very much. i would like to thangt witnesses. one famous person once said nothing more permanent than a temporary federal government program. i think probably president reagan. but it could have been my good friend dingell. i liked what he said this morning in regard to sgr in the

bipartisanship and all the work that is gone in to that. we continue to push try to get it across the finish line. in the next couple of months. i agree with him 99% of the time. i'm not sure i agree completely with his remarks. don't leave the extenders behind. as i saying, nothing more permanent than a temporary federal government program. our constituents need to realize that one of the most important things duo other than passing legislation is oversight of current legislation. and temporary programs and indeed maybe even all programs. it probably should be looked at every fen years. every five years and say, hey, you know, we need to continue to do this. is it serving its purpose? or the times in this program even if it was permanent. but certainly on these temporary programs like these extenders i

think we need to look at lot of them and question whether or not we need to go forward. let me then direct my question in the medicare balance -- it serves the med availabilitied in the medicare program. what have you ?ownd for instance, have you found growth in the number of providers or has it been a decrease or to put another way, has it been any evidence of -- of service inadequate sei in regard to the blanks program. >> yes. we found no evidence of inadequate service. we found on the contrary evidence of growth and service both in term of the number of trips paid for. but also significant new entrants. a lot of private capital.

some big private equity firms buying in to the blanks business. this is one area where we not have smart money is buying to an area. >> so are you getting some ominous signal in regard to that. i want to draw your attention to the blanks extend the title. temporary increase for ground balance services under the social security act. my office has been approach bid a ?urm of constituencies who want to make this extend permanent. my staff confirms for me this provision and the spending was never, never intended to be made inerm innocent. can you tell me, if congress intended to be a temporary

provision. do you believe it making the policy program? >> urban and rural blanks providers? >> that is a temporary provision . as being targeted at nonemergency blanks transport. >> yeah but, you know, urban transport accounting book 76% and increasing share of claims and nonemergency blanks transport. most common in the urban areas.

>> thank you for the yielding. since the time is so short. ly say reliable blanks services are very important to our district. we have watched very closely that the add on payments. we think they are necessary for rural districts like mine. and the low volume hospital adjustment is something for the rural hospitals we are concerned about. those are things that in my district would like to see those made permanent. with that i yield back to the again lman from georgia. >> the gentleman yield back. the chair recognizes doctor.

>> thank you. thank you for being here with us this morning to discuss these important extenders. i want to follow up on congressman green's questioning about the primary care bonus. the aca payment for primary care services for two years so it equal the medicare payment rate. i think it's an important step. i believe it's something worth continuing to the future. dr. robert byrd land, the commission doesn't have a recommendation yet on this policy. and i know there's some concern that it has been difficult to set up the payment changes especially for policy. which at the moment at least is only short term. and to me this further illustrates why important policy like the primary care bonus shouldn't be temporary. it should be permanent. can you comment how the short term nature of sub policy can

cause a disincentive? >> well, clearly the two-year period for the bump up in primary care payment is an important test of what the increase in payments will do to access to care. that is something that it's too early to evaluate. but also they what we know from program it is takes time to change incentive. and so the short two-year period may not have given enough incentive to many of the positions to participate knowing that it may expire after two years. i think it's important to both look at what the effect of it has been. there's been some concern within the commission about rather that payment bump limited to primary care physicians is really getting at some of the other gaps in participation. especially among specialty care and especially among mental health behavioral health people. >> i would share that consent.

as you said, it's early to really evaluate what impact bonuses have had on access to care. and i'm worried that some people would argue that we need more data besides we go forward with continuing the policy. which might set up a catch-22. because under current law, the policy will end before we might have adequate data. given what we know about underpayment and medicaid, it would seem highly unlikely that payment party would cause a decrease in access or beneficiary harm. clearly we need to look at what the effect has been. we know that medicaid payment levels have been extremely low in many areas. and the increase is likely to be one that will continue to be there for physicians that attract them. we need to look at the availability of primary care services and how to boost that

as we try to decrease the use of emergency rooms. >> sure. dr. gold stein, as we know, disparities that exist in different teen population groups for sexually transmitted diseases and teen pregnancy. we're pleased that under prep there's a focus on the vulnerable populations to reduce the incident of pregnancy and the sti. could you comment on the kinds of populations of prioritizes and within that what populations of states chosen to target. >> the most common is used in high-risk areas that have above average rates of teen birth or sexually transmitted infections. some states are focusing on specific vulnerable populations such as his hispanic youth, youth in foster care, and the

juvenile justice system. >> okay. and i believe that's a small portion of funding to implement and evaluate innovative strait ghoird to extend the menu or marginalized young people. ma is the process for evaluating these emerging strategies and the associated time line for findings? >> all of the grantees in the innovative strategies program are being evaluated. a few are included in a federal evaluation project and reports are expected in 2016. the rest of the grantees are conducting their own evaluations. hhs is providing technical assistance to ensure the evaluations are rigorous. the evaluations are designed to meet the hhs evidence standards. so when they are finished the result can be reviewed for evidence of effectivenesses. we expect the grantee's evaluation will have impact in 2016 as well. >> thank you.

>> i yield back. >> the gentlelady yields back. >> thank you. just to followup briefly on what mr. waxman said, in fairness, the cut to the program only 4% of them have been implemented so far. this is not a question. t a statement. i gather the demonstration project, which gao criticized the kind of worth of. nonetheless have mitigated the cuts up to now and they actually don't begin to be implemented until substantially this year. and by 2019 there's estimates of decreased enrollment in plans because of this. it's not a question per se. it's a kind of useful correction to mr. waxman's misleading. as regards the fully integrated

-- you make the recommendation that we continue all the programs. is that a fair statement? >> no. we recommend continuation of the fully integrated. those a that assume clinical and financial responsibility. >> so there are two-rided risk they would be allowed to continue? >> well, all medicare advantage plans -- are two sided. tell me when you say fully financially integrated. what do you mean? >> they assume under a global payment responsibility for providing all the covered services. >> that would be from what we said it would be all of those plans; correct? >> -- in the medicare advantage? >> yes. by definition assuming financial risk. the issue on it is to the assume responsibility for both medicare and medicaid benefits. >> correct. and what we see is evidence that

organizations that assume responsibility for both types of benefits actually can improve care and costs. if those two are separate -- >> i see. when you say integration you mean between medicaid and medicare. >> exactly. i agree with nap i think that's a positive policy. let me move to the balances. my colleague have addressed this. why toured one blanks service . they give them sugar of some sort. they wake them up. they don't transport them. they leave them there. that actually providing some basic services and saving money on the er visit, if you will. have you been to be look globally if it is true.

and does it decrease the part a amount, for example. >> yeah. i don't know about the specific example you have described. my understanding of the medicare pam rules for ambulance is medicare only pays if the patient is transported. so in the example you describe, if ambulance goes out and doesn't -- then i don't think it is covered under the ambulance policy at all. >> got you. when you mention the difference between certain geographic locations as regard the frequency of transport for things like -- absolutely. it seem like it would be variable upon poverty rates, upon degree of ma penetration that might provide services. >> i'm sure there a lot of factors that go in to this. but the variation is very -- >> can we understand that unless we do some sort of statistical analysis correcting for rate of poverty, for example.

>> well, we have not tried to do any sort of multivariate analysis of the variation. but i would be surprised if poverty alone explained the sort of variation we're talking about. we're talking about, you know, 20 -- 30 fold variation across states. >> i'll just say coming from a state in which there's high level of poverty among some of the poorest reinks in the country and in louisiana, i can understand how your rate of poverty may be 30 fold real toif a suburb in new jersey. >> i'm inte greeted -- inte degreed i know you reference that in your testimony. can you give any preliminary result as to aggravating what is the result in term of aggravating payment in term of coordination of care.

clearly there are efforts at the state level to try to integrate medicate services with the medicare we have. the financial demonstrations that are out in the field. there's no result back from this. most are in the process of being launched. what we've been looking at is how do you provide for better coordination as care. and as he noted there are some evidence that when a plan integrates both of the services that they're more to be maintain them. we're particularly concerned about how to merge the behavioral health aspect together with the medical care in plans. and have been looking not so much just at the dual eligible population, but at medicare's responsibility for people with disability. which includes many individuals -- >> if you have preliminary data i would love it if you share it with us.

>> we will after you have. it thank you for holding this hearing. i think we all wants to have a permanent fix to the sgr issue. and our committee passed out a bill last year. we've had ways & means and senate finance look at this in the legislation. i think we all desire the outcome. it's important having of hearing. we have to figure out how we're going handle all of these extenders have been associated with the temporary one-time fixes. 123-month advances, six month advances. sgr we had the extenders. what are we going to do if we don't have the regular process on sgr anymore. i applaud the committee for holding the hearing today. i've heard about the concern about specific program in a world where the sgr issue has been permanently fixed. and i want to say i'm going keep

my comments brief. i don't have any questions. i'll raise a couple of quick issues and yield back after that. i think there are a number of these extenders that have been traditional attached, as i said to the sgr patch. we talk about how important they are. what we do to fix them. critical programs like the special diabetes program which is wide spread -- or the infant and early childhood and home visiting program. which we heard about vertical earlying in the hearing. i think those a couple of examples of many of the programs which work to save money to provide -- they remove potential cuts to providers. they're going to maintain better access for beneficiary and provide important services to certain at risk populations response i'm glad we're going through regular order, mr.

chairman. i applaud you for holding the hearing. i appreciate our panel coming here today. i look forward to the work on the extenders. i yield back my time. >> the chair thanks the gentleman. and unanimous consent we could like to enter a record a at the same time by the rural hospital coalition. without objection. so ordered. the chair recognizes the gentlelady for five minutes. >> thank you. thank you to our panel today. this very important issue regarding sgr. doctor, i have a question in relation to some of the situations with the 2014 standoff changes that are coming with the position fee schedule. june 2013 the report reported to congress, quote, it's the same service safely provided in a sircht setting approve purchaser should not pay for more for that service in one setting than in another. and then it goes on to discuss some of the payment variations.

in the tbowrt medicare fee schedule, it seems to be doing the exact opposite. can you expand on that? and explain the thinking behind that? >> is there a particular example in the cms proposed rule? >> i'm particularly concerned with oncologist services. but certainly any of the outpatient services that can be provided in a hospital or outside of in an outpatient setting care. >> yeah. so you correctly stated we shouldn't pay higher rates for hospitals if the same service can be safely provided and lower cost settings. we are in the process of making recommendations to the congress to move medicare policy in that direction. we made a recommendation about

evaluation and management services a couple of years ago. at this upcoming meeting next week, we're looking at an additional batch of services. many cardiologist services, for example. cms doesn't always agree with our perspective on issues inspect is an example where i think there are some differences of p.r.n. >> okay. i cited oncologist services and some of the outpatient. i'm also concerned about reimburstment for some of the medicare therapy services. now earlier i crossed it aoff my list. what we've recommended on outpatient therapy, we don't

believe there should be hard caps imposed on therapy services. >> that said, we think that after some point additional services should be subject to review before they occur. which approach very similar to what private insurers typically use on outpatient therapy. >> and just lastly, and this is more of a comment and a question for you as well. you know, i continue to be concerned about the physician reimbursement in relation to part b payments through the hospital or part payments through hospitals with the upcoming change. i'm afraid with the trend that is moving forward it's going to affect those viability of medicare to our seniors. and i just want to get your reassurance, if you can dmoit continue to work with my office on making sure that med pack, we

work in conjunction to make sure that reimbursement is -- >> we are. >> thank you, sir. i yield back the minored of my time. >> recognize the gentlelady from florida. >> thank you, mr. chairman. i would like to thank you for organizing this hearing today. i would like to thank all of our witnesses for your service and attention to the health and well being of america's families. and to our ability to provide health service and the most efficient manner. i think most people understand that children have a better chance of success in life if they are health and have consistent access to a pediatrician in the doctor's office and the important checkups. and health services provided under medicaid have been understoodment tal to insure that millions of america's children do get those vision tests, the wellness checkup,

immunization in a consistent fashion. whether they are growing up healthy or they have certain special needs. i want to make sure everyone is aware in the congress we have active children health care cost. i co-chair the children's health care caucus with my republican colleagues, representative reichert of washington. and with the help of the children's hospital association first focus the american academy of pediatrician and others over the past two years we've had educational sessions on medicaid for members and for professional staffers here on capitol hill. i wanted to extend the invitation to all of my colleagues and everyone in attendance today to attend those sessions. we get in to a lot of detail we're discussing here today. a number of members have brought up the issue of access to

medicaid. we know that over time there's been a real problem with enough providers to serve the population. one good thing congress did a couple of years ago to bump up the medicare reimbursement to doctors. implementation didn't go as quickly as we wanted it to for primary care providers. fortunately we finally hhs finally finished that. we were able to include pediatrician and peed rick specialist. i think is important children's health care. but doctor, what can you tell us the status of implementation across the board now that hhs has that complete have states been able to implement it? >> well, we think that most states have been moving forward with implementing it. the commission is in the process of obviously looking what the can be learned from the state experiences. and going tout reinterview some of the states we talked to earlier about how implementation

has been proceeding. unfortunately, as data is always a delayed beyond where we would like it to be. there isn't any specific data yet on what the impact has been on changes in terms of participation and positions in the program. the one issue that the commission; however, has discussed and raised is rather that provision needs to also be broadened to other providers who help provide those primary care services. and do not fall within the definition in the statute. and especially the look at some of the specialists that are so important especially to some of the -- [inaudible] we should extend it at least now in based upon your data and recommendations go farther to make sure that people are getting the care they need under medicare. and we all have a goal of improvementing the overall efficiency of medicare and the

children's health insurance program. one tool states have to assist them toward the goal is the express lane eligibility. this efficiency simplifies and streamline the application and renewal process by allowing states to use eligibility information obtained from other income checks like the school lunch program or s.n.a.p. and we all get annoyed when government or you got doctor's office and they are asking you to fill out paperwork again and again. the same information and the express lane eligibility help reduces that duplicative paperwork. i understand 13 states have proven to be real leaders in cutting paperwork and we're able in doing that to reach thousand of more children and make sure they can get to the doctor's office. this sounds very promising, but 13 is still pretty low. could you i know the commission has not formally opined on express lane eligibility.

there's promising evidence. can you tell us in term of increasing enrollment as well as reducing state administrative costs. how effective the express lane eligibility has been? >> from what we can learn so far, it has been an effective way of shifting freedom one program eligibility determination process in to the medicaid program itself. so it has boosted enrollment in those states. now being looked at for adult el jiblght in two states to see under the waiver that have been granted through the aca. they can facility getting parents in to coverage as well. i think that the more we can simplify and streamline our eligibility process use electronic transfers to get more people covered without strog go through, as you said reapplying, reapplying, better off beneficiaries will be as well as the state that try to administrate the programs. >> thank you very much. >> recognize the jebt gentleman

from florida. thank you for holding the hearing. thank you for -- i want to thank the panel for their testimony as well. the march 2013 report included rights to -- integrated dual eligibility el special special needs plan that include the fully integrated dual eligible and the second model, one manage care organization administrates a medicaid plan and dual eligible special needs plan. the same dual eligible ben fish rare areas are enrolled in both. manage care organization across the two plans. questions, why is it important we retain this model in addition to the it? and can you tell us about the benefit of this model and why med pack included a more broad

definition of integration? >> well, the ultimate goal, as you say, is to get somebody to assume the responsibility for integrating medicare/medicaid financially and clinically. we allowed different paths to that. because there are various type of issues that arrive at the state level that may not make the fully integrated, single man model work in every state. plans approached us and said that this dual plan model with the same beneficiary is both in the medicare and the medicaid plan. they do the integration. ..

>> i think that is very important. thank you, mr. chairman. two the chair thanks the gentleman and we now recognize the gentleman from virginia, mr. griffith. >> thank you, mr. chairman. i