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Hearing on Examining Traditional Medicare’s Benefit Design

February 26, 2013

Hearing on Examining Traditional Medicare’s Benefit Design










February 26, 2013


Printed for the use of the Committee on Ways and Means

DAVE CAMP, Michigan,Chairman

PAUL RYAN, Wisconsin
DEVIN NUNES, California
JIM GERLACH, Pennsylvania
TOM PRICE, Georgia
DIANE BLACK, Tennessee
TOM REED, New York
MIKE KELLY, Pennsylvania

RICHARD E. NEAL, Massachusetts
JOHN B. LARSON, Connecticut
RON KIND, Wisconsin

JENNIFER M. SAFAVIAN,Staff Director and General Counsel
JANICE MAYS,Minority Chief Counsel

KEVIN BRADY, Texas, Chairman

PAUL RYAN, Wisconsin
DEVIN NUNES, California
JIM GERLACH, Pennsylvania
TOM PRICE, Georgia

RON KIND, Wisconsin







Glen M. Hackbarth
Chairman, Medicare Payment Advisory Commission

A. Mark Fendrick, M.D.
Director, University of Michigan Center for Value-Based Insurance Design

Tricia Neuman
Senior Vice President and Director, Kaiser Program on Medicare  Policy, Kaiser Family Foundation


Hearing on Examining Traditional Medicare’s Benefit Design

Tuesday, February 26, 2013
U.S. House of Representatives, 
Committee on Ways and Means, 
Washington, D.C. 


The subcommittee met, pursuant to call, at 10:26 a.m., in Room 1100, Longworth House Office Building, Hon. Kevin Brady [chairman of the subcommittee] presiding.

[The advisory of the hearing follows:]


Chairman Brady. The subcommittee will come to order.  Welcome to the first hearing of the Health Subcommittee for the 113th Congress.  Today we will review the outdated and confusing benefit design of the traditional Medicare program, the structure of which is essentially unchanged from its inception in 1965 it  maintain separate programs and benefits for hospital and physician services, and doesn’t coordinate care between the two. 

Because of the outdated structure of the Medicare benefit, today’s beneficiaries are inundated with an array of confusing deductibles, coinsurance and copayments with no protection from high healthcare costs unless they enroll in a private plan.  As a result, over 90 percent of seniors must obtain some type of supplemental coverage, whether a purchase on their own, through an employer or from Medicaid. 

Despite vast improvements and innovations in the healthcare sector that have transformed how care is delivered, Medicare has lumbered through the past half century on the same trajectory. Can you imagine a world where someone has to buy hospital and nursing home coverage from one insurance company, physician office coverage from another insurance company, prescription drug coverage from yet another company, and likely supplemental coverage from a fourth insurance company?  Yet this is exactly how the current Medicare benefit is designed.  No private insurance company in its right mind would design and offer a benefit that looks like this. And given a choice, most seniors wouldn’t accept it. 

The need to reform the outdated Medicare benefit is long overdue.  I appreciate the work of the nonpartisan Medicare Payment Advisory Commission and bipartisan groups like the Bowles‑Simpson Commission and Bipartisan Policy Center to further this issue.  Their effort to dig into this complicated topic and advance long-overdue reform has been critical. 

Updating the Medicare benefit design will bring the program into the 21st century and meet the needs of current and future seniors.  It will bring the traditional Medicare benefit in line with the types of benefits and cost sharing that one in four beneficiaries currently enjoy from Medicare Advantage plans.  These plans are able to offer predictable copayments versus coinsurance, protection against high out‑of‑pocket costs, and are often able to incentivize beneficiaries to receive care in high‑quality and efficient settings. 

However, as we will hear today, because of changes included in Obamacare and regulations developed by the Centers for Medicare and Medicaid Services, Medicare Advantage plans have fewer opportunities to design the benefit packages that beneficiaries want.  Instead of promoting this model, the President’s new healthcare law is pulling these plans and the 13 million beneficiaries enrolled in them back into the 1960s. 

For the sake of our seniors, we need to break down barriers and give these plans greater flexibility to continue to innovate and offer affordable coverage while improving patient outcomes.  This is something traditional Medicare has not been able to do.  Moving from Medicare’s half‑century old design to one that provides beneficiaries with rational cost sharing and protection from high healthcare costs will be challenging, but it is necessary.  Simply maintaining the current outdated, confusing and inefficient structure while the program remains on a quiet path to insolvency, is not the answer.  Instead we have to move forward to improve this critical program, providing greater protections for seniors and placing the program on sound financial footing. 

It is my hope that this hearing will be the start of efforts to work in a bipartisan fashion to modernize the Medicare program for all seniors and people with disabilities. 

Before I recognize Ranking Member McDermott for the purposes of an opening statement, I ask unanimous consent that all Members’ written statements be included in the record.  Without objection, so ordered. 

Chairman Brady.  I now recognize Ranking Member McDermott for his opening statement. 

Mr. McDermott.  Thank you, Mr. Chairman.  I look forward to this process.  And I was just sitting up here thinking that Mr. Johnson and I were the only two people who sit on this committee who remember the last time this committee tried to reform the benefit package.  That was 1988.  It was a catastrophic ‑‑ it was called the Medicare Catastrophic Coverage Act.  It had an outpatient prescription drug benefit and a cap on beneficiaries’ out‑of‑pocket costs.  And my first vote in the Congress in 1989 in this committee was to vote against the repeal of that change.  So I think that as we move forward into this area, we really ought to keep in mind what happened then. 

Republicans often assert that Medicare is outdated and needs reform, and I agree.  No social program could ever be designed that anticipates what is going to happen 50 years later, or 60 or 70 years later, but they ignore that substantial progress has already been made to strengthen the essential program. 

The ACA reduces Medicare spending, extends its solvency, and brings growth to per‑patient costs to record lows.  Preventive services are now free of charge to beneficiaries, and we finally have laid the groundwork to reward treatment value over volume. 

Yet further improvements are needed, but much of the current Republican proposal does more harm than good, in my view.  Benefit restructuring specifically to generate savings, whether in the name of deficit reduction, paying for other initiatives, or simply masquerading as reform, is bad policy and bad politics; 1989.  It may be tempting when running the numbers and calculating the averages, but it is all too easy to lose sight of the very real people whose lives and well‑being hang in the balance. 

For example, we long sought to add catastrophic coverage to Medicare, and I have talked about that.  If it is combined with a unified deductible to offset the change, it inevitably will mean raising the costs to roughly four out of five beneficiaries.  Moving to a combined deductible of $500 or more will triple the current Part B deductible.  A surprising number of beneficiaries have costs below $500 and so would pay monthly premiums for benefits they never use.  Meanwhile, the catastrophic cap almost certainly will be set at such a high level that it will benefit only a few, probably 5 percent or so, of the beneficiaries. 

These challenges become even more complicated if cost sharing is reconfigured by creating new copays or increasing coinsurance for current services like hospital visits and home health care.  And given the average beneficiary makes only about $22,500 and already spends disproportionately more on health care than a younger person, additional premium cost is done at some risk. 

At a minimum, benefit redesign would require a substantial expansion of the Medicare Savings Program to ensure affordability for low‑income Medicare patients.  And with all but 12 percent of Medicare participants receiving supplemental coverage that insulates them from potential changes, the question is, why do it?  The answer is because some want to prohibit or discourage first‑dollar coverage in supplemental plans. 

Then the tradeoffs get even more tricky.  Do you want to dictate terms of private insurance?  Do you instead penalize beneficiaries for choices they made in the free‑enterprise system?  Do you tell employers what retiree benefits they can or cannot offer?  What do you say to people who have already traded lower wages for better retiree coverage? 

Now, we are all searching for the ever‑elusive health policy holy grail that promotes value over volume and quality over quantity, but there isn’t a simple answer.  Our ability to reliably measure quality and value is in its infancy, and there is much work to be done.  Even with good information, purchasing health care is different from making other expenditures.  Few patients can shop around for bargains when their health is on the line, nor should we expect it of them. 

On a final note, I want to express my optimism that bipartisanship will enable the committee to move forward on the SGR reform.  We are all tired of doing the SGR patch.  The recent Republican outline leaves plenty of room for agreement if people want to find it.  If done smartly, this issue could reshape our entire health economy for the better, but costs can’t just be hoisted onto the backs of the beneficiaries.  There are better options with stronger policy justifications to pay for the needed SGR policy changes. 

With that, I look forward to discussing the many tradeoffs inherent in reconfiguring Medicare’s benefit package with today’s expert witnesses. 

Thank you, Mr. Chairman. 

Chairman Brady.  Great.  Thank you, sir. 

Chairman Brady.  Today we will hear from three witnesses:  Glenn Hackbarth, Chairman of the Medicare Payment Advisory Commission; Dr. Mark Fendrick, director of the Center for Value‑Based Insurance Design at the University of Michigan; and Tricia Neuman, senior vice president of the Kaiser Family Foundation and Director of the Foundation’s Program on Medicare Policy. 

Thank you all for being here today.  I look forward to your testimony.  You will be recognized for 5 minutes for the purposes of an opening statement. 

Mr. Hackbarth, we will begin with you.


Mr. Hackbarth.  Thank you, Chairman Brady, Ranking Member McDermott, and members of this Health Subcommittee.  It is a pleasure to be here to talk to you about the Medicare benefit design. 

Mr. McDermott, I am also one who has very sharp memories of catastrophic insurance.  In 1988, I was the Deputy Administrator of the Health Care Financing Administration, so I join you and Mr. Johnson in those recollections. 

The current Medicare benefit package is both inadequate and confusing.  It is inadequate because it lacks catastrophic coverage, one of the most important features of any insurance program, and it is confusing for all of the reasons that Mr. Brady mentioned in his opening statement; Part A and B, and various deductibles, and use of coinsurance instead of copayments.  Given that, it is not surprising that many Medicare beneficiaries, in fact the vast majority, want to have supplemental coverage to augment Medicare. 

MedPAC has recommended redesign of the Medicare benefit package using five principles as guideposts.  First of all, there should be no increase in average liability for Medicare beneficiaries.  We believe the existing Medicare benefit package is not too rich.  If anything, given the population served, it may be too lean, and so we recommend no reduction in the actuarial value of the benefit package. 

Second, we recommend that an out‑of‑pocket limit be added to the program, catastrophic coverage. 

Third, we recommend that design of the benefit be simplified so it is more readily understood and more predictable for Medicare beneficiaries. 

Fourth, we recommend that the Secretary of HHS be given broad authority to modify cost sharing, both reduce and increase cost sharing, based on the value of the services provided, and that assessment, of course, should be based on scientific evidence. 

And finally, we recommend a charge on supplemental insurance.  When a beneficiary buys supplemental insurance, that increases the cost of care incurred by the Medicare program.  The premium paid by the beneficiary only covers a fraction of that added cost.  We think it is appropriate for there to be a charge on that supplemental insurance to reflect, in effect, the implicit subsidy from the taxpayer for supplemental coverage. 

I want to emphasize that we do not recommend prohibiting various types of supplemental coverage.  If a beneficiary wishes to buy first‑dollar coverage, he or she should be able to do that, but they ought to face more of the added cost to the Medicare program resulting from that private choice. 

Whenever you talk about patient cost sharing, two types of concerns are raised.  In fact, during MedPAC’s discussion of this issue, we spent a lot of time on each of these questions.  The first concern is that cost sharing reduces the use of both appropriate and inappropriate services.  The evidence is pretty clear on that.  So if our supplemental charge were to cause Medicare beneficiaries to stop having first‑dollar coverage and face more cost sharing, there would be the risk that some appropriate services would be stopped as well as inappropriate services. 

The fear, of course, is that when that happens, two bad things can occur.  One is the total cost of care could increase.  If patients don’t get needed care, they could end up with hospitalizations that cost more.  In addition, they could end up with a worse outcome, which none of us want.  This is why it is so important to give the Secretary of HHS authority to modify copayments based on the value of the services provided.  If a service is shown to be a very high value for patients, we ought to seek to lower the cost sharing.  If the value is low, we ought to seek to increase the cost sharing. 

The second concern that is often raised when patient cost sharing is discussed is the effect on low‑income beneficiaries, and that would be true, of course, also with our charge on supplemental insurance.  If the concern is protection of low‑income beneficiaries, as well it might be, we think a targeted approach is preferable. 

For example, expansion of the Medicare Savings Program, the program for qualified Medicare beneficiaries that pays cost sharing for low‑income beneficiaries.  That sort of a targeted approach is preferable to this implicit subsidy that is offered for supplemental coverage that is available to beneficiaries of both low and high incomes.  So target our response to these problems. 

With that, Chairman Brady, I look forward to your questions. 

Chairman Brady.  All right.  Thank you, Mr. Hackbarth.

[The statement of Mr. Hackbarth follows:]

Chairman Brady.  Dr. Fendrick.

Dr. Fendrick.  Good morning, and thank you, Chairman Brady, Ranking Member McDermott and members of the subcommittee.  I am Mark Fendrick, a professor at the University of Michigan.  I address you today as a primary care physician, medical educator, and a public health professional. 

Mr. Chairman, I completely agree with your statement that the current structure of the Medicare benefit is outdated, confusing, and in need of reform.  Moving from a volume‑driven to a value‑based system requires both a change in how we pay for care, and how we engage consumers to seek care. 

With some notable exceptions, most U.S. health plans including Medicare implement cost sharing in a “one size fits all” way, in that beneficiaries are charged the same amount for every doctor visit, every diagnostic test and every prescription drug.  As Mr. Hackbarth just mentioned, asking Americans to pay more for all services results in decreases in both non-essential and essential care.  While this blunt approach may reduce short‑term expenditures, noncompliance with high‑value services often leads to adverse health outcomes and higher overall costs.  This is penny wise and pound foolish.  Conversely, asking Americans to pay less for all services can lead to the overuse of harmful services and those that provide little value.  The concept that medical services differ in the health benefits they produce is referred to as clinical nuance, and clinical nuance should be utilized in the reallocation of medical spending.

Mr. Chairman, does it make sense to you that my Medicare patients pay the same copayment for a life‑saving cancer drug as a drug that will make their toenail fungus go away?  Due to the lack of appropriate incentives, Medicare beneficiaries use too little high‑value care, and too much low‑value care.  It is common sense; when barriers to high‑value treatments is reduced and access to low‑value treatments are discouraged, we obtain more health for every dollar spent. 

Medicare is a key component to our Nation’s commitment to our elderly and disabled, and it must be sustained.  Even with the recent advantage regarding preventive services, as Mr. McDermott mentioned, traditional Medicare allows little flexibility to implement clinically driven benefits.  Specifically program administrators cannot lower cost‑sharing levels for services recommended in clinical guidelines, and they are also limited in the amount they can increase coinsurance rates for a harmful procedure. 

Since changes to traditional Medicare are difficult, an interim step could be to legislate changes to Medicare Advantage.  Today the tools available to MA are also blunt instruments.  Legislative and regulatory restrictions prevent clinical nuance in MA, including the lack of flexibility to steer patients to high‑performing providers in a very rigid benefit design. 

To this I recommend the following recommendations:  First, MA plans should have the flexibility to vary cost-sharing for a particular service according to where the service is provided and by whom.  The Commonwealth Fund recently estimated that nearly $200 billion in savings would accrue to Medicare over the next decade if we were to “develop a value‑based design that encourages Medicare beneficiaries to obtain care from high‑performing systems”.  Currently MA plans use provider networks, but they are limited in how they may vary cost-sharing within that network.  This restriction forces MA plans to either exclude low‑performing providers completely or permit complete access to them.  There is no intermediate step. 

Second, MA plans should have the flexibility to impose differential cost sharing based on evidence.  There are evidence‑based services that I beg my patients to do, such as critical treatments for asthma, diabetes, and depression.  There are also other services that are harmful or unnecessary, and according to the literature, these services account to nearly 20 percent of Medicare expenditures. 

Last, MA plans should have the flexibility to set enrollee cost sharing based on clinical information, such as diagnosis.  MA plans are currently constrained by non-discrimination rules that prohibit different benefits for targeted subgroups of beneficiaries.  Even though the clinical appropriateness of a specific service may vary widely among MA enrollees, cost sharing for any service must be the same for everyone.  The flexibility to enroll cost sharing based on scientific evidence and clinical information is a crucial element to the safe and efficient allocation of Medicare expenditures. 

So as you consider changes to Medicare benefits, it is my hope that you will take the commonsense step to allow MA plans to vary cost sharing on the amounts of health produced.  Despite the urgency to bend the cost curve, Congress should avoid blunt changes that reduce quality of care.  Using benefit design to encourage utilization of high‑value services and deter access to low‑value services can improve health, enhance personal responsibility, and reduce costs. 

I look forward to your questions. 

Chairman Brady.  Thank you, Doctor, very much. 

[The statement of Dr. Fendrick follows:]

Chairman Brady.  Ms. Neuman.

Ms. Neuman.  Thank you, Chairman Brady, Ranking Member McDermott, and distinguished members of the subcommittee.  I appreciate the opportunity to testify at a hearing examining the traditional Medicare benefit design. 

Since the 1970s, the idea of simplifying benefits under traditional Medicare has been under discussion, but proposed solutions have typically involved very difficult tradeoffs.  A change in the benefit design could streamline and simplify benefits, could provide greater financial protections to people with significant expenses, and minimize the need for supplemental insurance, but as structured to produce Medicare savings, such a change could also be expected to increase costs for the majority of beneficiaries. 

Medicare provides highly valued health insurance for 50 million people, Americans, many of whom have significant medical needs and modest incomes.  Four in ten have at least three chronic conditions; one in four has a mental or cognitive impairment; half live on an income of less than $23,000. 

As noted in your announcement for today’s hearing, Medicare has a complicated benefit structure.  It also has high cost‑sharing requirements and no limit on out‑of‑pocket spending for services covered under Parts A and B. 

As a result people on Medicare tend to have relatively high out‑of‑pocket costs, including cost‑sharing requirements for Medicare, but also premiums for Medicare, premiums for supplemental coverage and for uncovered services.  Health expenses now account for nearly 15 percent of Medicare household budgets.  On average that is three times the share for non‑Medicare households. 

Proposals to change the traditional Medicare benefits design can have different goals which have direct implications for beneficiaries and for program spending.  Proposals to change the benefit design could simplify benefits, encourage the use of highly valued services as you have just heard, improve benefits, or trim them back.  Achieving Medicare savings could be a high priority or not. 

Several recent proposals would simplify benefits, set a limit on cost‑sharing obligations, and also reduce Federal spending.  The Kaiser Family Foundation, with Actuarial Research Corporation researchers, examined an option to simplify the benefit design and achieve Medicare savings based on an approach specified by the Congressional Budget Office in their budget options report in 2011.  That option includes a $550 unified deductible for Parts A and B, a uniform 20 percent coinsurance, and a new $5,500 limit on cost sharing.  This approach would be expected to reduce spending for a very small share of the Medicare population, but generally people who are very sick with high costs. 

Five percent of beneficiaries in traditional Medicare are expected to have lower out‑of‑pocket costs than they would under current law, and they would receive substantial savings on average.  This would affect, for example, people with multiple inpatient stays, or a lot of postacute care, so it would be helped by the limit on out‑of‑pocket spending.  But most, and the analysis estimated 71 percent, would be expected to face higher costs.  So seniors in relatively good health who may go to the doctor or see a couple of specialists in a year would see their deductibles triple from current levels to $550.  And that illustrates the tradeoff. 

This particular benefit redesign could be modified in a number of ways.  Lowering the cost‑sharing limit would help more people, but could also lead to higher Medicare spending.  Raising the limit would help even fewer people and generate additional savings. 

Another modification also described by the Congressional Budget Office would include restrictions in supplemental coverage along with a benefit design.  It would prohibit Medigap from covering the unified deductible by limiting Medigap coverage beyond that point to a certain extent.  This approach would increase the Medicare savings, mainly because people who have Medigap would be expected to use fewer services when confronted with higher cost sharing.  Under this option nearly a quarter of people on Medicare would see costs decline, mainly due to lower Medigap premiums, but half would be expected to pay more; again, a difficult tradeoff. 

Another modification would incorporate stronger protections for low‑income beneficiaries in conjunction with a benefit design.  Such an approach would simplify the program for all beneficiaries, protect those with limited means, but could diminish Federal savings, if not result in higher Federal spending. 

Mr. Chairman, Medicare today enjoys strong support among seniors.  Finding an approach that will streamline benefits, encourage beneficiaries to use highly valued services, and provide greater protections to those with high out‑of‑pocket expenses, all without shifting undue costs onto beneficiaries, remains a challenge, particularly in a deficit‑reduction environment. 

And I thank you, and I look forward to working with you and answering your questions. 

Chairman Brady.  Great.  Thank you. 

[The statement of Ms. Neuman follows:]

Chairman Brady.  All three witnesses are very helpful. 

Mr. Hackbarth, for seniors listening today, besides just simplifying it and making it less confusing to handle all of the deductibles, copays, everything that goes with that, are the two biggest benefits to modernizing the design that, one, a cap on that out‑of‑pocket cost so that you sort of have that peace of mind that if you are one of those who hits the high‑cost health care, and many seniors do, you know you are limited to what damage that might do?  And secondly, looking at copays, which is a fixed dollar amount, versus coinsurance, again on that very expensive health care again, that too many seniors fear, for seniors are those the two biggest benefits of redesigning the system, and how many seniors will be impacted by that over their lifetime? 

Mr. Hackbarth.  Yes.  Chairman Brady, those are, I think, the two big benefits. 

With regard to how many people benefit from catastrophic coverage, it is important to look at that over time.  So in any given year, we estimate the number of beneficiaries that exceed $5,000 in out‑of‑pocket costs is about 6 percent.  But if you look at a 4‑year time horizon, that number doubles.  And obviously, over the duration in Medicare of the typical Medicare beneficiary, the percentage grows and grows over time.  So it is important to look at that value not 1 year at a time, but over the course of participation in Medicare. 

Chairman Brady.  Yeah.  And this is what I want to ask Ms. Neuman.  One, I appreciated reading your analysis and testimony.  Did you look at ‑‑ is your analysis done over the lifetime of a Medicare senior or someone on disabilities, again, who is likely to face higher costs over a lifetime? 

Ms. Neuman.  No.  We looked at a ‑‑ we did a 1‑year analysis of what the effects would be, and I don’t disagree with Mr. Hackbarth.  I think for a catastrophic benefit, there would certainly be more people who would benefit from a spending limit over time.  Whether they perceive their lifetime risk is a different question, but we did not look at that.  We looked at a single year. 

Chairman Brady.  Can you do that?  And here is why.  One, the analysis was very interesting to read, and helpful, but, looking at 1 year of Medicare is like looking at the cost of 1 year of auto insurance, the year you didn’t have an accident.  Yeah, the price looks pretty high, but spread over time, and the difference here being everyone is likely to get sick.  Many are likely to be seriously ill.  Most are going to drive up some pretty healthy costs.  So while on the front end there may be higher monthly premiums, deductibles, copays, over time that could be a significant savings for a senior.  And Kaiser Health Foundation has a great reputation.  Would you consider redoing that analysis and looking at it so we could look at a senior’s healthcare costs over a longer period? 

Ms. Neuman.  We would certainly be happy to take a look at that.

Chairman Brady.  That would be very helpful.  Thank you. 

And, Dr. Fendrick, I read your testimony, but it was in four‑point type, and so for us old geezers, you might consider making that a little bigger in the future, for those of us who are struggling to read these days. 

The design that both encourages the use of value‑based ‑‑ I mean, the services you really need to make sure a senior wouldn’t skip health care that they really need, how would you design ‑‑ as we simplify it and unify it, how would you design it to make sure that we are encouraging seniors into those essential value services?  What would be the key ingredient? 

Dr. Fendrick.  First off, I would make sure ‑‑

Chairman Brady.  Can you hit that microphone? 

Dr. Fendrick.  First thing I would recommend, no copayment for you to see your eye doctor so you could read my testimony. 

I think the nice thing about the three witnesses, we all agree that the discussion should go beyond how much we spend on Medicare, but instead how well.  In this concept of clinical nuances, you mentioned some good services which are highly recommended by professional societies, other organizations, are those that we would immediately identify and have already done in hundreds of organizations in the private sector to say these services are so important that patients should not pay a substantial out‑of‑pocket for them.  As Mr. McDermott mentioned, that is currently the case for preventive services in most public and private plans, and we are, in fact, trying to extend these services for common chronic diseases for doctor visits, diagnostic tests, and drugs that have been identified by professional societies as the things that should be performed.  And that would be the basic premise for us to move forward on the carrot side, or the high‑value side, of value‑based insurance design. 

Chairman Brady.  On a scale of 1 to 10, how difficult is it now that ‑‑ what we know today versus half a century ago? 

Dr. Fendrick.  Given that almost all of your expenditures in Medicare are in chronic diseases, and most of those chronic diseases can be lumped into about 14 of them, and the fact that there are guidelines that are evidence  based in most of those conditions, I would say that that is fairly straightforward. 

Chairman Brady.  All right. 

Well, thank you all very, very much.  This was helpful.

Dr. McDermott? 

Mr. McDermott.  Thank you, Mr. Chairman.  I don’t think ‑‑ there is general agreement across this dais, I am sure, on the need for catastrophic limit.  I don’t think that is the question.  The question really is, how do you pay for it?  Now, we tried once in 1989, and maybe we will do better this time, but that is really the issue here.  And, Mr. Hackbarth, I ‑‑ or Dr. Hackbarth, I guess. 

Mr. Hackbarth.  Mr. 

Mr. McDermott.  Mr., did MedPAC in their looking at this, at the redesign, expect any savings to come out of the redesign of the way the payment was made? 

Mr. Hackbarth.  From the redesign of the benefit package, no.  As I said in my comments, we think the existing benefit package is not too rich, and so we were looking at a restructuring of the benefit package while holding average beneficiary liability at the current level. 

Mr. McDermott.  If you shift the cost to beneficiaries, how does that get paid for? 

Mr. Hackbarth.  So the other major feature of our proposal was the charge on supplemental insurance.  And if you have a charge on supplemental insurance set at about 20 percent, then you generate additional revenues that can be used to either reduce federal spending or to cover additional benefits. 

Mr. McDermott.  What did you assume was too high a supplemental coverage when you put that 20 percent surcharge on? 

Mr. Hackbarth.  Well, we don’t say that you can’t have a particular type of supplemental coverage.

Mr. McDermott.  You could have it ‑‑

Mr. Hackbarth.  You could have it ‑‑

Mr. McDermott.  ‑‑ but if you have a certain income, you are going to pay a surcharge?  Is that the way it works out? 

Mr. Hackbarth.  Yeah.  What we modeled was everybody pays a surcharge under supplemental insurance.  Then there is the question if you want to provide adequate protection to low income beneficiaries, how do you do that?  Rather than having no surcharge, we think the way to do the low income protection is through something like the Qualified Medicare Beneficiary Program. 

Mr. McDermott.  I remember in the Simpson‑Bowles proposal, there was a lot of talk about this whole issue, and they said broad‑based entitlement reform should include protections for vulnerable population.  So I think it is generally accepted by everyone that whatever manipulation you do, you have to take care of the people at the bottom.  Is that fair to say? 

Mr. Hackbarth.  Yes.

Mr. McDermott.  And it is true that any proposal needs to be packaged with additional financial insurance ‑‑ assurance for those in need, including not just people at 135 percent of poverty, but up to 200.  Would you say? 

Mr. Hackbarth.  Well, we have not made any recommendations on exactly where to set that level.  Under the Qualified Medicare Beneficiary Program, the level is set at 100 percent of poverty level. 

Mr. McDermott.  Is that high enough? 

Mr. Hackbarth.  Again, if your goal is to protect low income beneficiaries, that number ought to be increased.  Now, we do have some additional Medicare savings programs that go a little bit higher, but they are focused on paying the part B premium as opposed to cost sharing at the point of service.

Mr. McDermott.  Ms. Neuman, you are probably aware of the National Association of Insurance Commissioners that reviewed the literature and produced a letter that says that they were unable to find evidence that cost sharing encouraged appropriate use of health care service.  Are you aware of that? 

Ms. Neuman.  Yes, I am.

Mr. McDermott.  I ask unanimous consent to have that letter put into the record, Mr. Chairman. 

Chairman Brady.  Without objection. 

[The letter follows:]

Mr. McDermott.  What does that mean in terms of using copays as a way of getting people to make decisions about their ‑‑ I mean, if you are in an automobile accident and the ambulance comes and picks you up, do you shop at that point for which emergency room to go to? 

Ms. Neuman.  Cost sharing can be a blunt instrument.  In some cases, for example, in the part B drug benefit, it is a little bit more straightforward with generics versus brand name drugs.  And even at the pharmacy, there is some ‑‑

Mr. McDermott.  I will give you drug benefit.  Now, tell me some ‑‑

Ms. Neuman.  But beyond that ‑‑

Mr. McDermott.  Give me some other area where people shop ‑‑

Ms. Neuman.  Beyond that point, this is where I was heading, it gets ‑‑

Mr. McDermott.  Do people shop for artificial knees? 

Ms. Neuman.  I don’t think so.

Mr. McDermott.  Well, I mean, one of my colleagues just had his knee replaced.  Do they go around and ask the doctor, how much do you charge and how much do you charge?  And I am going to take the cheaper one? 

Ms. Neuman.  It is generally very difficult for patients to do that, and often patients are motivated to do what their doctors tell them to do.  That is why a lot of the work that has been done has been focused more on the providers side to give providers information to drive people to more value‑based services, because in theory, the doctors have more information to sift together in order to advise their ‑‑ advise consumers, so they don’t use services that are not needed.

Mr. McDermott.  My point is, Mr. Chairman, patients don’t shop, they follow what doctors tell them to do. 

Chairman Brady.  Hence the problem.  Mr. Johnson, you are recognized. 

Mr. Johnson.  Thank you, Mr. Chairman.  I would like to follow up on his question, because you didn’t answer it.  If you break a leg or something and an ambulance comes, you don’t have a choice of where to go or what doctor to see, generally speaking.  They take you to the emergency room of some close hospital, or the county hospital if it happens to be close by.  So how do you explain fixing that charge in Medicare?  Any of you.  Hackbarth, you have addressed that before.

Mr. Hackbarth.  Yeah.  So I agree that when a person is in an automobile accident and they need to go to the emergency room, there is zero opportunity for shop, and nobody is thinking about which emergency room to go to and what the cost is.  But there are decisions that beneficiaries make where they do make a decision about whether cost matters or not.  For example, a decision about how many times to see a physician, or decisions about some tests.  You hear from physicians all the time about patients saying, well, you know, I want the extra test, I want to be really sure.  If there is some cost sharing on those decisions, patient decisions change, and so it is at that end of the spectrum, not the catastrophic illness end. We all agree that we need complete coverage for really sick patients. 

Mr. Johnson.  Well, you know, I just experienced one with a hospital right here in Washington.  They ordered some x‑rays, and for crying out loud, you go in the x‑ray room and they don’t x‑ray what the doc tells them to x‑ray.  They x‑rayed about 10 or 15 other things, and they are going to charge you for it. 

Dr. Fendrick.  If I could ‑‑

Mr. Johnson.  And you are a doctor.  Tell me how you avoid that? 

Dr. Fendrick.  No.  If I may, I think the very important point that is emerging, as Ms. Neuman said, that most of the initiatives that have come out both in the private and public sectors have been how to change how we pay and manage care on the supply side. 

I think the important discussion, as we talk about reforming Medicare’s benefit design, is to absolutely make sure that the patient and the doctors are alined and, in fact, there is no conflict.  The example, Mr. Johnson, I will give you is as I practice in a medical home, I am given a financial bonus to get my patients’ diabetes under control and get their eyes examined.  At the same time, cost sharing to get their insulin and to get their eyes examined have gone up.  So the important alignment of provider and consumer incentives is critical. 

And as a physician I will tell you, the emergency example is one reason why there is no recommendation in value‑based insurance design to lower or raise cost sharing, because it is not a patient‑sensitive issue, but the decision to get your fourth endoscopy or to see your seventh specialist, I think there are many situations where we could use soft paternalism and cost sharing to get patients to make better informed decisions, to A, get the high value care they need and, maybe more importantly, to cut the 20 percent waste that is driven by reasons that are not really understood. 

Mr. Johnson.  You know, it is kind of hard to get all the docs on the same page all across this country, too, because of the differences in where they live and how they operate.  That is a real problem. 

You know, Mr. Hackbarth, I appreciate your work to figure out which approach can improve the coordination of care in our fragmented system, but I reject the notion that the bureaucrats in Washington can tell providers how to care for patients, and I am interested in how you think that using payment policies to ‑‑ reward good outcomes, and how do you approach that system with the docs and hospitals? 

Mr. Hackbarth.  Yeah.  So our thinking about payment reform, Mr. Johnson, is that we want to put more decision‑making authority in the hands of clinicians as opposed to in the hands of bureaucrats.  So one payment reform that moves those decisions out, but when you do that, there needs to be accountability for results both on total cost and quality.  If we don’t have that sort of payment reform, what I fear is increasing intrusion, defining the rules about what qualifies for fee‑for‑service payment and the like.  So I think we are in accord on what the objective should be.

Mr. Johnson.  Thank you, sir.  Thank you, Mr. Chairman. 

Chairman Brady.  Great.  Thank you, sir.  Mr. Thompson is recognized. 

Mr. Thompson.  Thank you, Mr. Chairman.  Thank you for holding this very important hearing. 

Ms. Neuman, is Medicare really as popular as those of us who go back to our district every weekend hear from our constituents?  Do you have data or polling information? 

Ms. Neuman.  Yeah.  I mean, our polling shows that Medicare is not only popular with the general ‑‑ with seniors, but also very popular with the general public.  Seniors like the way it works and say it is working well for them.

Mr. Thompson.  So as complicated as it is, what is it about Medicare that makes it so popular with the general populace as opposed to a big corporate plan? 

Ms. Neuman.  Medicare gives people peace of mind when they get ‑‑ have a disability or when they get older that they will have most of their health expenses covered. 

Now, Medicare, as we have been talking about, has high cost‑sharing requirements, but a lot of people have supplemental coverage.  A lot of people who are retirees have gotten retiree health benefits from their former employers, others have MediGap, the very low income have Medicaid, so a lot of people have a pretty full package of benefits.  That is not to say they don’t pay for the services they receive in many instances, but they do have supplemental coverage. 

Mr. Thompson.  Thank you.  As we deal with the whole issue of benefit redesign, it seems to me that that is going to ‑‑ whenever you reform something, you are disrupting the current system, so you are going to have some beneficiaries who end up paying more and some who end up paying less.  And I guess my question to all of you is how is that going to be perceived in the beneficiary community?  Is it going to disrupt the popularity of Medicare?  Will beneficiaries think it is a fair redistribution of the benefit?  And we could start with you, Mr. Hackbarth.

Mr. Hackbarth.  Yeah.  I think, Mr. Thompson, the commune ‑‑

Mr. Thompson.  I can’t hear you.

Mr. Hackbarth.  I am sorry.  I think that communication is really important.  The nature of insurance is a lot of people pay a little so that a smaller number of people are protected, and so the fact that a redesign might mean that a lot of people pay a little bit more to provide catastrophic coverage for the most seriously ill, that is just basic principles of insurance. 

What people don’t often take into account is the issue we discussed earlier.  Don’t think of this on a 1‑year basis; think of this on the basis of your full time in Medicare as a beneficiary.  The likelihood that you are going to benefit from that back‑end protection grows dramatically over the course of your time as a Medicare beneficiary.  That is not well understood, and it needs to be communicated. 

Dr. Fendrick.  Mr. Thompson, I will just say two things:  First, the movement toward free or low cost preventive care, both in public and private programs is universally accepted and one of the most important and well received aspects of healthcare reform. 

As we have done focus groups in both commercial populations and in seniors, the idea of explaining to them about this one‑size‑fits‑all system and giving them the comparison as opposed to paying the same for a drug that will save your life as one that is so dangerous, you wouldn’t give to your dog, and instead set up a system that will encourage you to get the services that are recommended by their own doctors and their professional societies, and make it a little bit harder to get those services that are recommended by those same societies in an initiative called Choosing Wisely is almost universally accepted. 

It is the communication piece that Mr. Hackbarth mentions that is so important in explaining to them the system that does not delineate your benefit design at all on what makes you healthier and what makes you harmful.  And you can imagine with the right communications techniques, this is something in our focus groups that is seen almost universally as positive.

Ms. Neuman.  Mr. Thompson, I think it would be a massive communication effort that would be required.  In at least our polling, people, seniors are ‑‑

Mr. Thompson.  To preserve the popularity and ‑‑

Ms. Neuman.  To preserve the popularity of the program with what people perceive to be our increases in cost sharing.  You know, for good or for bad, the public is pretty resistant to increases in cost sharing, perhaps because they are sensitive to the costs that seniors are already incurring. 

So a catastrophic benefit, while very important for financial protection and would help more people if you look at it over a life span, it may be difficult to convince the public of that in the short term.  And I am mindful of the experience of the catastrophic coverage program, which would have provided a catastrophic benefit, but it was a very tough sell and it was a very tough repeal, and despite efforts at communications, it just didn’t work out. 

Mr. Thompson.  Thank you.

Mr. Hackbarth.  Could I just mention one other point on this I think may be useful to the committee?  What we found in focus groups was that people who are not yet Medicare beneficiaries, may be in their 40s or 50s, early 60s seem to have different attitudes about redesign than current Medicare beneficiaries.  The younger people are more receptive to the idea of, oh, I pay a little bit more at the front end in exchange for a better protection at the back end.  So that may be something to consider also. 

Chairman Brady.  Thank you, sir.  Mr. Roskam is recognized. 

Mr. Roskam.  Thank you, Mr. Chairman.  You know, I was interested in the exchange, Ms. Neuman, between you and Mr. Thompson a minute ago in that you were describing the popularity of Medicare, which I agree with, but it is sort of the smooth ride as we are going towards the cliff and then, yeah, the road can be smooth and you can’t maybe perceive the problem, but 12 years out when insolvency is upon us, that is a stark reality that this committee, I am sure you appreciate, has to deal with.  So popularity notwithstanding, there is a real challenge there in terms of the reality. 

The other thing was, I sensed from you a little bit of an admonition and a word of caution about a massive effort being required in terms of large changes, and yet at the very beginning of this hearing, Mr. McDermott pointed out there is going to be a massive effort and we were told to gird up in terms of the calls and so forth into our district offices as it relates to the implementation of the Affordable Care Act.  So Congress hasn’t shied away in the past from some massive efforts and it is upon us, but I think the reality is that these things are here.  So I don’t expect a reply, but just a word about the exchange. 

Mr. Hackbarth, question.  In your testimony, or in your report, you highlighted how a lot of the durable equipment doesn’t have a copay, and that is basically a thing of the past.  Could you elaborate on that?  Or it should be a thing of the past? 

Mr. Hackbarth.  Well, durable medical equipment does have a copay under the ‑‑

Mr. Roskam.  I am sorry, home health.

Mr. Hackbarth.  Yes.  Home health services is one of the few services under the current benefit that does not have any copay.  A year or so ago, we recommended the addition of a copay on home health services.  Again, we think part of any fee‑for‑service insurance program is to have modest, appropriate copays.

Mr. Roskam.  And what is your hope and your expectation of having that? 

Mr. Hackbarth.  Well, you know, we have seen very rapid growth in the number of home health episodes.  And we are talking about not people being admitted to home health after hospital admissions, but admissions from the community.  And that care is, to some degree, discretionary care, and so we think it is appropriate for the beneficiary to pay some contribution to that so they think carefully about whether this is needed versus other alternatives they might have. 

Mr. Roskam.  A minute ago you were referencing some of the ‑‑ shifting gears ‑‑ you were referencing some of the attitudes of younger ‑‑

Mr. Hackbarth.  Yes.

Mr. Roskam.  ‑‑ future beneficiaries.  Could you speak to that?  Could you give us a sense of sort of the range of their tolerance for change?  The earlier you implement the change, sort of is there an arc to it, is there a science to it?  Did you come to any conclusions? 

Mr. Hackbarth.  Well, our information is based on focus groups, so it doesn’t lend itself to quantifying this dynamic, but it was a pretty clear one that the younger population is used to thinking about these trade‑offs, they have experienced change in their employer‑based coverage perhaps, where, they have been asked to pay more front end copays in exchange for something else.  So it is just more familiar, they are more receptive to it.  They don’t have the same reflex reaction that some existing beneficiaries might have.

Mr. Roskam.  Thanks.  And then, just another observation.  It seems in the discussion that the three of you had a minute ago with Mr. Johnson, you know, there is this feeling that we have got a system essentially where it is very difficult to interact and get answers about price from a consumers point of view. 

Dr. Fendrick, you used the phrase “soft paternalism,” which makes us all very nervous, and, you know, sounds like slight discomfort during a medical procedure, but there is an inability on the part of a lot of patients to find out just sort of clear information.  And we have ‑‑ all of us are complicit in creating a health care system where asking a physician the cost of the procedure is almost ‑‑ is a taboo question.  And you can imagine going in, hey, doc, what is this going to run me?  It is like, well, I don’t ‑‑ I don’t know.  It is almost as if we have asked, you know, how much does your spouse weigh or something.  It is that kind of question.  And we are admonished, no, you got to go to talk to the front office.  I don’t deal with this. 

That is unsustainable, and that, I think, is one of the factors that is driving part of our challenge today.  And I think that is why I appreciate the chairman having a hearing focused in on redesign with an idea of patient empowerment, setting aside the weaknesses of a market that isn’t highly functional in some areas, but is highly functional in others. 

And I see the red light, so I will yield back. 

Chairman Brady.  Thank you.

Dr. Fendrick.  I will just briefly say that in this issue of deciding about clinical nuance or not, in a typical branded drug copayment system, you pay the same out of pocket for insulin, depression drugs, critically important drugs for health as you would for drugs for allergies and male pattern baldness and other types of things. 

And terminology notwithstanding, when we talk to Medicare beneficiaries and ask them do they understand inherently that some physician visits are more important than others, that some medications that they take are more important than others, they universally say yes.  And when asked, would you prefer to have your insulin and your depression drugs and your anti‑seizure drugs to be lower cost because they are more important, as opposed to the current system that make them lower cost because they are lower cost and even though they might make you healthier, is almost universally accepted. 

Chairman Brady.  Right.

Dr. Fendrick.  And I think that is why we have seen clinical nuance in terms of cost sharing recommended by all three of the witnesses and from management and labor and a number of organizations who see that one size fits all is truly archaic. 

Chairman Brady.  Thank you, Doctor.  Mr. Roskam, my favorite is, “You may feel a pinch with this.”  That means get ready for searing pain coming your way.  Mr. Kind. 

Mr. Kind.  Thank you, Mr. Chairman.  And I want to thank our panelists today.  But just to stay on the line of questioning about benefit redesign and greater cost sharing, Ms. Neuman, I think you are exactly right.  I think there will be great resistance with current Medicare beneficiaries for any increased cost sharing that might be asked of them.  I was taken aback a little bit with the stats that you were reading off at the beginning of your testimony.  One half of current Medicare beneficiaries are surviving on $23,000 or less in the system?  So to be talking about greater cost sharing with that population is going to be met with fierce political resistance, I would predict. 

And, Mr. Hackbarth, it is not surprising that the younger population might be more amenable to some changes and greater cost sharing or benefit redesign, but they are not the problem.  I mean, if we continue to exempt current Medicare beneficiaries to any changes or the 55‑and‑above population, which is the Baby‑Boom generation, we are really not advancing the ball that well and addressing the huge health care cost issue that we face with the budget.  So to me it tells me we have got to continue today to move forward on delivery system and payment reform today with the eye towards cost saving while still enhancing quality and not jeopardizing access. 

Dr. Fendrick, I understand your laudable goal of trying to drive consumer decisions to more value‑based care and less low value care and have a price commensurate with that, but I have always found that the health care field is different.  We do have asymmetrical information out there.  I think the providers are the experts.  I am reasonably astute when it comes to health care decisions, but when I go into a doctor’s office, I don’t know if I need a CT scan or an MRI and I don’t know what the best course of treatment is going to be for me. 

So at lot of this is going to have to be provider‑driven, which means they are going to need information on what makes and what doesn’t work, which brings us back to comparative effectiveness research.  Do you think that is something we need to continue to go forward on, doing comparative effectiveness research and driving that into the hands of doctors and patients alike so they know what the most effective treatment option is? 

Dr. Fendrick.  So obviously as an academic, I support research that will tell us the services that help patients and the services that harm patients.  I think that we have to think very hard about this decision in understanding the asymmetry of information, but it is possible.  The enormous popularity of the free preventative services in Medicare and in health care reform justify that. 

I think, given the numerous studies that show the large amount of waste in the system, I have to go on record that I would like to see increased cost sharing for harmful care.  And if ‑‑ the initiative called Choosing Wisely, which I mentioned forward, is over 20 medical specialty societies, not bureaucrats, but physicians themselves saying that there are services that individuals should talk with their doctors very carefully about, because the evidence would suggest that not that we are not sure, which I am totally happy leaving the value‑based cost sharing outside, but for those services where the evidence is of harm, I do believe that this is a conversation that we ‑‑ all of the stakeholders are willing to engage in. 

Mr. Kind.  Well, Dr. Fendrick, I mean, we had some bruising battles, you know, discussing this over the last few years or so, whether it was funding for comparative effectiveness research under the American Recovery Act, under ACA.  We actually instituted the Patient Center Outcome Research Institute to help sponsor clinical studies out there so we can get better information into the hands of providers.  Do you think that was a good idea to move forward on? 

Dr. Fendrick.  Research to answer the tough questions about how to spend our health care dollars are important, both from the private and public sector, but I think, Mr. Kind, what is really important to say is that our own work shows that even in the setting of solid scientific evidence, without the appropriate incentives for both patients and their providers, the best possible care is not provided.  There are these no‑brainers.  You know, we are not talking about in the middle.  There are these no‑brainers:  diabetic eye exams, physical therapy that people don’t ‑‑

Mr. Kind.  Doctor, you got me on that.

Dr. Fendrick.  Okay. 

Mr. Kind.  I am in complete agreement.  This is where we need to be going as far as health care decisions and that, but I am you a little surprised that in the course of today’s hearing and the questioning, the R word hasn’t been mentioned yet, because we are really talking about rationing.  I mean, if you are talking about changing the cost incentives within the system and that and driving people to high value care and away from less value care, that is a form of rationing, which I get, I understand.  We need smart rationing within the health care system, because you don’t want to be spending money on stuff that doesn’t work or leave patients even worse off when they go in. 

So I don’t think we should be necessarily scared or frightened from that concept, yet it is such a political bludgeon around here.  When you start talking about comparative effectiveness research and making smart decisions, suddenly it becomes rationing, and that is a big bugaboo that we can’t approach and that. 

So, you know, I commend your message and what you have been working on, but there are political minefields that, you know, all this too that I just caution you about.

Dr. Fendrick.  All I will say, is very quickly, is that the option that we have before us is whether the benefit design should be nuanced or not.  And if you feel that Medicare beneficiaries should spend equal out‑of‑pocket amounts for things that hurt them and things that incredibly well benefit them, then I would keep the status quo. 

What we have seen both in public and private plans thus far is that people really do prefer a nuanced approach, working from the edges for the things we are really certain on the things that help and the things that harm, and avoid the contentious issues that your committee and the public have dealt with over decades.

Mr. Kind.  Okay.

Chairman Brady.  The time has expired.  Mr. Price. 

Mr. Price.  Thank you, Mr. Chairman.  And I want to thank you, congratulate you on chairing the Health Subcommittee and look forward working with you, and I want to thank you for this most important hearing today, and I look forward to having many more. 

People ought to be sitting up and taking notice as we use terms like “soft paternalism” and “rationing” within almost the same paragraph. 

The real question is how does this affect patients?  As a physician who took care of patients for over 20 years, I can tell you that when they felt that somebody else was making the decision that potentially adversely affected what their doctor could do for them, that is when they said that this isn’t the system I want to participate in.  We need to be very, very careful in what direction we head. 

The home health was talked about, I think, by Mr. Roskam.  The current design of a new benefits package for home health is now in phase 2 by CMS.  And I would suggest to you that it is harming patients, making access to home health care more difficult for patients.  Is it going to cost less?  Yeah.  You know, we will pound our chests up here and say how wonderful it is because it costs less, but it is hurting people.  And that is the challenge that we have, is to design a system that doesn’t hurt people. 

So then you have to ask the question, okay, well, who is going to decide whether it hurts or not?  And that is where the whole issue of one‑size‑fits‑all really gets to the heart of the issue. 

Dr. Fendrick, you talked about the current system being one‑size‑fits‑all, and it is.  Do you have any concern that we trade one one‑size‑fits‑all system that doesn’t necessarily work for everybody for another one‑size‑fits‑all system that doesn’t necessarily work for everybody but may work better for government? 

Dr. Fendrick.  My consideration is the Medicare beneficiary.  And I look at exorbitant amounts, billions of dollars that could be spent on services that would improve the quality and length of life of those beneficiaries that are instead being wasted on things for which medical societies say harm patients. 

So I understand that there are issues and challenges, but all I can tell you, the popularity among patients and physicians to see cost sharing removed for services that save lives, whether they be preventive services or management of chronic diseases, seems to me like something that we move forward in.  And almost all the implementations thus far of clinically‑nuanced benefit designs have been around subsidies of high value services.  Because most high value services, as you well know, tend to increase costs in the short term instead of lower them, the fiscal pressures that we have confronted has required us to look at not just the motivation for me to get into this is to make the high value services more accessible to patients and their providers, but also understand this waste problem.  And it is MedPAC and other organizations that continue to tell us the billions of dollars that are spent on harmful care. 

And I think as ‑‑ having some fiscal responsibility, we need to understand that we could reallocate these funds, maybe not perfectly, but in a better way than we currently are with no clinical oversight. 

Mr. Price.  Let’s talk about the patient that we come up with this grand design for a new benefits package for folks and a system that is going to work better than the current system, and we say to our senior population, you have got to see do this, should there be any flexibility in that?  Should a senior be allowed to, I don’t know, opt out of that system? 

Dr. Fendrick.  You are the legislator, I am not.  All I am going to say is another ‑‑

Mr. Price.  No.  For the patient.  You are talking about the patient.

Dr. Fendrick.  I think the important point that I may have glossed over is that these type of benefit designs never decide what is covered and what is not.  And for you as a physician as well as a congressman know that there is a multiplicity of small print in cost sharing, both in Medicare as well as in private plans.  So this idea of confusion is going on already.  And my simple point is instead of using profits or the cost of a service to generate how often it is done, that we think about taking advantage of the points that were made by a number of you moving from volume to value, and value must include clinical nuance.

Mr. Price.  My time is short, but the concern that many of us have is that value is quality over cost.  And quality is in the eye of the beholder, so what is quality for you as a patient, what is quality for me as a patient or another patient may be something completely different.  That is not to say that there ought not be comparative effectiveness research, because there ought to be.  As scientists, we all understand that you have got to ‑‑ that you want to know the best thing to do for a patient.  But at the end of the day, it is patients and families and doctors that ought to be making these decisions about what kind of care they receive, and not anybody else. 

Dr. Fendrick.  I agree.

Mr. Price.  Yield back.

Chairman Brady.  Thank you, sir.  Mr. Blumenauer. 

Mr. Blumenauer.  Thank you.  I find this very interesting and very helpful.  I guess my concern is that we have a situation that too often it is not so much dictating services, we have a system where nobody decides, where we kind of are a captive of the original program design, add‑ons that continue.  I don’t know about soft paternalism or hard paternalism like just cutting you off with money, or just going along till we run out, or somebody figures out how to game the system.  And what I hear you saying is there may be some ways that we can do a better job of incenting everybody to make the right decisions, and I am comfortable with that. 

We have had experience on this committee where people would not agree to allow the results of comparative effectiveness research to be used in determining how much the government is going to pay for what.  Seems kind of goofy, but that is the political process.  And the complexity that some people want is just going to add costs and water down the ability to deliver overall high quality service, which is, I think, in microcosm, why we pay more than anybody else in the world for results that are mediocre on average.  And so I am intrigued with the ‑‑ Mr. Chairman, with your bringing the witnesses here and for us to think about benefit structure and how it impacts it. 

I want to just go back to something, Dr. Fendrick, you had when you talked about infusing clinical nuance into Medicare Advantage.  That was the bold print that was 6‑point type.  But I wonder, Mr. Hackbarth, I don’t think you referred to Medicare Advantage in your testimony.  Would you react to that for a moment?  I mean, this is kind of a grand experiment that we have had.  We have found out that not all Medicare Advantage programs are equal.  Some are hopeless rip‑offs, where we found some people who figured out how to game the system.  We had in the Affordable Care Act some incentives to try and reward better programs, and we are slightly ratcheting down the premium. 

I am old enough to remember when Medicare Advantage was supposed to deliver the same quality and quantity of health care and it was supposed to be able to do so for 5 percent less, using the magic of private sector and unshackling.  Didn’t quite work out that way, but we are ramping down the subsidy and we are seeing, at least the conversations I am having, that some people are starting to take advantage of that platform. 

But can you speak to ways from MedPAC that Medicare Advantage might be an area where we could make some adjustments to inject a little more nuance into the program and not sacrifice either quality or, again, lose cost control? 

Mr. Hackbarth.  Yeah.  We think that Medicare Advantage, offering a choice of private plans to the Medicare beneficiary is an important part of patient engagement.  So beneficiaries ought to be able to go in that direction if they wish. 

We do think that private plans have the opportunity to do some things that traditional Medicare finds difficult to do; for example, identify high value providers and steering beneficiaries to those providers, which is one of the points that Dr. Fendrick made.  The regulations, we need to look at those regulations, make sure that they provide appropriate flexibility to private plans to identify high value providers.  Similarly, they need to have appropriate discretion to vary the benefit structure. 

So recently one of our recommendations was that rather than having chronic care SNPs, special needs plans, that are focused on particular chronic illnesses, what we ought to be doing is give all Medicare Advantage plans the opportunity to adjust their benefits for diabetics versus asthmatics versus patients with cardiovascular problems.  And, again, I think that is something that Dr. Fendrick recommended. 

Mr. Blumenauer.  Thank you very much.  Thank you, Mr. Chairman. 

Chairman Brady.  Thank you.  Mr. Smith. 

Mr. Smith.  Thank you, Mr. Chairman.  And thank you to our witnesses here today. 

Dr. Fendrick, I know you are obviously well studied on a lot of things relating to Medicare Advantage and current limitations. Would you have specific recommendations on how to break down some of the barriers to flexibility perhaps that would end up improving care? 

Dr. Fendrick.  I do.  And I would just add on to what Mr. Hackbarth just said.  I think they come into two most elemental buckets; is the first, the ability to allow the flexibility in MA plans to alter cost sharing, depending on the provider that chooses or where that is done.  An example might be, for instance, a highly recommended service for individuals over 50 is colonoscopy.  You could get a colonoscopy in a number of settings, as shown in the Pacific Northwest, at a cost between $700 and $7,000.  And I think to be able ‑‑ in those situations, when most people do believe that colonoscopy is performed at reasonable, same quality in most places, that you might wants to encourage people to go to the lower cost centers that provide the same quality as those that are high. 

So provider and venue is the first, but the second and most important is this issue of allowing Medicare Advantage to alter cost sharing for specific services based on clinical information.  And to follow up on what Mr. Hackbarth said, I think that one of the easier things to say, given the comments about the size of my testimony type, is the recommendation of a diabetic to see an eye professional on an annual basis. 

In Medicare Advantage, their current abilities now are to make eye exams either low cost or high cost regardless of your clinical condition.  I would like to see a plan that offers annual low cost eye exams to diabetics but not offer that same benefit design for someone without that condition. 

Mr. Smith.  Ms. Neuman? 

Ms. Neuman.  Medicare Advantage really could be an opportunity to learn more about benefit design changes that are being talked about today, because plans do have flexibility, not quite as much as might work, but there could be opportunities to learn more, and it may be something ‑‑ the committee might want to consider perhaps giving the highly rated plans greater flexibility to modify the benefit design and use that as a learning opportunity to see what changes drive people to high value services and perhaps lower costs for the program. 

Mr. Smith.  Sure.  And I realize that, you know, the term “flexibility” is very vague and oftentimes even misunderstood, but the fact is representing a rural constituency, I know that things are done differently in rural America, and oftentimes more efficiently, but, you know, a supply of health care means mere access in rural areas and it means more competition in urban areas.  And so in trying to balance many of those things, I was wondering if, Chairman Hackbarth, if you could reflect a bit on the impact to rural communities, rural health care in terms of, you know, recognizing some of those differences that are out there. 

I mean, it amazes me how we empower medical professionals to make very intricate decisions based on their expertise, and yet in other areas of health care, we don’t allow the judgment to be utilized of the very same medical professions.

Mr. Hackbarth.  So you are talking, Mr. Smith, more broadly about Medicare as opposed to just within Medicare benefit design ‑‑

Mr. Smith.  Right.

Mr. Hackbarth.  ‑‑ how do we ‑‑ Well, as you well know, Medicare has a large number of special provisions related to rural providers.  It tries to address the particular, the unique needs of rural providers, for example, ensuring access to care for beneficiaries in isolated areas through the Critical Access Hospital Program. 

One of the areas that we have started to look into a little bit, based on the interest of one of our commissioners who practices in South Dakota, is that medical professionals and staff are used differently in isolated rural facilities than they may be in an urban facility.  And ‑‑

Mr. Smith.  And it would seem to me that oftentimes that is undermined given a one‑size‑fits‑all approach coming from Washington.

Mr. Hackbarth.  Exactly.  So I think that is one area to look at, and we have just begun to pay some attention to that, but we need to make adjustments to accommodate the unique circumstances that exist in, say, an isolated rural hospital and how they configure their staff and how they make decisions.

Mr. Smith.  Okay.  Thank you.  And, Mr. Chairman, I yield back. 

Chairman Brady.  Thank you.  Mr. Pascrell. 

Mr. Pascrell.  Thank you, Mr. Chairman.  Ms. Neuman, can I just get a clarification, if I may, on policy and demographics, particularly on the issue of home health copays?  Who are these people? 

Ms. Neuman.  People who use home health services tend to be old, frail women.  These are the oldest, the frailest that Medicare ‑‑

Mr. Pascrell.  The most vulnerable? 

Ms. Neuman.  Yes, sir. 

Mr. Pascrell.  Would you use that word? 

Ms. Neuman.  Yes.  I think that is fair.

Mr. Pascrell.  Okay.  Look, you have heard it many times:  health care reform is entitlement reform.  You may not agree with it, some folks here.  Not only did it reduce costs for Medicare, but it also reduced costs for beneficiaries.  That is what we know. 

The attempts to repeal reform and turn Medicare into some kind of other program will hurt the beneficiaries, that is my conclusion, because they have to pay more money out of their pocket.  That has to be clarified.  So I am not going to be disillusioned about the kinds of income seniors make.  You mentioned in your testimony that the beneficiaries have an average income of close to $23,000, below $23,000, actually.  They already spend 15 percent of their incomes on health care.  And when you add that into how many people are living on their Social Security check and how that is increased over the last 10 years, paying more out of pocket is just not an option for many of our seniors.  Would you agree with that? 

Ms. Neuman.  I would.  And I want to come back to Mr. Hackbarth’s comment when he talked about expanding coverage for the low income population and doing that in a targeted way.  You know, while some with very low incomes do qualify for Medicaid, many low income Medicare beneficiaries are not on Medicaid ‑‑

Mr. Pascrell.  That is right.

Ms. Neuman.  ‑‑ either because they are not eligible based on their assets or their income, but there are many people who would feel directly any change in cost sharing.  So a lot of the proposals have talked about protecting the low income, but more work needs to be done on how that would be done and what vehicle would be used and who be helped.

Mr. Pascrell.  Now, your organization, the Kaiser Foundation, found that 70 percent of Americans prefer Medicare’s guarantied benefits to any other kind of plan.  I think that it provides a clear picture of how our Nation values the program.  The average Medicare beneficiary has an annual income of $22,500. 

So, Ms. Neuman, can you talk about these higher rates to some seniors that they have to pay disproportionate or whatever as you concluded? 

Ms. Neuman.  Well, there are certainly some people on Medicare who are wealthy by standards that ‑‑

Mr. Pascrell.  Right. 

Ms. Neuman.  ‑‑ generally would be considered wealthy, but only 5 percent of people on the program have incomes of $85,000 or more.  So for people with modest incomes, an increase in out‑of‑pocket costs would be a real issue. 

And what the research has shown is that it is people with lower incomes and people in poorer health who are disproportionately affected by increases in cost sharing, because higher people can probably absorb to pay more if it is worth to them.

Mr. Pascrell.  Or possibly leave the program.  You may raise the rates on those higher income seniors, which is a relative term when we look at what they are making, they may move ‑‑ leave the program altogether.  What is that going to result in? 

Ms. Neuman.  Well, the issue there, I think, has to do with the part B and part D premiums ‑‑

Mr. Pascrell.  Right.

Ms. Neuman.  ‑‑ and the income‑related premiums.  And already today, people with higher incomes are paying higher premiums, and there is some discussion about expanding income premiums to cover more people.

Mr. Pascrell.  What do you think about that? 

Ms. Neuman.  What do I think about that?  Well, I think, you know, the public certainly prefers to ask higher people to pay more than everybody else, but depending on what the policy looks like, it could scale back and start to hit middle income people.

Mr. Pascrell.  But when you talk about higher income, that is a relative term in terms of the seniors that we are talking about who are very vulnerable.  It is a different kind of situation than we are talking about when we refer to our tax policies, general tax policies.  It is a very different situation altogether. 

We need to be very careful here about who we are helping and then what are the consequences of helping a few, and many people getting really hurt.  So thank you, Ms. Neuman, for your testimony.

Ms. Neuman.  Thank you.

Mr. Pascrell.  Thank you, Mr. Chairman. 

Chairman Brady.  Thank you.  Ms. Schwartz. 

Ms. Schwartz.  Thank you.  And I appreciate the invitation of the chairman to join you on this important discussion.  And I do have to say, I have had some of these discussions a bit about redesign, benefits redesign, and I appreciate some of the work that you have done on this.  And actually, the notion of simplifying the way we actually do this to make it more understandable is certainly important to include beneficiaries in this really very important debate we have about making sure that seniors have access to the benefits that they expect and they need, and doing it in the right way. 

Everyone knows that I have done a lot of work on redesign of the way we pay physicians and providers as key to this, and potentially I think maybe more important, because as we have all heard this morning, it really is very much in the ‑‑ if your doctor recommends it, you are sort of inclined to do it, and you should be, and the potential of having copays get in the way of necessary services, something that many of us are very concerned about, and yet the ‑‑ and you talked about it earlier, we have to protect poorer seniors so that they actually don’t ‑‑ so they are able to get the care they need.  And maybe $50 a copay is enough to say, I can’t get it now.  And I am sure, Doctor, you have seen that.  That we want to protect primary care.  We have talked about already doing that; that we want to protect access to care of chronic ‑‑ those with chronic diseases so they don’t get sicker; that we also want to protect the sickest. 

So we are starting to include a whole lot of seniors in this.  We are narrowing the window of who we are actually asking to pay more. 

So really my question and the real discussion I would want to have is how we really don’t pay doctors to sit down and really talk to their patients about what they shouldn’t get.  I mean, I think Dr. Price said let’s not get in the way of the doctor‑patient relationship, but right now there is somewhat of an incentive to say, here is a prescription, because that is quicker than the conversation about, you know, you really don’t have to take this and you can call me in 3 days if you are not better, than just giving them a prescription, which they may or may not fill, of course, or some of the other ‑‑ or go have this test, and somebody might come in and say, I heard that it is really important for me to get an EKG every month. 

Now, I don’t know if that is true or not.  I just made it up.  I am not a physician.  But, you know ‑‑ but, in fact, maybe that is not such a necessary thing, and it may not be harmful, but it certainly is a cost to all of us.  But taking time to say, no, here are the things that you ought to do instead of having these extra tests really does take more time. 

So we don’t reimburse very well, except under patients in medical homes to do that, but can you speak to how important it is for patients to, yes, take some responsibility in this and not demanding more from their doctors than they necessarily need, but for that communication between the doctor and patients, and for us to incentivize providers to take that time to really provide what is important and necessary, not more than important. 

And right now, while Dr. Price will say, you know, one size doesn’t fit all, right now we pay for everything, more or less, and that is what you are sort of trying to get to:  how can we get the doctor and patient to actually engage in that conversation when in fact it is very difficult for patients to really know whether, in fact, they are asking for more than what is appropriate or less than is appropriate.  It really is very much on the part of the provider. 

I believe strongly we should pay providers differently under this, under Medicare, and we ought to do it, but could you speak to that, about whether we ‑‑ the risk of redesign of benefits really putting the burden on beneficiaries who really have a difficulty making this judgment and really need that relationship with their provider, it may be a doctor, may be a nurse practitioner, and really having the information not just about a cost, but really more about the appropriateness of services and the utilization, excessive utilization potentially of some services. 

And maybe, Mr. Hackbarth, do you want to start with that? 

Mr. Hackbarth.  Sure.  So I want to emphasize that we think that it isn’t enough just to reform the Medicare benefit package.  You also need to reform how physicians and other providers are paid. 

Ms. Schwartz.  Yes.

Mr. Hackbarth.  And one dimension of that ‑‑

Ms. Schwartz.  Maybe first, even?  I mean, do you think one comes before the other? 

Mr. Hackbarth.  I think it has to happen simultaneously.  I wouldn’t put an order on it.  And one dimension of that you have touched on, Ms. Schwartz, which is we need to pay physicians for communicating with patients.  And there have been some positive developments in that recently.  Some new codes have been added for transitional care, a big part of which is communication with patients as they make a very difficult transition from a hospital admission to the community.  So I think that is a very important complement to this. 

Other approaches you have alluded to are like medical home, where we are not even using the fee‑for‑service payment model exclusively, we are adding additional payments.  They go hand in hand.  It is not either/or, it is both are required. 

Ms. Schwartz.  Okay.  Thank you.  Do we have time for others to comment? 

Dr. Fendrick.  Yes.  Briefly I will just say that the most important part is that we make sure that whatever is happening with the incentives on the physician side and the provider side, they must be aligned with the consumer side, because what I see in both the public and private programs, often they are in parallel, but often moving in the wrong direction. 

Conceptually, though, speaking about it from the patient side, cost sharing is an insurance tool to encourage beneficiaries to think twice or thrice about things they may not need. So when we think about home care or hospitalizations or visits, it requires me to pause and think why would there be cost sharing on something that is absolutely essential for the patient’s health, which is the entire motivation for clinical nuance. 

So thus, I would like to close where I started, is that, I do believe that cost sharing has a role in Medicare and I think cost sharing should have a substantial role on those services that don’t make beneficiaries any healthier. 

Ms. Schwartz.  Well, it seems to me we have a fairly high threshold on what is harmful or not.  I mean, right now it is not absolutely clear, we don’t have all the information ‑‑

Dr. Fendrick.  I will just say ‑‑

Ms. Schwartz.  ‑‑ about what is actually too much or ‑‑

Dr. Fendrick.  Very quickly, and why to the chairman’s credit, this initiative called Choosing Wisely, which I suggest the staff learn about, is a physician‑specialty society motivated initiative to identify services that may be overused.  So this is a very important step not only for us to identify the services that we should make less expensive for which the evidence is strong, we also now have a physician‑driven movement to identify those services that we may do less of.

Ms. Schwartz.  I agree that is important.

Chairman Brady.  Thank you.  Dr. McDermott has asked for a question, and he is recognized.

Mr. McDermott.  Thank you, Mr. Chairman.  And I want to say I have appreciated your slow gavel so that we could allow the witnesses to finish what they have to say, and I think the committee is really interested in what happens.  And one of the issues that I would like to ask a further question about is the whole question that you just raised, Dr. Fendrick, and beyond that, I would like for the committee, that you would submit to us, all of you, if you have it, evidence that backs up the theory that people go to the doctor more often than they need to, and if we put a copay on, they won’t go. 

And I want to give you an example to let you ‑‑ and there are thousands of examples.  Everybody who is anticoagulated, who is on Heparin or on Coumadin is supposed to go back in to the doctor and get a checkup as to whether they are at the proper level, too high or too low or just right.  There are problems on being too high, there are problems on being too low.  The patient has no sense of what that is.  They don’t feel anything particularly until they have got a problem. 

So the idea that I have to pay $10 to go back in and put my finger out and have it stuck and have them then read it on a machine and tell me, yep, you are right in the right place, when I didn’t feel anything, why would I do it if it is going to cost me 10 bucks? 

And so what I am looking for is how you think you can design, and is there any evidence, is there any across‑the‑board ‑‑ same way with ‑‑ the Time magazine this month has tuberculosis on the front page.  And taking pills, in my experience personally, and I think probably for everybody in this room, you take pills when you feel bad; when you don’t feel bad, you stop taking them, whether the doctor said you should take all 10 days doesn’t make any difference.  Every drug cabinet in every bathroom in this country has half finished ten packs, or Z‑Paks.

So what I am getting at is how do you ‑‑ where is the evidence that people go to the doctor just because they don’t have anything to do on Wednesday afternoon?  That is really what I am looking at. 

Dr. Fendrick.  I will just start briefly by, your comment basically hits the essence of clinical nuance, that someone on Warfarin must be not only be discouraged, but must be encouraged to follow the protocol to maximize the health of that beneficiary.  I am not so sure that someone not on Warfarin should have the same ability to go to see the doctor to have their blood checked to see how thin their blood is.  And that is, as I said, the essence of clinical nuance. 

There is a lot of evidence that we are happy to supply to the committee, but one of the best examples in Medicare is The New England Journal of Medicine paper examining the impact of increases in cost sharing on ambulatory visits in Medicare Advantage. 

As you might expect, Mr. McDermott, beneficiaries went to the doctor less often.  Those beneficiaries who went to the doctor less often, went to the ER more and were hospitalized more, and, in fact, total costs went up, which is why our proposal is that primary care visits in Medicare Advantage and in Medicare should be free. 

Now, there are other services actually where the money is, as Mr. Hackbarth knows better than anyone.  It is not in primary care visits and it is not in prevention.  It is in hospitalizations and the management of chronic diseases, for which ‑‑ to respond to the chairman’s question earlier, for those chronic diseases, we are fairly certain in the services that should be encouraged for which cost sharing should be minimal or not at all. 

Mr. Hackbarth.  So what I would highlight, Mr. McDermott, is the importance of doing both payment reform and appropriate cost sharing for patients.  So one piece of evidence that we have that is relevant to your question is the prevalence of repeat testing of various types.  There is a lot of it, a lot of it that exceeds all clinical guidelines, and there is huge variation across the health care system.  Probably the most important reason for that is not patients demanding repeat testing, but physicians have incentives to do repeat testing.  We need to change that, but when we change the physician incentive and they say, oh, well, maybe you don’t need to be tested so often, you don’t need so many return visits, we want the patient also to be aligned with that.  We don’t want the patient to say, well, I like the old pattern of, you know, I am going to come every month or every 2 months, whatever.  If there is a modest appropriate copay, then the physician and patient are talking the same language. 

I believe physicians care about their patients and will modify the recommendations if the patient has some cost sharing involved, and will recommend things differently than if it is absolutely free to the patient. 

Ms. Neuman.  Well, I would agree that there is a lot of evidence on the side that says if you increase cost sharing, it has an effect on utilization.  I don’t know about the evidence on decreasing utilization and whether there is, for example, too much of preventative services.  And that might be something that one could take a look at, but it would be hard to imagine an effect like that in the literature, but we could take a look at it. 

I also agree on areas of where there is evidence of overutilization, there are a number of ways to attack the issue, one of which is cost sharing.  And even then, in the example of home health, there are different ways of doing that that would have different effects on people depending on how ‑‑ whether it is, for example, a copayment or a co‑insurance, which would disproportionately affect the sickest of the sick.  But if the issue is that there are too many people using too many services, then I would also agree on going at it, going around and going at the provider side, the supplier side and think about how to make changes that would slow the growth in this benefit without necessarily asking beneficiaries to parse out whether or not they need a service that their doctor has told them they needed. 

Mr. McDermott.  Thank you, Mr. Chairman. 

Chairman Brady.  No.  Thank you.  I would like to thank all of our witnesses for their testimony today.  Obviously there is a ‑‑ the current structure of Medicare benefit design needs a hard look at, has it is challenges.  I hope we continue to work together in a bipartisan way, to explore how we can try to limit those out‑of‑pocket costs, make a little more rational sense out of the design, but just as Mr. Hackbarth has asked Ms. Neuman, –go back, and I will send a letter to this effect, take a look at again the changes of a design over the life of a Medicare senior I think is very important. 

The other area, we sort of looked at one side of the ledger, okay, if you unify, A and B it may raise costs and some others, but what we didn’t explore is what is the impact of MediGap, you know, do you need it?  Does it have a different side?  Does it carry a different cost that offset some of that?  Any information any of you all have to that regard would be very helpful. 

As a reminder, any member wishing to submit a question for the record will have 14 days to do so. If any questions are submitted to the witnesses, I please request you answer them as promptly as possible. 

With that, the subcommittee is adjourned. 

[Whereupon, at 12:02 p.m., the subcommittee was adjourned.]

Submissions For The Record

Alliance for Retired Americans
American Academy of Actuaries
California Health Advocates
Center for Fiscal Equity
Council for Affordable Health Insurance
Leadership Council of Aging Organizations
National Alliance on Mental Illness
National Association for Home Care and Hospice
National Committee to Preserve Social Security and Medicare