▶ 0:14:44The hearing of the subcommittee will come to order. Good afternoon. I want to thank our witnesses for being here today. I know a lot of you traveled away, so we appreciate that. Discussing important issues. Uh, I'm excited about reducing and preventing chronic illness. Someone said, well, I'll get to that, but someone said we spent5 trillion dollars uh last year in terms of health care, and we're getting worse results.
▶ 0:15:09So, that's why we're glad to have you here and get your thoughts and ideas to combat the chronic diseases epidemic. I strongly believe we need to empower empower each other to work together to treat and manage patients. The US has a larger share of people with chronic diseases compared to other countries. More than twice as many Americans in terms of obesity. In fact, uh chronic uh diseases make up about eight out of 10 of the top causes of death in the United States.
▶ 0:15:39This crisis spans all ages approximately when you look at it. Even young children at 20%, adults at uh young men, women uh between 20 and 31 aren't even eligible to serve in the service because uh they they're obese, 31% of them. And then adults in the country, depends on what what what you believe is somewhere between 40 and 50%. We spend $5 trillion a year. I looked at it, someone said it was 4.9.
▶ 0:16:08I looked at it today and they said five four point. Yeah, they said 4.5. They said uh five almost five trillion on health care costs 90 90% from the chronic disease alone. We must do do more to help patients and taxpayers. Too often our health care system responds to health problems only after the the crisis instead of preventing them in the first place. And that's my philosophy. Let's not get the cancers and the uh heart disease and everything.
▶ 0:16:36Uh there's always a percentage that do unfortunately, but there's a lot of them that shouldn't get it and they do get it because they haven't done the preventative things. Ideally, that's that's your choice. I'm not telling anybody. I just bring that up. So, I'm I'm pleased to uh recognize the the and my good friend from TE Texas, Mr. Dogget, for his opening statement.
▶ 0:16:59Well, thank you very much, Mr. Chairman. It's uh great for us to finally be back together after a long break. Uh, and I appreciate your leadership on lifestyle medicine, on improving care coordination. This is something that, uh, I certainly support. Uh, I just wish that there was bipartisan coordination to come up with a solution to prevent millions of Americans from losing their access to a family physician and vital medications.
▶ 0:17:27About 60% of American adults have at least one chronic condition. And I think of people like Walter, a constituent of mine, a small business owner down in Austin. The Affordable Care Act has protected him from unjust coverage denials due to the fact that he has diabetes. Many of our Republican colleagues appear to be afflicted with amnesia.
▶ 0:17:52They have forgotten what life was like before the Affordable Care Act, not only for those people who rely on the marketplace, but for everyone. When it came to denials for pre-existing conditions, a term that was defined broadly to include everything from diabetes to surviving a domestic assault to being a woman to being of a certain age or any other excuse that an insurer might come up with. Thanks.
▶ 0:18:19Thanks to the protection for pre-existing conditions, Walter and his wife have been able to rely on marketplace plans to maintain his diabetes treatment and protect them from any other type of unforeseen emergency. Next year, however, they will pay $700 per month more than they are paying this year for that coverage that is so important to them because Republicans have taken away the tax credits that allow them to obtain coverage.
▶ 0:18:48Uh, I agree with Republicans that we need better cost containment, but they have not acted on some of the remedies that would get us there, such as prescription drug price gouging and Medicare fraud proposals I've advanced.
▶ 0:19:04And after failing more than 70 times uh to replace Obamacare with nothing care, I don't think they really have a alternative plan that begins to offer the kind of basic medical care uh offer protection against a medical emergency when 60% of our fellow Americans do not say they do not have the resources available to cover a $1,000 emergency.
▶ 0:19:30Uh after more than eight years, all we have from President Trump is what he calls concepts of a plan. It's a secret plan. Apparently, he says it will be called Trump Care, which I'm concerned will no doubt be only as successful as the failed Trump University. The closest thing to a plan that I've heard in the last few days uh is the suggestion that we can eliminate the ACA.
▶ 0:19:57Give people some direct cash and they'll use uh health savings accounts uh to address all of their problems. Health savings accounts are not a substitute for the Affordable Care Act. They were an excuse. uh they do provide some benefit to some citizens today, but they have also become massive uh tax shelters for some of those at the top.
▶ 0:20:21Uh lucrative uh enough to be advertised for taking a vacation, buying a boat or a sauna. Uh there are many reforms that are necessary to the HSAs for them to protect consumers.
▶ 0:20:36Uh I think that uh I've tried to incorporate those into some new legislation that I will be filing uh concerning uh protecting consumers and protecting our treasury when it comes to HSAs because even if taxpayer dollars are provided for HSAs, expecting the sick and injured to have the time to go out and negotiate against a powerful insurance company uh or healthcare conglomerate, uh they face uh some pretty uh
▶ 0:21:06tough circumstances in terms of negotiating and I doubt that President Trump's claims uh that he made in August of this year that he was going to bring down lower he was going to lower drug prices by 1,500% not 50% he said but a 1500% reduction uh will work that this will work any better than that kind of claim so I would say at best we have to come up with a way for people like Walter and and other Americans to
▶ 0:21:36afford access to uh their care. Uh extending the tax credits is the best way to do that. We need to avoid faulty programs that will leave vulnerable Americans without protection. Let's improve care coordination. But first, let's assure that we protect the ability to receive that care. And I yield back and thank you, Mr. Chairman.
▶ 0:21:58Thank you. Uh and now I introduce our witnesses. Dr. Hoben is the chief medical officer of the population health services at Novak Health. Miss Riker uh is a pharmacist and I it's kind of interesting because she was telling me I was reading you've been I think in town close to 100 years your family or someone in your family. So you got a pretty good sense of what's going on. You're fourth generation. So it's exciting to see you here. Thank you. Um Mr.
▶ 0:22:28Pudins is the chief uh population health officer at Summit Health. Mr. Cornell is the vice president of the federal affairs at blood cancer uh united. Thank you for all joining us. Your written statements will be part of the congressional record and you'll have five minutes to deliver your oil royal oil arguments remarks. Dr. Hoben.
▶ 0:22:56Thank you, sir. Chairman Buchanan, Ranking Member Doged, and members of the subcommittee, thank you for the opportunity to speak with you today. I'm Dr. Michael Hoben, and I serve as chief medical officer for population health services at North Novant Health, an integrated not for-p profofit health system that includes more than 900 locations across the great states of North South Carolina. I also serve as a medical director of one of our ACOs, and I still have a clinical practice in family medicine in Charlotte.
▶ 0:23:23At Novant Health, our 42,000 team members share a simple cause, to create a healthier future for our community. Care coordination centered on prevention and management of chronic disease is essential to the future we're building. And we appreciate the subcommittee's focus on this important topic. Why care coordination? Well, it starts with patient centered care and a team-based approach that aligns patients, providers, ancillary teams, and family members in a care plan collaboratively developed and implemented.
▶ 0:23:51Coordinated care allows us to anticipate needs in real time to be proactive rather than reactive so we can avoid complications and emergencies resulting from unmanaged chronic conditions. It transforms patients experience into something simple yet comprehensive, intuitive and supportive. And it's a cornerstone of the care we deliver at Novant Health.
▶ 0:24:11So, what this looks like, our system cares for roughly 650,000 attributed patients across 18 valuebased programs, including Medicare, Medicare Advantage, Marketplace, and commercial plans. Our two ACOs in the Medicare shared savings program care for about 75,000 Medicare beneficiaries, and we are in the enhanced track, which assumes full downside risk.
▶ 0:24:33I'm proud to say our ACOs have been very successful in these programs, saving CMS over $90 million net since 2017 while maintaining while maintaining highest quality care. Our acco ranked in the top 4% for quality in 2024 and our physician quality partners acco ranked number one in the country in 2023 and 2024. Maintaining quality outcomes is our focus.
▶ 0:24:58Our physicianled clinically integrated network, Novalink, ensures collaboration between 900 independent clinicians and 4,000 Novant Health providers. It's developed evidence-based protocols such as best practices to reduce emergency room utilization and hospital readmissions based on the experiences and expertise of our frontline clinicians. Our population health service organizations is the engine for all this work.
▶ 0:25:22providing services like care management, community partnerships, practice transformation support, pharmacy collaboration, social needs in navigation, all backed by data and analytic chassis to support real-time risk identification and interventions. We use a unified electronic health record allowing our 2.6 million patients to access their information and providing us the ability to use predictive analytics and AI modeling to improve patient outcomes.
▶ 0:25:48Through this approach, we built a sepsis care protocol that led to a 40% reduction in septus sepsis mortality since 2021. That's 25 lives saved per month from sepsis. We also identified areas in our community needing more primary care access. Through our partnership with Michael Jordan and his family, our clinics in these neighborhoods have shown a 36% reduction in hospitalization and a 20% reduction in emergency room visits. Access is critical.
▶ 0:26:17Tellah health has further enabled care coordination. In 2024 alone, Novon Health delivered 373,000 teleaalth encounters. We were able to cut specialty care wait times from 80 days to less than 30. It's allowed more than 90% of our stroke patients to be rapidly diagnosed through our teley teley stroke program reducing time to care time to care saving vital brain tissue. Our teleahalth platform also supports hospital at home program which has a 98% patient satisfaction rate.
▶ 0:26:48Meeting patients where they are also means meeting them in community. Our coastal North Carolina, our community paramedics serve patients who fall through every other crack, such as those who lack stable housing or are experiencing behavioral health or substance abuse challenges. We also have a team of community health workers who focus on our high utilizer and rising risk patients. Their efforts in just one year have shown upwards of a 50% reduction in high acuity care, keeping patients out of crisis and improving outcomes.
▶ 0:27:15As we strengthen coordinated care, we must also find solutions to limit unnecessary regulations and reduce complexity for our patients and our providers. A recent white paper from the Novant Health Center for Public Policy Solutions outlined ways to simplify medic medical coding regulations. One example being to ensure that during an annual visit, providers can provide guidance for patients both on their wellness journey as well as address their chronic conditions. Like most of my colleagues, I became a doctor to care for the people in my community.
▶ 0:27:44I'm grateful for that opportunity and the opportunity today to share ways Novant Health continues to build care models that I envisioned when I went to medical school. With your partnership, we can continue to find solutions built on what we know works. team-based care, top oflicens work, aligned incentives, reduced regulation, and stable access to to virtual and community based care.
▶ 0:28:06On behalf of Novant Health and Novant Health Center for Public Policy and Solutions, I want to thank you for this opportunity, and we stand ready to support efforts that reduce complexity, empower patients and clinicians, and create a health system that keeps our community healthy. Thank you.
▶ 0:28:21That's a great story, the company. Great story. Uh, thank you, Miss Riker. You're
▶ 0:28:29Chairman Buchanan, Ranking Member Dogget, and members of the subcommittee. Thank you for the opportunity to testify today. My name is Allison Riker. I am a doctor of pharmacy, licensed pharmacist, and vice president of operations at Bodie Drug in Vienna and Mound City, Illinois. My family has operated in Southern Illinois for over a hundred years, and I've seen firsthand how pharmacists evolve to meet the needs of our communities.
▶ 0:28:54I am honored to speak with you today about the essential contributions pharmacists make in expanding access to care, particularly in rural communities like my own and the urgent need to empower pharmacists to help prevent and manage chronic conditions. In rural areas like mine, pharmacists are often the most accessible health care professionals. The pharmacy isn't just where people pick up medicine. It's their front door to the health care system.
▶ 0:29:19When a parent has a question at 700 p.m., when transportation is a barrier, or when a senior is managing multiple medications, the community pharmacist is often the only healthcare provider available. Many of my patients have my personal cell number. We offer after hours emergency lines, bring vaccines and screenings to workplaces and assisted living facilities, and provide chronic disease monitoring.
▶ 0:29:43These services are essential especially for patients managing conditions like hypertension, diabetes, CKD, COPD and heart disease. I see patients far more often than their other healthcare providers. I check blood pressures, review lab values, and identify adverse drug events. I communicate with physicians and advanced practice providers to intervene when needed.
▶ 0:30:05This will be enhanced as interoperability is strengthened among other providers and pharmacists, increasing access to real-time health data to collaborate more efficiently as members of the healthare team. Hospital pharmacists currently perform all of the functions I have described and more, often independently and in collaboration with other healthcare providers.
▶ 0:30:25Some states provide pharmacist prescriptive authority to adjust doses, change antibiotic therapy based on culture and sensitivity results, and switch IV medications to oral ones to facilitate discharge planning. These pharmacists have undergone identical didactic and clinical curriculums as community pharmacists. The difference lies in the access to data that drives clinical decisionmaking.
▶ 0:30:48Community pharmacists represent a currently underutilized health care resource with clinical training and skills to prevent the depletion of higher level services such as emergency departments. Let me share a few stories. A patient came in on a Friday afternoon with respiratory symptoms. The best I could do was send that patient to an emergency room 30 miles away. That's not sustainable.
▶ 0:31:11Another elderly patient wanted better coordination between their cardiologist and pharmacist, but the provider didn't have a pharmacist on staff. These stories show that there are gaps in health care that can be filled by pharmacist and that providers are willing to collaborate, but the system doesn't support it. We know that rural patients have higher rates of chronic health conditions compared to patients in urban areas and we know that there are fewer providers available to those patients.
▶ 0:31:38Rural community pharmacists are an environment where our patient population has higher rates of disease and fewer providers to manage these conditions. Preventative medicine and chronic health conditions can reduce hospitalizations, emergency department visits, and dramatically increase the quality of life in our patients. Providers cannot address what they do not know or see about their patients, and pharmacists can contribute a great deal of information on their patients that can be shared to improve outcomes.
▶ 0:32:06Legislation like HR 3164, the Ensuring Community Access to Pharmacist Services Act, would allow Medicare to reimburse pharmacists for services like testing and treating common conditions. This enables pharmacists to provide access to health care for Medicare beneficiaries that promotes reduced hospital ad readmissions, improves chronic disease management, and strengthens care teams. I was raised in a pharmacy. My father is a pharmacist, and it is part of my family's and my own identity.
▶ 0:32:35As I grew up, I saw the profession evolve from simple prescription and refill processing to patient education to medication therapy management to healthcare screenings and to most recently coordinating with physicians, advanced practice providers, and nurses to help treat patients with chronic health conditions. I have seen pharmacists provide quality care to patients in my community and across the country. But we can do more to help and I ask that you give us that opportunity.
▶ 0:33:02Thank you for your time and for your commitment into improving access to care. I look forward to your questions.
▶ 0:33:08And thank you Dr. Bookie. You're now rec
▶ 0:33:13Chairman Buchanan, Ranking Member Dogget, and members of the subcommittee. Thank you for this opportunity to speak with you. [clears throat] I'll try to speak slowly, but I'm excited. And I since I only have five minutes, I apologize if I start going at New Jersey speed. My name's Ashish Periq. I'm a primary care physician and the chief population health officer for Summit Health Village MD, a physician-led med uh medical group that is the medical home for over 750,000 individuals.
▶ 0:33:42We participate in outcomes based alternative payment models including the Medicare shared savings program as well as CMMI's acco model. Since we're discussing care uh coordination and chronic diseases, I want to start with a true patient story. A few months ago, my first patient in the clinic told me that she was having suicidal thoughts because of all the multiple multiple medical problems she was facing.
▶ 0:34:06I talked to her for a few minutes, but then I was able to connect her with an integrated behavioral health specialist through a virtual um tablet that we keep in our office and then I was able to leave the room to go see my other scheduled patients. About 45 minutes later, I went back in the room and together with the psychologist and the patient, we decided that it was safe for her to go home with very close follow-up with all of her care team members.
▶ 0:34:30This helped her avoid an unnecessary emergency room visit, which most likely would have ended up with a hospitalization, and it helped me stay on schedule so I didn't inconvenience all my other patients. This is what seamless team-based care looks like and what every patient deserves in America, especially the six out of 10 Americans you mentioned who who live with chronic diseases.
▶ 0:34:52But there are two major issues that limit provider groups from investing in the necessary population health infrastructure such as social work, nurse care managers, pharmacists, behavioral health services, and advanced technology and analytics needed for coordinated care. Those two issues are unstable reimbursement rates and misaligned incentives. First, reimbursement rates not not only from Medicare but from all other payers have not kept up with inflation.
▶ 0:35:20And this forces clinicians to focus on volume over outcomes leading to fragmented care that's reactive instead of proactive. So, we need to stabilize Medicare reimbursement rates. Uh and to that end, we thank CMS for finalizing the 2026 Medicare fee uh physician fee schedule, which prioritizes valuebased primary care. The second issue is that incentiv costs in a fee for service payment model.
▶ 0:35:51Alternative payment models can change that formula. Shared savings arrangements allow groups like ours and Novant um to invest in the care coordination services that I that I listed that allow our physicians to focus their limited time on complex decisionmaking and treatment plans. But do these investments in care coordination actually work? We have proven along with many other ACOs that they do lead to lower costs and better outcomes.
▶ 0:36:20Our ACOs have far higher annual wellness screening rates. cancer screening rates and diabetes and blood pressure control rates than the overall Medicare population. In our Medicare shared savings program, patients experience 38% fewer hospital uh emergency room visits and 30% lower hospital visits than the overall Medicare population. And all of this then secondarily the main out main goal is better outcomes.
▶ 0:36:46This does secondarily lead to savings both for CMS as well as for our groups to reinvest in population health. In 2023, our village medical a uh reach acos generated $140 million in gross savings and we expect even better outcomes in 24, but they're embargoed. And in MSSP in 2024, uh our two ACOs uh had gross savings of 35 million.
▶ 0:37:12So, in closing closing, uh we're grateful to the committee for supporting Ever Better Health and we urge you to continue action on these four recommendations. Strengthen Medicare reimbursement and ensure annual adjustments keep pace with rising practice costs. Continue advancing alternative payment models that appropriately share savings with those delivering highv value care.
▶ 0:37:35enhance payments that support preventive services and primary care, the foundation of chronic disease prevention and control, and make the pandemic era teleaalth flexibilities permanent to maintain access and continuity. The patient I described at the start received the right care in the right moment because our because our model allowed us to invest in the care coordination she needed. And I think every individual in America with or without chronic conditions deserves the same level of support.
▶ 0:38:02So on behalf of our clinicians and patients, I thank you for your leadership and for your commitment to strengthening Medicare and for advancing coordinated valuedriven care. And I look forward to your
▶ 0:38:13Thank you, Mr. Kadell. You you're
▶ 0:38:17Thank you, Chairman Buchanan, Ranking Member Dogget, members of the committee. My name is Brian Connell. I serve as vice president of federal affairs at Blood Cancer United, formerly the Leukemia Lymphoma Society where we represent the voice of nearly 2 million Americans living with a blood cancer We have a clear mission. It is to cure blood cancer and to improve the quality of life for patients and their families.
▶ 0:38:47It's an honor to participate in today's hearing, especially as a representative of the patients most affected by the action and the inaction that we see in Care coordination is an important topic as the standard of care requires ever greater specialized expertise. It has never been more necessary for treating clinicians to be in constant communication and alignment. Yet we cannot afford for provider coordination to become simply a synonym for provider consolidation.
▶ 0:39:18Consolidation is at the heart of the cost burden borne by patients today as well as consumers, employers, and Therefore, as policymakers seek to promote care coordination, it's essential to ensure that the incentives created do not inherently reward monopolistic health systems and disadvantage independent practices.
▶ 0:39:41But while coordinated care is a well-intentioned goal, for many Americans, any healthcare at all will soon become a luxury that they cannot afford. We are now only weeks away from a truly catastrophic event for many households across America. The expiration of the current enhanced premium tax credits. For 22 million Americans, the expiration of the enhanced tax credits will make their healthcare less affordable.
▶ 0:40:08In fact, for nearly two million people with a pre-existing condition, failure to authorize the enhanced tax credits will put healthc care coverage completely out of reach. John in Texas will pay $122 more every month. Kristen in Maine, $162 more. Brandy in Georgia, $221 more per month. Jill in Connecticut, $1,020 more per month.
▶ 0:40:36Kenny in North Carolina, a blood cancer patient, will have to pay $1,530 more every month in 2026 to keep his We are just 43 days away from these numbers taking effect. Some in Washington are suggesting that Congress should in the next few weeks uh scrap the current tax credits to that more than 20 million Americans rely on and start developing a new federal program from scratch.
▶ 0:41:03New rules, new systems, new unintended consequences. We urge you on behalf of each and every American who's losing sleep right now, not knowing how they'll get their care in January, to please give these families a lifeline. Extend the current premium tax credits.
▶ 0:41:24These Americans lives are too important to hang in the balance while Congress writes a new policy on the back of a With an extension in place that allows these families to continue to access their care that they need, Blood Cancer United will be first in line to work with Congress to enact policies that lower costs for all consumers while saving taxpayer dollars. Our test for whether a cost cutting idea is worth considering is simple.
▶ 0:41:54Ask yourself, would it make life better or worse for the Americans who need health care the most, people with pre-existing conditions? Any idea that hikes their costs, weakens their protections, and worsens their access to quality care is a bad idea. So today, as you seek to lower healthcare costs, you have a choice.
▶ 0:42:18You can choose to endorse and vote vote for the long list of policies that save money for consumers and taxpayers while also protecting people with pre-existing Or you can choose to achieve savings at the expense of people with pre-existing If your choice sacrifices the sickest families, America will be worse off. More Americans will be left with unthinkable medical debt. More Americans will be forced into bankruptcy.
▶ 0:42:48More Americans will have to shutter their small businesses. And more Americans will lose their loved ones too early, even when a cure for their condition is just behind the pharmacy counter. The choice is yours and on behalf of the nearly two million people living with the blood cancer, please choose wisely. Thank [music] you.
▶ 0:43:08Thank you for your testimony. We now proceed to the Q&A sessions, questions, and answers. And we'll start out with Mr. Smith.
▶ 0:43:15Thank you, Mr. Chairman. Thank you to all of our witnesses. Uh I'm tempted to go uh in a in a different direction than what I have here. uh maybe if I have time I'll do that based on the the last uh few comments. But I think we all know that our task is large when you look at uh uh chronic diseases. I mean just on the numbers over 800,000 Americans are living with endstage renal disease. 38 million with some form of diabetes.
▶ 0:43:42120 million Americans nearly one out of every two adults uh with hypertension. And these diseases obviously impact all of us either directly or certainly through family members. So treating these conditions are expensive as we know neglecting them is even even worse and even more expensive. So I hope that we can really take a close look at at how we can address healthcare hopefully bending the cost curve not not just shifting around who pays how much.
▶ 0:44:12We've been doing that since uh 2010, I think it is. And throwing money at the wall, hoping it'll help someone uh with with disregard to so many other things certainly is not what I think our task should be. But uh when we look at our trained professionals and and Mrs. Riker, thank you for being here. [clears throat] Excuse me.
▶ 0:44:35I'm a particular fan of of pharmacists and the the opportunity we have to tap into their ability uh not just in rural America that it might be my district but even urban communities where we know that there's more access to pharmacists than there are other providers and I think you know whether it's pharmacists physicians assistants nurse practitioners nurse anesthetists EMTs and even others you know I I think we and
▶ 0:45:05adjust our policy to meet the maximum opportunity of these professionals who can help care for patients. And I think we can do so in a very constructive way, ensuring that patients have have uh safety along the way and that we our our patients can be better off. But I'm particularly proud of my legislation. Thank you, Mrs. Riker, for mentioning it. The Ensuring Community Access to Pharmacy Services Act, we call it ECAPS.
▶ 0:45:33And this is something that I think is particularly uh important uh to to offer patients more options. We offer already offer Medicaid patients and a lot of commercial pay uh patients this opportunity for treatment testing and treatment from pharmacists but not Medicare. And we know that uh we we've got a a large portion of of patients under Medicare that we want um to to help.
▶ 0:46:03So, uh, I do have a couple questions, uh, Mrs. Reicher, and and again, thank you for being here. As you know, care coordination is essential for managing both acute and chronic health problems. In a state where a pharmacist would be able to test and treat for a disease like COVID or influenza, how would the pharmacist be able to inform the patients primary care provider about the encounter?
▶ 0:46:26Thank you for the question and thank you for the bill. Um so in in our current practice with collaboration with providers and test to treat our current form of communication is largely via telephone.
▶ 0:46:40And so I think that as we move forward enhanced interoperability uh would really be something that could help benefit not only the pharmacist uh provider relationship but also our patients in providing quicker outcomes for them. Um you know pharmacists work daily in collaboration with providers. This is something that's been a cornerstone of the pharmacy profession for as long as I can remember.
▶ 0:47:09But it is our our communications are often um largely you know prohibitive to telephones and so waiting for a call back or you know that sort of thing. So enhanced interoperability is something that I think could really provide better outcomes for our patients.
▶ 0:47:28Very good. Thank you. Now, I appreciated your uh reflection on your relationships with your patients. Uh that's pretty unique to communityarmacies. We also know that communityiesarmacies across the country have have suffered. Many have closed, especially in rural areas. Can you maybe expand on how uh the ECAPS bill could enhance opportunities for pharmacists to maintain practices all across the country?
▶ 0:47:53Yes, thank you. In my home state in Illinois, in 2024, we lost over a 100 pharmacies. And to me, that number is staggering. So legislation like ECAPS helps to preserve the care for those patients who need it most. So shifting the care from emergency rooms to community-based settings to more accessible settings for those patients really helps to preserve that care and helps to um preserve the thearmacies in that area.
▶ 0:48:23All right. Thank you. My time is expired. Thank you, Mr. Chairman.
▶ 0:48:26Thank you, Mr. Dogget. You're
▶ 0:48:28Thank you very much. Thanks to each of our witnesses. Uh, Miss Riker, we have that same problem with uh our communityarmacies vanishing all over Texas. I just have to say that uh while I'm pleased that there have been some legislative steps, if we have 15 million Americans, which is about to happen, lose their way of financing access for health care, it will not be only the physicians who are not getting patients in, but it will be our pharmacies that will have many patients
▶ 0:48:58that want to be able to pay for a prescription but can't do it. And Mr. Connell, you mentioned a number of people for whom uh the end of affordable care act uh tax credit increased enhance ones uh will be catastrophic. Are each of those individuals you mentioned from across the country people that have uh blood cancer or have someone in their family in that condition?
▶ 0:49:25Yes, the the folks I mentioned run the gamut of folks that have people that have conditions in their family. Um, some of the folks that I mentioned by name are are blood cancer patients are caregivers for people with blood cancer. Uh, Kenny, you know, I know from North Carolina, you know, is a blood cancer
▶ 0:49:41What will happen uh to those individuals you mentioned who are not just numbers but real people that have been in contact with you that are afflicted with conditions that uh all of us would dread to have for ourselves or a family member. What will happen is if instead of the Affordable Care Act, we do what President Trump said and just give them a couple thousand dollars and tell them to fend for themselves.
▶ 0:50:07Well, [clears throat] let's look at what we would replace if we uh decide to scrap um those uh tax credits. You know, we right now when consumers go to a market the marketplace uh they are shopping for whatever plan works best for them and they have essentially a discount code to lower the upfront cost of that so that the amount that they pay is is lowered uh kind of at that choice at that selection.
▶ 0:50:30If we scrap that system and we replace it with one that forces patients to buy plans with higher deductibles, much higher out-ofpocket costs, out- of- pocket limits uh for the year, even if we do set aside uh a few thousand, even several thousand to fund an HSA, uh we're just shifting more costs to the consumers. Um and we've seen it again and again that when we do shift those costs to patients, um they get stuck with more bills. They cut back on all their care, not just, you know, unnecessary care. care, they cut back on all their care.
▶ 0:51:00And people with a blood cancer obviously can't afford to do that. Um, and meanwhile, you know, some people might be better off in terms of their finances. Uh, you know, thousands of dollars sent into a bank account with your name on it,
▶ 0:51:12um, can be beneficial and unfortunately after age 65, uh, folks could be able to take that out of the bank and use it for boats or, you know, trip to Bali and instead of healthcare. You know, we want folks to be using the taxpayer dollars today to get the healthcare they need today. Really can't afford to to have that happen with HSAs.
▶ 0:51:32I noticed a a tweet from Mark Cuban of all people uh saying it is really really dumb because when you give it to insurance carriers under the Affordable Care Act, they have to spend at least of it on care for plan holders. when sent to people's HSAs, there's no assurance that the money will be spent on health care cost at all.
▶ 0:51:56So, if they they are fortunate and they don't have blood cancer or another dread disease, and they just keep the money in the account, as you were referencing, they can take it out without any penalty at all at age 65, go on a vacation, buy a boat, uh do whatever they want to with it. And unlike other uh accounts of this nature that are tax advantaged accounts, of course, they don't have to provide any verification at all.
▶ 0:52:21Uh if uh I'm using a flex account coming to your pharmacy, I've got to take and show the prescription I got in order to have the tax benefits. But under an HSA, your triple tax benefits uh and no verification at all. One of the other HSA problems, of course, employer is only providing these highdeductible plans.
▶ 0:52:43Uh the individual involved uh has no incentive to to have preventive care to go uh see someone for something that may cost a few hundred dollars when they don't have the money to do that. U and with this high deductible plan, they have no help on that at all.
▶ 0:53:01And then another problem with HSAs that I hope to see corrected with the HSA Consumer Protection Act that I'm will be filing uh is the fact that if you're not able to make use of the account, you're any value provided by your employer or you put in can be uh consumed with junk fees by those who manage the HSAs month after month.
▶ 0:53:26So while they may have some value for some individuals, certainly as a tax shelter as a substitute for the Affordable Care Act, they are no substitute. They are nothing care uh for the kind of folks you're talking about. Uh and uh would really present the catastrophe you've described if we're unable uh to maintain the Affordable Care Act and try to substitute something of this meager nature. Thank you very much. And thank you, Dr. Murphy.
▶ 0:53:56You're
▶ 0:53:57Thank you, Mr. Chairman. I hope we can stay on topic about talking about chronic disease, but since we've veered off, I just want to bring up a few things. Mr. Connell, I think your comments about consolidation were spot on. Um, the absolute destruction of the health care system uh has been, I believe, primarily driven by the consolidation in the last decade primarily. Um, but you went off the rails when you started talking about the impremium tax credit. So, let me let me bring some some facts back to you.
▶ 0:54:25The ACA was written by insurance companies for insurance companies. If you look at their profits since 2014, up up up up up. And what we've done as a federal government is ensure that insurance company profits have been sustained. When the CR came out of the Senate and it didn't have anything about um the continued of the enhanced temporary premium tax credits, guess what? Pull the top four insurance companies. Look at what their stock prices did. They went down. they went down. These are just facts. These are just facts.
▶ 0:54:56So, these were temporary. And let me ask you a question here because I think facts matter. You're talking about gloom and doom. People are going to um you know crash and burn. How much prior to the enhanced premium tax credits did someone who was at 100% poverty level pay per year for Obamacare? Do you know that by any chance?
▶ 0:55:16I don't have that number on me. No. So someone who made $15,000 or let's say a family of four paid about $400 for their healthcare. So with the enhanced premium tax credits, it went to zero. So we're asking them to pay a little bit of money for their healthare. That's not going to put them in the uh you know, good lord, look at what happened inflationary period during the Biden administration. That is what put people as far as not being able to afford things.
▶ 0:55:42And as far as this nonsense about vacations to Bali and everything, I wish we'd stopped that hyperbole. Nobody's doing that. Nobody's doing that. You know, I if you believe and let me ask you this. Do you believe that patients should have a choice in their healthcare or should that we as a federal government tell them what to do with their healthcare? That's what HSAs are about. They give patients choices. That's what they do. And so, nobody's getting rich on these things.
▶ 0:56:09My premiums have gone up 100% because I'm on the exchange because I have to be as a member of Congress have gone up 100% in four years. The issue and the problems are is that this this city, this government has been feeding an insurance industry with its insatiable appetite for more and more and more. So we we we fund the impre enhanced premium tax just credit from before. You have six million people who never filed a claim. Maybe up to 12 million people who've never filed a claim.
▶ 0:56:38They don't even know they're on this plan. Guess what? Checks go directly from the federal government into United's pocket. That's what happens. Look, we need efficiency. We need accountability. I want Look, good lord, I've been taking care of poor people for 35 years. I want them to get care. But you know what? A little skin in the game is never a bad thing. And the fact that insurance companies have become rich off Obamacare is anathema to what we should be doing about healthcare. Dr. Hoben, um, let's talk medicine here for a second.
▶ 0:57:08because we want to talk about chronic disease. What do you think is the biggest driver of chronic disease in the country? If you had to say one thing, what what is what makes the American if you compare us to Britain Britain or Italy or France, what drives us more into chronic disease than anything else?
▶ 0:57:25So I appre appreciate the question as you know there are lots of things that drive it but one of the one of the largest is in my opinion lifestyle choices and access to healthy food access and time to exercise and things that drive those healthy behaviors and in and lack of incentives around those.
▶ 0:57:41So what is the federal government's role in trying to change that? I would I would submit this is a hard hard question because people have choices. I live in eastern North Carolina. There's um fast food everywhere. Um there are food deserts everywhere. People have don't have much choice. But I I believe 100% that a lot of chronic disease in this country, a lot of it's genetics, especially minority populations, higher rate of endstage renal disease, cardiac disease, diabetes, obesity, etc., etc.
▶ 0:58:12A lot has to do with genetics, but a lot has to do with choices. I wish I knew how to put the genie back in the bottle. We look at ultrarocessed foods and the maho movement is spot on spot on about how we are poisoning our body. Look, I I love me a cheddar bow biscuit every once a year and you know everybody does but I think we are driving this issue and I don't know how and I've really really thought very very hard about this how we put that genie back in the bottle other than through education.
▶ 0:58:41Other than through education um Mr. Riker if I can ask just a quick question here first. Um,
▶ 0:58:49there are a lot of good models about how pharmacists work together with doctors. How am I going to prevent somebody when you have TV commercials that said got COVID need Paxlovid for pharmacists to just give everybody paxlovid
▶ 0:59:04especially if they're employed. I'll go back to a little vertical integration here by PBMs and insurance companies. I I got just answer real quick if you
▶ 0:59:11Yes, thank you. Um, well, I believe that, you know, pharmacists are medication experts and so by allowing pharmacists to test to treat, we would only treat a patient if it were appropriate. Um, I don't believe, you know, we're just going to be out handing out packs of
▶ 0:59:28I don't I don't think so either. I I really don't. I I love our pharmacist, have wonderful relationships with them. I do worry about in the world of vertical integration about perverse incentives from insurance companies that own pharmacies, etc., etc., that this would happen. So, thank you, Mr. Mr. Chairman, I'll yield back.
▶ 0:59:43Thank you, Mr. Thompson. You're
▶ 0:59:46Thank you, Mr. Chairman. I want to thank all the witnesses for being here today. Uh care coordination throughout our health care system is essential to ensuring patients the best outcomes possible. But, you know, we can't discuss care coordination if patients can't get the insurance they need in order to see a doctor. And over the last six months, our congressional Republican friends cut $1 trillion dollar from Medicaid.
▶ 1:00:13And they failed to extend the enhanced premium tax credits that make insurance affordable for middle class Americans. Now 15 million Americans are losing their health coverage. If you're lucky, your nearest hospital has only had to reduce services in order to keep the doors open, laying off staff. But some facilities have been forced to close or they are closing altogether.
▶ 1:00:42And I'd like to offer uh this uh article about some rural health clinics being closed, Mr. Chairman, into the record.
▶ 1:00:52And and I I don't want to hear that. Yeah, but but we gave them $50 billion because that same ugly bill cut 136 billion and that and 50 billion put it put back in doesn't make up the difference. And under the Republican control, patients are seeing their health care costs skyrocket because they failed to extend the Affordable Care Acts premium tax credits.
▶ 1:01:19And as a result, millions of Americans health care premiums are set to double and in some instances even triple. Millions of Americans will be unable to afford health insurance coverage come January 1st because our Republican friends refused to act. But it's not just ACA enrolles who are seeing their health care costs go up.
▶ 1:01:45The Trump administration just announced that Medicare PartB premiums will increase And that's uh following on a Social Security bump of only 2.6%. So between Medicare and the ACA premium increases, Americans are going to be spending more of their hard-earned money on health care because of these failed policies.
▶ 1:02:10Patients are losing their insurance and patients are losing their access to health care and patients who are fortunate enough to have coverage can't even rely on access uh for teleaalth services and Dr. Hoben thank you for bringing uh this up. Health care has been a godscent. It's improved the lives of millions of people and we need to extend it.
▶ 1:02:37we need to extend it uh now and in rural parts of the country and I I represent a lot of those rural areas Americans are facing those hospital closures clinic closures and to get improved health care outcomes uh they're going to have to rely on telea medicine and when tea health flexibilities expire expired during the shutdown patients went without care I heard from one constituent of mine who said that because of teleaalth,
▶ 1:03:08she was able to get the consistent level of care for her chronic uh disease. But when the health care uh when the teleaalth expired and the Republicans failed to uh to allow us to extend it, uh she has to pay a hundred bucks each way to Uber to her health care. That's not making health care uh more affordable. And uh I have legislation with Mr.
▶ 1:03:35Swiker, who's a member of of this committee, has got over 150 co-sponsors and another 65 co-sponsors in the Senate. Uh that would make it permanent. And I would u I would really appreciate if the chairman would work with us to uh bring that up so we can pass that and uh and and provide better health care. Uh so Mr. McConnell, can you explain how it would would be even even be possible for a patient to get care without healthc care coverage
▶ 1:04:07for blood cancer which is one of the most expensive uh treatments you can or conditions you can have um but like a lot of other pre-existing conditions there are no self-pay cancer patients in United States of America the the costs are enormous absolutely enormous uh patient the cost of providing care for a blood cancer patient in their first year is about uh $500 to a million dollars u and that it adds after that. So it's unconscionable for someone to pay pay
▶ 1:04:34Will tella health uh provide better access for people across all of our
▶ 1:04:39Yeah, I think tellahalth is a is a great arrow in the quiver for patients and providers as they seek to to treat especially complex conditions like like
▶ 1:04:46Saves lives, saves money.
▶ 1:04:48Thank you very much. Yield back.
▶ 1:04:54Thank you, Mr. Kelly. Thank you, chairman. Um, we all get five minutes to talk, but I think what I'm going to do is I'm going to take my time because I'm an automobile dealer. I'm not in healthcare. I want to go to my friend here beside me who lives this every single day. And you know, when he goes home from Congress, you know what he does? He takes care of patients back in Carolina. So, Dr. Murphy, I'm fascinated because you have a depth of knowledge that uh transcends a lot of what we would be doing up here. We get notes and we say, "Here, ask them this question.
▶ 1:05:23Ask them that question." I want to talk to somebody who actually does this. Dr.
▶ 1:05:28thank you. I I would love Dr. Periq. Let me ask just a few questions. I love your knowledge on this stuff. So, you know, I think about what's trying to what drives the cost of healthcare now? What drives the price of this right now? And I I I look at so many different things. You know, the insurance company profits are a huge part. I I would love your experience and what your thoughts are. What are the main drivers of the cost? We're we can debate on subsidies from the government. um whether they're appropriate, not or do we keep just shilling out money?
▶ 1:05:58Um how can we bring the cost of this health care down? I think that's really critical. It's the it's the question that needs to be asked a lot more and it needs to be answered a lot more. So I'm just interested you practice. How do you think we do it?
▶ 1:06:10Yeah. So I could [clears throat] speak to it from the physician or medical group point of view. I think what you brought up earlier is very important that a lot of healthcare comes from disease that are preventable. So I think that doubling down on prevention on preventive screening and preventive services is one way that that we can uh make sure that longer term health care costs don't continue to skyrocket. This is a delayed gratification, right?
▶ 1:06:36If you're if you're uh screening everybody for colon cancer today, you may actually increase cost of care, but in the long run, this is going to be better for our population and reduce cost of care. So that's one thing. And the second thing as I've mentioned is aligning the incentive so that all stakeholders in the health care system are held accountable to best outcomes for the patients.
▶ 1:06:58When people are uh incentivized to just do more for this uh patient here and and more for this patient there without any coordination without any communication you it ends up with duplicative uh avoidable preventable uh services being uh given to patients and and complication then later.
▶ 1:07:18So I think when you drive with value, when you hold people accountable for their population, making sure that you not only um get paid for the patients you see, but you're accountable for the patients don't come in to see you so that you can bring them in, give them the preventive services, give them care so that their diseases don't progress uh are ways that we can uh continue to make healthcare affordable and accessible for everybody.
▶ 1:07:40I I I would agree completely and this is truth be told trying to be absolutely objective one of sometimes the downside part of fee for service. I I I mean I'll be very plain and service. I lived in that world for for 25 years. My practice went bankrupt the day I resigned because our my uh my margin or my payer mix was 75% Medicaid, Medicare, no insurance. You can't pay the bills on these things. You can't pay the bills. But I also want to get us back to the fact again the fact that patients have choice about doing things.
▶ 1:08:10You look at my emergency department, it is flooded with individuals who don't want to go to a primary care doctor, don't take the time, come in at 2 am, etc., which is an infinitely more expensive place of care. ACOs and actually the whole purpose of Medicare Advantage was to try to lower costs again supposed to be 95% of fee for service. It's turned in 122%. We know where most of that money is going now to insurance companies.
▶ 1:08:36But if you look at where we're going and the challenges that we face, we are living longer primarily because we intervene. We intervene with more tests, more studies, more treatments for leukemia, more transplants, etc., etc. We do the best in the world on so many things. We don't do a great job on other ones. A lot of that has to do with patient choice. A lot of it has to do with genetics. A lot has to do with the heterogeneity of our populations.
▶ 1:09:05So I don't know how we change that. This isn't a very important thing. But constantly throwing money at problems is a different ethos that I can't subscribe to. That doesn't fix the root cause of these problems. Doing coordinated care, I agree 100%. The electronic medical record, the cost of it, I think the juryy's still out on this.
▶ 1:09:26It's a good tool, but how much millions upon millions upon millions, if not billions now have been spent in electronic medical record that not only causes angst to physicians, it causes angst to patients because you're looking at a computer screen. It turned out it basically was a billing model that turned into a computer medical record. These are challenges that we face, but we have to address the causes of the healthcare in the issue rather than just pouring money into a failing system. Thank you, Mr. Chairman. I'll yield back. Thank you, Mr.
▶ 1:09:56Chup.
▶ 1:09:58The topic of today's hearing is about modernizing care coordination to treat pre and prevent chronic diseases. But we cannot coordinate care for people if they do not have health coverage to begin with. And that is the crisis we are facing today because of Donald Trump and Republicans betrayal of their promise to lower costs for the American people. Just four months ago, Republicans stripped health coverage from 15 million people.
▶ 1:10:26Then for eight weeks, they kept our government shutdown because they refuse to extend the ACA premium tax credits that make coverage affordable for millions more. So that brings us to today where we were just 42 days away from 22 million Americans seeing their premiums double, triple, or even quadruple in cost.
▶ 1:10:50People from my home state of California will pay over $1,000 more per month per on average. And I've heard so many of my constituents who will suffer immensely from this reckless refusal. Now I represent the areas that were devastated by the wildfires, Aladena and Pasadena, and they have contacted me. They are frantic.
▶ 1:11:16Jenny from Altadena, who is a single mother, a small business owner who saw her home burn down and everything she owned in the Eaton fire says that now her premium is more than doubling, going from $350 a month to $800 a month.
▶ 1:11:37Another constituent battling serious health issues told me her insurance is going up by more than $300 per month and she doesn't know how she'll be able to keep paying for By the way, I've heard some of my colleagues talk about insurance company profits and that's why they are against extending the ACA.
▶ 1:12:00I'd just like to remind my colleagues that insurance companies make their biggest margins not from the ACA or the individual market like my colleagues would like you to believe. The biggest insurance company's margin is from Medicare advantage. Medicare advantage margins are almost double other lines of business.
▶ 1:12:25So if we are talking about why insurance company profits increase, we need to look at the cause, we need to look at Medicare But back to the issue of losing ACA premium tax Mr.
▶ 1:12:46McConnell, after more than a decade of promising to replace the ACA with no actual plan and now an outright refusal to stop these cat catastrophic premium spikes that they've known about all year, what does Republican inaction mean for people like your members, people with blood cancer who cannot survive one month without coverage.
▶ 1:13:11Let's just say they decide after their sticker shock of looking at oh their mailbox and and seeing that it's going to double and they can't afford it.
▶ 1:13:20I'm I'm just wondering with somebody with leukemia and other kinds of blood cancers, what will happen January, February, March, tell me what the progression would be.
▶ 1:13:29Yeah, I mean it's not an academic question. Um, we expect about 1.7 million people with a a chronic condition or a pre-existing condition like a blood cancer to lose coverage just next year if these expire. Um, you know what happens? Their conditions will worsen. Uh, if you don't if you're unable to access your course of treatment, it gets it gets worse. Um, when you lose access to your meds, um, to your doctors, many will become too sick to work. You know, the folks on the exchanges are working Americans.
▶ 1:13:58Um, they will end up in the ER. um they will rack up tens of thousands of dollars in medical bills that they'll never be able to pay. Uh they'll exhaust their savings, they'll exhaust their kids, college funds, um the charity of their friends and their neighbors. Um we we at Blood Can United know people in this situation [music] in the past and and this is what we expect to see again. And you know, sadly many will there will be some uh many will succumb to their condition um as a result.
▶ 1:14:29And now, let me say, I know Republicans, uh, there are many that want to eliminate these tax credits and replace them with HSAs, health savings accounts. But the reality is HSAs simply do not function as a replacement. HSAs cannot be used to pay premiums. People would still face the full unsubsidized cost of insurance every month. No wonder Mark Cuban said this is dumb. Really, really dumb.
▶ 1:14:54He said that when money goes to the ACA, 85% must go to the plan to the care for the plan holders, but money going to an HSA doesn't have to be spent on [music] healthcare at all. Indeed, they can take it out and throw big parties, and that's not right.
▶ 1:15:13Thank you, Mr. Hearn. You're recognized.
▶ 1:15:15Thank you, Mr. Chairman, uh, for holding this hearing, and thank you to our witnesses for being here today. I saw a lot of head shaking yes when Dr. Murphy was talking. I'll come back to that in a minute. Representing a state like Oklahoma showed me how fractured our health care system really is. Uh rural patients have trouble finding specialists who are nearby or feel a primary care appointment is not worth a 2-hour drive. A couple of years ago, I saw something incredible that the Oklahoma State University Medical School is doing that was a great answer to these problems.
▶ 1:15:43Their medical school has collaborated with their extension programs to offer the great folks of Oklahoma mobile virtual care vans. The focus of the OSU mobile care program is to quote concentrate on non-life-threatening conditions like common illnesses, chronic disease processes, and minor energy injuries with the goal of providing accessible care to rural communities of Oklahoma. They focus on chronic disease management such as diabetes, high blood pressure, and simple medication refills.
▶ 1:16:12They also treat minor injuries with preventive uh infections and keep people out of the emergency departments. In addition to on-site treatment, the staff can connect patients with primary care physicians if they do not currently have one. This helps ensures patients have ongoing trusted relationships for follow-up care. Navigating the health care system can be a considerable burden for many patients. So having a professional there to help ease this burden helps dramatically.
▶ 1:16:41The success they've seen goes to show how vital teleaalth and mobile health is for our rur rural communities. My colleague Congressman Moyan from Guam was just telling me the other day about how teleaalth is so important to our territories. I'm incredibly proud of OSU and director Jared Dro for being innovative and meeting Oklahomaans where they are. And this is just the type of care I think needs to be applauded and expanded. Dr.
▶ 1:17:07Hoben, what benefits have you seen for patients and the local health system when communities have access to mobile health clinics?
▶ 1:17:15Thank you for the question. I think what you describe is exactly right. Lack of access creates poorer outcomes when it comes to chronic disease management. And so the telealth opportunities, the mobile opportunities, the connect, the quick connectivity to both primary care and specialty care through those easier access venues is where we will land on better outcomes and reduce cost because we're decreasing the complications and the emergency care versus more the chronic prevention care.
▶ 1:17:44I appreciate that. You know, my colleagues on the other side talked about the promise that Republicans Donald Trump made about lowering health care costs. Uh, I wonder how that lays in comparison to the promise in 2010 with Obamacare where you could keep your doctor, health care costs would be lower, access [snorts] would be greater. And since that time, we've had 80% increases in health care costs. Doctors, second [snorts] generation doctors are no longer going into practice because they can't afford the medical school and the payment afterwards.
▶ 1:18:13So, they go to work for hospitals if they stay in the business. We've had some 150 hospital closures since then. all of these prior to the one big beautiful bill. But it's also interesting, you know, some would describe that as reckless when many people, as Dr. Murphy, who practices every single day, would tell you that anytime you do that, you're going to have a real problem with your health care system.
▶ 1:18:37And just as they predicted, here we are today trying to figure out through patchwork to make this a better I I would like for anybody to answer this question because I think there's been a real convolution of the message when it comes to premium tax credits that nobody seems to want to delve into. But you you say that they're going people are going to lose health care costs, Mr. Connell or healthare.
▶ 1:19:02Um for every there's 168 million people on employer health care plans. Does the premium tax credit help lower their cost at all? the premium tax credit only goes to folks who are buying plans on the marketplace, not folks who are getting coverage through their [music] employer. So, so just for the record, um, when you see your plan go up as mine did, because I I don't do anything with the government. I I still have my private plan from being in business for 35 years and I pay 100% of it.
▶ 1:19:31And so Kevin in Oklahoma, as you describe Susie in Wyoming or whatever, Kevin in Oklahoma, my monthly prem are going up 500 bucks a month. And so the premium tax credits do nothing for me. Correct.
▶ 1:19:43The premium tax credits don't go to people who are unemployed sponsored
▶ 1:19:47So I think that's important to note, right? I mean theund almost 170 million people that have a plan with their employers will see increases in their plan because of why? Because the underlying health care costs are exorbitant on a per patient basis. We spend more on a per capita basis in America than anywhere else in the world. I think everybody would agree with that.
▶ 1:20:07And so we have an underlying responsibility to lower health care costs for all Americans, not just 2 million or the expanded COVID relief that the news from my Democrat colleagues is CO is over. They're the ones that set the two-year expiration at the end of 2025, not us. And they're asking us to extend what they thought should expire as well. And so we're going to work together, assuming our Democrat colleagues want to work together to try to figure out how to lower health care costs for everyone. All Americans.
▶ 1:20:38We all work for all Americans, not just a sliver. I yield
▶ 1:20:43Thank you, Mrs. Miller. You're
▶ 1:20:46Thank you, Chairman Buchanan and Ranking Member Dogget. And thank all you all for being here today and taking the time to speak with us. I'm from West Virginia. Of West Virginia's 1.7 million residents, 1.2 million live with at least one chronic disease and more than manage two or more. This is an alarming burden for a state of this size.
▶ 1:21:15For these chronic disease patients in rural West Virginia, pharmacists are not just someone who fills their prescriptions. They are often the most accessible and trusted health care professionals for patients managing chronic conditions like diabetes, hypertension, and heart disease. Independent pharmacies, for this reason, have long served as a frontline access point for patient cares in rural communities.
▶ 1:21:42I remember when my children were little, I often would talk to the pharmacist before I'd ever bothered to call the pediatrician. Unfortunately, as we know, many of the umarmacies are closing at an alarming rate.
▶ 1:22:00Miss Riker, can you speak on how pharmacists have stepped up as community providers in rural areas and how federal rec recognition of pharmacist clinical services could actually help stabilize these businesses and preserve access to care in communities like mine?
▶ 1:22:18Yes, thank you for the question. Pharmacists are an underutilized healthc care resource with training and clinical abilities to reduce ER visits, hospitalization, and increase quality of life for patients. When pharmacists are empowered to provide preventative care, we know that hospitalizations and readmissions goes down. ECAP's legislation helps Medicare to spend smarter.
▶ 1:22:44It shifts cares from ER to accessible community-based settings where we have access to care for our patients who may otherwise go without. In the rural area where I'm from in southern Illinois, the nearest emergency room is 30 to 40 miles away. And I gave that example in my testimony. Patient comes into my pharmacy, that's the best option I have to give them is say, "Oh, you think you have the flu? Go to the emergency room." That's just not sustainable.
▶ 1:23:11And I know as a healthcare provider that that's not coste effective either. If we could provide these services and be empowered to provide these services for our Medicare beneficiaries in our own communities, I really do feel that we could make an impactful difference for them.
▶ 1:23:25Thank you. A particularly vulnerable group of chronic disease patients are Americans that are living with kidney disease and kidney failure. Later this week, Representative Su and I will be introducing the Kidney Care Access Protection Act, a bipartisan bill that takes important steps to stabilize the kidney care system while we work toward broader payment reforms.
▶ 1:23:50This legislation ensures patients can continue receiving highquality care and innovative new treatments can actually reach them without delay. Dr. Hoben chronic kidney disease management hinges on patient education, diet, medication adherence, and blood pressure control.
▶ 1:24:10Can you discuss how innovations in care delivery, including education programs or digital health tools featuring multidisciplinary care teams, might actually strengthen patient engagement and improve kidney health outcomes in underserved areas?
▶ 1:24:26Absolutely. And and thank you for the question. You're right. um chronic kidney kidney disease is a crisis in this country due to downstream effects from high blood pressure and diabetes and I think one of the main ways we tackle that is the collaborative care that Miss Riker talked about.
▶ 1:24:41So those patients need wraparound care with diabetic educators and with nurse care managers and partnerships with pharmacists and partnerships with nutrition all on the e on the education side and access to that is easily done virtually so they can connect to those providers in a virtual way and then leave to the physicians the more complex decisions that need to be made around further management. I think it'd be remiss to say we also need to get upstream of it.
▶ 1:25:07So you talked about that in your community with the one to two chronic diseases in so many of your um constituents in Western Virginia. We have to get upstream and prevent the progression of the diabetes and the high blood pressure. So remote patient monitoring, sending that data back to a care manager who can assess that and then elevated to the level that if there needs to be management to the pharmacist or the physician to help manage those decisions on the next best treatment.
▶ 1:25:32If we've already maximized lifestyle modification, the care model has to be collaborative and it has to be top oflic work for each one of us who are providers in the health care system.
▶ 1:25:43Thank you. I yield back.
▶ 1:25:45Thank you, Mr. Evans. You're recognized.
▶ 1:25:51Thank you, Mr. Chairman. I also want to to improve our health care system for Americans with chronic conditions. Unfortunately, Republicans are rejecting the chance to actually help patients by continuing the ACA tax credit.
▶ 1:26:09One of my constituents is self-employed and a caregiver to her Through the ACA marketplace, her premier will already nearly $1,500 a month. She has a chronic disease and told my office she does not know what she will do if the premium goes up. Mr. Connie, is it that expiring ACA credit could cause all insurance premiums to rise?
▶ 1:26:40It is true that without the enhanced premium tax credit um almost everyone on the ACA exchanges will see [music] some increase uh in their premiums. uh some might be smaller and some are as high as uh $1,500 $2,000 uh every single month.
▶ 1:26:57Mr. Connley, we all know that chronic disease put a heavy financial strain on patients. Can you talk about how Republican proposals to repeal the ACA will affect people with chronic disease and disabilities? Well, I'll say, you know, we we don't I haven't seen any proposal.
▶ 1:27:20Um I think we hear in the news proposals around uh HSAs, health savings accounts, um that have to be paired with uh high deductible uh plans and plans that have uh essentially the highest out-of- pocket that you can have on the exchanges, like a bronze plan, um to have about $18,000 um annual maximum out of pocket. Um the worst thing if you have a condition like a blood cancer is to be in a plan with a very high deductible and a very high maximum out of pocket.
▶ 1:27:48Um when that happens, you know, folks uh see their bills quickly mount. Um weeks later, debt collections uh the debt collectors call um and they right out of the gate threaten to put a lean on your house or threaten to garnish your wages um sometimes while you're in the hospital. U this happens to blood cancer patients every single day.
▶ 1:28:09Um and so there's some care that actually requires you to pay upfront and uh like at a pharmacy counter generally you have to pay uh before you get the med u and so there are also patients who will just um be completely unable uh to access their their care as a result of um you having those extraordinary out-of- pocket costs that are seemingly a part of of that So as you have just stated and you have observed this particular
▶ 1:28:40situation that's occurring what sense do you have you telling us here members Democrats and Republicans what's your advice to that you telling
▶ 1:28:56My advice is a a two-part plan. uh it is to extend these tax credits today because we have you know 40 days left. There's not enough time to come up with a comprehensive plan to replace or even contemplate adjusting really the affordable care act. Uh it's a complicated system and it requires thoughtful approach. Uh that would have been great earlier this year but I think now we don't have that time on our hands. Uh so I think we have to first extend the enhanced preune tax credits.
▶ 1:29:23Second, you know, I will say in my written testimony, I think I have about a trillion dollars worth of savings that actually is patient friendly and lowers healthcare costs for everyone, not just folks on the exchanges, but folks in employer plans, folks in Medicare. Um, you know, we need to have a conversation around costs to bring everyone's costs down and that will reduce everyone's premiums once we are able to have those folks not hanging in the balance um because of the expiration of these tax I hate to put you on the spot again.
▶ 1:29:54Are you optimistic that someone will be listening to you?
▶ 1:29:59You have to be optimistic. Um there's a lot of patients that I've met just this year. I've worked at Blood Cancer United for 11 years. U I've met a lot of blood cancer patients. I've met a lot this year who rely on the premium tax credits. Um and they are some of them I'm sure watching now. Um they're definitely watching what Congress is doing and they are afraid. Um and I think working on their behalf um we have to be optimistic.
▶ 1:30:26Thank you, Mr. Chairman.
▶ 1:30:28Thank you, Mr. Fitzpatrick. You're
▶ 1:30:31Thank you, Chairman, and thank you to the ranking member for holding this hearing. Thank you all for being here. With a majority of Americans managing at least one chronic disease, care coordination is essential for better healthcare delivery for Medicare patients. unfortunately has been laid bare here in this hearing. Uh fragmented care delivery has become the new normal with Medicare beneficiaries seeing 50% more specialists for care compared to just two years ago.
▶ 1:30:59Fragmented care also has resulted in thousands more in health care spending per Medicare patient which would uh would would be entirely preventable uh with proper coordination efforts for physicians to have time to focus on patient care itself. Uh one specific aspect of care coordination for those struggling with chronic disease uh I want to discuss is the use of teleaalth.
▶ 1:31:25Teleahalth services have allowed patients to more frequently engage with their healthc care providers for follow-up appointments and improve their treatment adherence. Tellahalth has made it easier for specialists and primary care physicians to work together to improve care for patients with complex chronic conditions. This has directly led to fewer hospital readmissions and as well as greater healthcare savings. Uh Dr. Dr.
▶ 1:31:52Hobin, can you speak to the specific ways that your provider group um has utilized teleaalth for treating chronic disease and what were the impacts uh to these services with the lapse of Medicare payments during the recent government
▶ 1:32:08Thank you for the question. So, we've leveraged teley health significantly when it comes to managing chronic disease by access points to the right level of care. So our chronic care managers who are RNs that help do a lot of chronic maintenance monitoring data like blood pressure values or blood sugar values tells connected to our farmd who connect to the advancing of medications or titration of medications to control those conditions and prevent crisis and prevent
▶ 1:32:38urgent and emerging conditions from happening. So it it's been a huge help for the patients that we take care of and we serve in reducing their utilization for higher cost venues like the emergency room and the hospital. Um obviously that was not accessible for some of those Medicare patients during that time. So that was certainly a challenge and we certainly appreciate that being opened up because it it is a large tool that we have to enhance the the long-term positive outcomes for the patients that we serve.
▶ 1:33:07Thank you. Uh Dr. Pri I want to jump to another barrier to care coordination and that's the unstable Medicare physician payment system um and the successes seen um in examples of valuebased care. Um your group has utilized uh alternate uh payment models uh offered by CMS.
▶ 1:33:26Can you speak to the specifics of this model and how um you have seen it impact patient outcomes and beyond the patient outcomes how has this model impact uh impacted overall health care costs? So essentially [clears throat] in an alternative alternative payment model instead of getting paid or in addition to getting paid for the services you're providing at the end of the year they look at the outcomes for the population that's attributed to us.
▶ 1:33:55So if we have make a simple number of 100,000 patients at the end of the [snorts] they they look at all the conditions that the patient has had and all the utilization from the year before and they set a specific cost benchmark at the end of the year then they look and did we keep the cost below that expected cost benchmark but more importantly they make sure that this wasn't done by withholding right we're giving better care to keep cost of care down uh and so we are reporting on quality metrics on these patient So
▶ 1:34:25that holds us accountable for this population. For the people coming in with chronic conditions, we're focusing on primary prevention, right? So they don't get a new new chronic condition, screening, education, weight loss. Secondary prevention that [clears throat] diabetes doesn't get worse and and cause blindness, cause vascular disease, cause heart attacks. And then tertiary prevention, those people already have the complications that they don't get worse if they've got retinopathy that we treat it early and and prevent them from from going blind. So that's one part of it.
▶ 1:34:55The second part of it is that now we're accountable for patients who are not coming in. Right? So now we have registries and we use uh analytics to make sure that the patients that we are um accountable for have diabetes but just haven't come in that that we reach out to them. We bring them in we if they can't come in use tele medicine uh to make sure that they get the care that that they need.
▶ 1:35:16And what the outcomes from this show is as as I've I've said earlier is that that when you use an accountable care organization, those patients particularly MSSP, Medicare Share Savings and AC Reach have shown that they have higher screening rates, they have better chronic condition management, they have lower emergency room visits, they have lower hospitalizations, and then with all of that lower cost of care. Medicare SA saves money and then we get some of that uh shared savings to again reinvest in care coordination.
▶ 1:35:47Thank you. I yield back, Mr. Chairman.
▶ 1:35:49Thank you, Mr. Moore. You're recognized.
▶ 1:35:51Thank you, Chairman. Um Mr. Connell, you just uh highlighted one of the limitations with held savings accounts by mentioning that they are primarily focused or used only in high [snorts] deductible plans. You highlighted that that's a that's an issue.
▶ 1:36:08I've the earlier this year I introduced um it's called the hope the hope act the the hope act the health out of pocket expense um hope act HR955 what this bill does is um you know it's a critical step towards getting better healthcare access to to more people it would create flexible tax advantaged hope accounts that any insured American regardless of income could use for everyday medical costs um
▶ 1:36:39modernizing the way that they they use these um flexible spending accounts and count on your support for this bill.
▶ 1:36:47I'm encouraged
▶ 1:36:48you basically just endorsed it.
▶ 1:36:49I'm encouraged by what I hear. Um, but I know enough about tax and healthcare policy to know that I don't know uh until I look at the details.
▶ 1:36:56And that's what I'm highlighting it for you to sincerely look at this. And I hope we can move past this like what what I just heard too like oh HSA accounts I mean used by millions of Americans to be able to to to to you know choose how to um get a tax advantage way uh having the choice and the ability to lower their own costs and make it more affordable.
▶ 1:37:19And we all we all I hear from my colleagues on the left is, "Oh, they throw parties with this stuff or this is for retirement." I'm getting sick and tired of it. This has been a huge penetration of of Americans that have said, "This is a great way to help more affordable." And we have something right in front of us. It's a bipartisan. It's been introduced in this committee. Um, and I'm hoping that it gets some traction so we can actually address the issues because what my also my colleagues have said, we just keep throwing money.
▶ 1:37:49um at a subsidy, it's never going to make, you know, consumer choice drive a market to affordability. So, I appreciate your willingness to take a look at this. Miss Riker, this committee's been fortunate to hear from CMS director Dr. Oz several times and we've been pleased with the work the CMS is doing on the rural implement the rural health transformation program and its implementation. One of the things Dr. draws has stressed the importance of allowing pharmacists to practice at the top of their license or take more expanded and active role in patient care which they are educated and equipped to do.
▶ 1:38:19What opportunities and benefits do you see for pharmacists to take more active roles in chronic care management, testing and treatment for Medicare
▶ 1:38:26Yes, thank you for this question. As we've said before, pharmacists are an underutilized healthcare resource. We have training and clinical abilities to reduce ER visits, hospitalization and increase outcomes. So legislation like ECAPS helps to empower Medicare beneficiaries by providing coverage for test to treat testing and treatment by pharmacists. ECAPS help to preserve access for the patients who need it the
▶ 1:38:53Awesome. Dr. Periq, one of the silver linings, there may have been few, but one of the silver linings of the of the 2020 COVID era lockdown moment was uh the ex increased experimentation and implementation of tellahalth. Many of the telealth flexibilities put in place by Congress were on a temporary basis and this committee has been working to extend several of them.
▶ 1:39:17What is the impact of teleaalth options for patients with chronic conditions especially in rural areas um across state lines?
▶ 1:39:26So anything that increases access to care will improve outcomes and we need to give patients ver variety of avenues for the type of care they need. Tellah health absolutely has to be part of the armamentarium there. Um in in terms of chronic conditions we can think of it in in several ways. One is people with chronic conditions still get acute issues, right? They still get a rash. They still get sinus infections.
▶ 1:39:49And for for those things, if they don't have to miss a day of work, if they don't have to leave their child home alone, if they don't have to um they can't afford to get transportation in, we it's a great way to treat them for their acute issues and also avoid that expensive ER visit which may be the only other option for them. Second is chronic condition management.
▶ 1:40:10If you if you have a patient who has a chronic condition, you've seen them once, you've done the exam, the followup a lot of times the follow-up visits to make sure that the plan is working, that they're improving, that uh you're on the right track can certainly be done by tele medicine. And again, it's convenience and sometimes uh saves the patient a lot of money. And then the third is avoiding uh a serious complication. You have a patient with heart failure. We talked about remote patient monitoring.
▶ 1:40:35If there's someone that you note that that may be having signs that they're going into early worsening, you can have a tele medicine visit, adjusted medications, adjusted treatment plan, and again avoid them ending up having to go to the emergency room or hospitalization.
▶ 1:40:48Yeah, I think this would be catastrophic to miss on this opportunity to have seen something work well and not take advantage of it um just because of whatever difficulties we have, you know, getting things extended and approved for future use. Tellah health should be something that we should all be able to to rally behind and um goes to the larger issue of what has worked in the past.
▶ 1:41:12Let's make sure that we're doing that going forward and what has had maybe a good intent but has not had the outcomes that we've wanted and be able to scrap that and move in a better direction. With that, I yield back.
▶ 1:41:27Thank you, Mr. Davis. You're recognized.
▶ 1:41:31Thank you. [clears throat] Thank you, Mr. Chairman, and let me thank all of the witnesses. You know, it's very interesting to me that on Monday night, every Monday night, I have something called Couch Chat with the doctors and we have five, six physicians every and we just happen to have been this issue on Monday.
▶ 1:42:01And I'm reminded there are some things that we know and then there are some things that we about or we project what might happen, what could happen, what should happen.
▶ 1:42:19One thing that we know is that in 2014, a Supreme Court decision gave states the choice [snorts] of whether to expand Medicaid to cover adults with incomes below 138% of the poverty As a result, individuals earning between 100 and 138% can qualify for a premium tax credit in states
▶ 1:42:50that do not expand Medicaid if states don't already cover those And as a result of the Affordable Care millions of Americans are eligible for a premium tax credit that helps them pay for health coverage. The American Rescue Plan Act increased the size of the credits and made more people eligible for them.
▶ 1:43:22Beginning in the 2021 coverage year, the Inflation Reduction Act extended these enhancements through the end of 2025. The Republicans have refused to extend this tax credit to assist people to buy health coverage through the market exchange.
▶ 1:43:47Yet all of the measures that we have been talking about are tied to the affordability of health insurance and also SNAP and Medicaid benefits were cut in the big ugly law.
▶ 1:44:07Many of the beneficiaries on Medicaid of course also get very little money in which to live um because their social security checks or whatever their retirement checks are really aren't that great.
▶ 1:44:33And so talking about coordinating health care is a very interesting topic because I'm amazed if we cut we cut health centers, if we close the numbers that I've heard that have closed in rural America.
▶ 1:45:01But I can tell you we do the same thing in urban America. I grew up in rural America and there were things we were taught things like you can't get blood out of a because it's just not there. There's nothing there but turnip juice.
▶ 1:45:27And no matter what you do to it, you're still going to get term use. We were also taught that if you cut green corn, [snorts] it will die. I the these are rural uh in rural America.
▶ 1:45:52And so if you're trying to coordinate And you've closed the hospitals. You've closed the health centers. You've cut graduate medical education. You're not training that you need.
▶ 1:46:18And even tele medicine, which takes up a little bit or some of the [snorts] slack. What is there to coordinate? I'm I'm I'm I mean I I I think coordinate means bringing it Uh Mr. Cornell, is that a way to do a good job of coordinating?
▶ 1:46:50It is hard to um coordinate your care when you can't access it at all. So, um it's a challenge for patients.
▶ 1:46:59Thank you, Mr. Chairman.
▶ 1:47:01Thank you, Mr. Kustoff.
▶ 1:47:04Thank you, Mr. Chairman, and thank you to the witnesses for appearing today. Dr. Obin, if I could with you, and you've talked about it maybe on a couple of different occasions about remote patient monitoring and the importance. Can you talk about how uh remote patient monitoring fits into Novin's mission to improve the proactivity, if you will, of of addressing chronic disease and chronic disease management?
▶ 1:47:34Yes, Sarah. In chronic diseases, one of the great things we have is a plethora of data. And so when we have data from patients when they are in their home environments, we actually get longitudinal information rather than one-time information. So if you use blood pressure as an example, you may come to me with some anxiety in my office and your blood pressure is high, but at home your blood pressures are normal while we're monitoring them remotely.
▶ 1:47:58So having access to that data allows us to make better treatment decisions and long-term decisions for that patient to improve their outcomes. The other key to that is managing that plethora of data which means we have to have create support mechanisms for topoflic work so the nurses care managers and others can help us manage that data leveraging the providers to really be taking care of the complex patients when they're chronic conditions are out of control.
▶ 1:48:28Can you talk about some other chronic conditions and maybe some uh whether it's devices or or wearables or what have you where you were able to monitor those patients?
▶ 1:48:41Sure. So in our hospital at home for example, we've got devices that will measure blood pressure and oxygen saturation and other vital signs that are taken back to a care team that manages that care outside of the facility. So the concept is we have access to that real-time data. We can make real decisions preventing complications and improving improving their outcomes.
▶ 1:49:06Do you have any way of of um noting, if you will, when somebody needs the in-person attention, the fact that they they will follow up and and go into your
▶ 1:49:19Sure. So connecting to them electronically through our patient record is an easy way to do that from an access standpoint. Right. So, there's direct communication with their care team. They have access to generate not only in-person visits if they need to. So, schedule an appointment. They can also do a virtual visit. That's video that allows us to actually see the patient, see body language, sometimes see rashes and things that might show
▶ 1:49:41Very good.
▶ 1:49:42Yes, sir. If I could on a different line, in your written testimony, you talked about a a white paper from 2023 making annual wellness visits work. And you talked about the time and attention, primarily the time that a physician has to spend on electronic health records and maybe up to two hours.
▶ 1:50:08Talk about the talk about how that takes away from your primary goal as a you as you can imagine our primary care our primary goal as a practitioner is to be with the patient and electronic records have certainly been distracting at times um that's where it's really important to gain the efficiencies where we can in that tool so in things like annual wellness visits if I want to combine that with chronic conditions to be more efficient for the patient there's a slew of additional
▶ 1:50:38codes that I have to know or remember or find in the electronic record that is quite challenging so I think it's an opportunity to create efficiency ies and leveraging the capabilities of these tools to simplify those codes we need to justify the time we spend with our patients which is the valuable time to really improve and enhance their
▶ 1:51:00Do you think you can do that and reduce the amount of time that you have to spend creating the electronic health
▶ 1:51:08I think it's possible. Yes. I think it also involves leveraging a team and so I think making sure that I'm mostly spending my time with the sickest patients as the one who should be doing that work and to your earlier comment on the remote patient monitoring that may be happening by another skilled team member that doesn't quite need the expertise of the physician.
▶ 1:51:29Thank you Mr. Riker. Thank you for coming and testifying today. I I know that all the practitioners are on the front lines, but you really are on the front lines. And I I the district that I represent is uh suburban and rural. I'm thinking about my rural pharmacist. I I can hear Jason Kaiser, Derek Holyfield talking about the counseling that they spend with the with their patients.
▶ 1:51:58Do you have any idea the people you come into contact with that you counsel how many or what percentage don't have a primary care physician where you're acting as their primary care physician in effect?
▶ 1:52:11Thank you for this question. I don't have an exact number but I can tell you that many of the patients I see in my pharmacy, we are their primary access point. And it may be that they come to us looking for a primary care provider, but unfortunately in the area where we live, they are so scarce and there is such a lack of resources um that often they seek care at emergency departments or convenient cares or whatever it may be and they really don't have that kind of homebased
▶ 1:52:42primary care provider.
▶ 1:52:44Thank you for your service. Thank you, Mr. Chairman. I'll yield back.
▶ 1:52:47Thank you, Mr. Stwie. You're recognized.
▶ 1:52:49Thank you, Mr. Chairman. My home state of Florida is made up to 8.3% of the nation's population who is 65 and older. My congressional district has the most Medicare beneficiaries of any congressional district in the entire country. Chronic disease is a topic of great importance to the state of Florida as it's affected more than 13.1 million Flidians. It's the job of lawmakers and healthcare providers to ensure that those with chronic diseases have access to the utmost attention and quality of care. Millions of Americans live with chronic conditions that affect nearly every aspect of their daily lives.
▶ 1:53:19yet instead of receiving the support they need, many patients encounter a health care system that consistently falls short in effectively managing and preventing these disease. Um, Dr. Hoben, I'll start with you. Um, I'm glad you were here to talk about chronic diseases and the cost they put on our health system. I have a bill, the chiropractic Medicare coverage modernization act that seeks to address this in another way. Chronic pain, especially lower back pain.
▶ 1:53:42Uh, this over 1.25 25 bipartisan members and more than half of this committee have co-sponsored this bill and no doubt tens of thousands of Americans live with pain and often seek solutions through surgeries and medications. Instead, I believe that better use of chiropractics and pain medicine techniques could lower those costs at high cost interventions while still helping patients get pain relief, but they can't because of Medicare's antiquated payment systems. Dr. Hobin is the chief medical officer of population health services for health system.
▶ 1:54:11What are the multidisciplinary strategies and interventions your organization pursues to treat chronic pain? Thank you for the question. We we use as you described a multid-disciplinary approach. So when you involve care teams between neurologists, anesthesiologists, surgeons, physical therapy, chiropractic care, ph pharmacy team. It is a collaborative effort to care for a complex disease state like chronic pain because it involves more than just the physical aspect.
▶ 1:54:40There's also the psychological aspect and the social as aspect to that complex condition.
▶ 1:54:45And how do chiropractors fit into that
▶ 1:54:48We see chiropractors as part of the care team. So as we think about the modalities that they are skilled in and trained in and have access to, they can integrate into that care team appropriately where it fits in for those
▶ 1:55:00Uh Dr. Periq, am I pronouncing that correctly? uh what recommendations would you suggest to our committees to address teleaalth resources to rural and lower income individuals? I think the first thing is to make the um pandemic era expansion permanent right we need to be sure that we [clears throat] can use tele medicine as an access point like we've all talked about uh to enhance care needed for uh our patients particularly
▶ 1:55:31in rural areas where there is a um scarcity of providers I I think it can it can offer an alternative for all the things that I mentioned for acute illness for chronic condition management and then for prevention of exacerbations that lead to hospitalizations. We were just talking that there there areas where where there isn't a hospital in a 100 mile radius for those folks.
▶ 1:55:52If you can catch that heart failure early with remote patient monitoring and adjust those medications with tele medicine um and a consultation with the pharmacist then then you've you've saved that patient's life in addition to significant uh cost savings
▶ 1:56:07and senior citizens and I have a lot of them in my district uh often have challenges with tech devices and iPads and all that sort of thing. So what can we do to utilize teleaalth easier for senior citizens? Um, one is uh to to make it built into the electronic record and easily sending uh the link so that there's a one-click uh way for them to to access it through their computer or their phone. The other is to allow for audio only tele medicine visits, right?
▶ 1:56:36The almost every senior can use a phone and we have found that there are many times that you can get equally good care uh through uh tele medicine with audio only. And then the last is um um non-synchronous care, right? Where they can send you a message, leave you a message, you can answer it uh off uh not in real time but but in a timely way that you can give them the care that they need.
▶ 1:57:01In the remaining time I have left, Miss Riker, um from your experience in providing rural communities with better access to health care, what are the most successful techniques you found to reach those individuals who may not have access or resources?
▶ 1:57:14Yes, thank you for this question. I think for a pharmacist a lot like myself, other pharmacists like myself, the the best technique is our frequency of interaction with our patients. I lay eyes on my patients. I see a lot of my patients on a weekly basis. And I think that that sets pharmacists apart. We have that frequency of interaction where we're able to um reinforce adherence, prevent complications, and coordinate with their physicians when needed.
▶ 1:57:43Thank you. I yield back. Thank you, Mr. Horseshford. You're recognized.
▶ 1:57:47Thank you to Chairman Buchanan and Ranking Member Dogget uh for holding this important hearing. After just 10 months of full Republican control of the federal government, they have moved with unprecedented speed uh to pass Trump Care to drive up cost health care costs for American families and to jeopardize health care access.
▶ 1:58:09Trump Care enacts cuts that would cause millions of Americans to lose their insurance while saddling millions more with higher cost and new red tape. Trump Care cuts more than a trillion dollars from our health care systems at the expense of hospitals, providers, and patients. Trump Care allows major cost increases for Medicare beneficiaries. and Trump Care slashes funding for clinical trials and other critical research.
▶ 1:58:40Long story uh Trump Care and Republicans war on health care knows no bounds. Mr. Connell, I feel like my Democratic colleagues and I have been beating the drums, sounding the alarms, raising the flags all year long on the necessity of protecting healthcare. And one of those areas is extending the advanced premium tax credit.
▶ 1:59:05As you stated in your written testimony, coordinated care is a well-intentioned goal. For many Americans, any health care at all will soon become a luxury that they cannot afford. One of the most serious consequences of allowing the advanced premium tax credits to expire is the direct impact on healthc care affordability and accessibility for everyone. Mr.
▶ 1:59:32Connell, can you walk us through how letting the advanced premium tax credits lapse would increase cost across states, zip codes, ages, racial demographics, and income levels regardless of coverage type. I guess so. Most immediately folks who are on the exchanges um and it differs a little bit depending on income since it's a sliding scale uh would face increases in their costs.
▶ 2:00:02And [music] so um there are some folks who might be able to cut back on things here and there and just could barely hold on and pay their premium and keep their coverage. Um hopefully they're able to spend out of pocket then to get their the care that they actually need once they get that premium. The premium is only the first step. Um, there other folks who will be unable to bear this cost. You know, there's folks facing and mentioned in our testimony, Kenny in North Carolina, he's facing $1,500 a month increase.
▶ 2:00:30Um, folks, a lot of folks who just can't afford that at all, they will have to forgo their coverage. They they can't make the math work. Uh so as folks then lose their coverage and you know have to go to the ER or um try to get charity care where they can u that does add to the costs that we all pay. All of us who are left in the system with insurance um have to cover uh in some way or another those costs.
▶ 2:00:54Um and it's a that the tragedy is that they both don't get the care that they need and that [music] we suffer those those higher costs um all the rest of us. So, the reality is it affects everyone regardless of where you're from, whether you're a direct recipient of the tax credits or if you're just connected one way or another to the healthcare system.
▶ 2:01:16In October of uh 2025, the Social Security Administration announced a cost of living adjustment of just 2.8% 8% which is about $56 per month for 75 million retired seniors and disabled workers who are already struggling with higher prices heading into January of 2026.
▶ 2:01:39At nearly the same time, the Centers for Medicare and Medicaid Services announced that monthly PartB premiums will rise $22.90, one of the largest Part B increases in the program's history. To put that in perspective, seniors face a 9.7% cost increase compared to a 2.8% COLA bump.
▶ 2:02:07How can we realistically expect seniors, many who are already living paycheck to paycheck, to eat that difference? That's why I, alongside Representative Larson of Connecticut, am introducing the Social Security Emergency Inflation Relief Act to help seniors weather the rapidly rising cost of President Trump's economy.
▶ 2:02:28Our bill would provide Social Security beneficiaries with the $200 per month emergency increase in their checks from January through July of 2026. Mr. Connell, I know this is a bit outside of your direct area of expertise, but can you speak to how rising cost from essentials, food, transportation, housing, and health care affect seniors ability to access the care they need while living on a fixed income?
▶ 2:02:58Yeah, I'll I'll just say the Medicare program already requires extraordinary out-of- pocket costs for a lot of uh patients, particularly folks who have a serious condition, whether they need expensive medication or whether they need uh expensive care uh at a hospital or other physician office. And so they already have a lot of high out-of- pocket costs. Um, so adding premiums, [music] uh, higher premiums to that in addition to the higher cost of a lot of other things in our economy, um, is is a huge challenge for those who are already just kind of struggling to get by.
▶ 2:03:28Thank you. I hope that we'll be able to take immediate action on this bill to give the relief to seniors on Medicare. That should be a priority, as should extending the premium tax credits under the Affordable Care Act. With that, I yield back.
▶ 2:03:43Thank you, Miss Tenny. You're recognized. Thank you, Mr. Chairman and ranking member. And I also want to say thank you to the witnesses uh for being here today as we examine these uh real pressing issues of chronic disease and ways to bolster prevention and treatment. Uh we've heard compelling testimony from you. Thank you on highlighting uh the growing burden that chronic diseases posed for our communities, obesity, diabetes, heart disease, all which are straining uh our health care system and impacting millions of Americans.
▶ 2:04:11Uh just a little bit of an overview of my district. Um in upstate New York near 24, we have over people of my 774,000 constituents who are enrolled in Medicare. I'll be joining them next year at the same age group. Uh and that represents over a third of our population. Uh which is far higher than the national average, about 18%. So we're over a third. We're we're one of the more senior districts.
▶ 2:04:37And of these Medicare beneficiaries, approximately 180,000 are enrolled in a Medicare Advantage plan, making up about 66% of our Medicare enroles. Um, this is well above uh the 54% of the total population enrolled in the MA or Medicare Advantage. Um, this makes uh the issue of a Medicare Advantage plan uh and the and the benefits deeply relevant to us, especially with my community.
▶ 2:05:02So, um, as we look to improve the health care for our older Americans, and I come from just just a little bit of an editorial aside, if the Democrats want to scream about health care and Obamacare, come to New York, where ever since Obamacare was passed, a premiums have gotten more expensive. Health care is more unattainable. Everybody's got an insurance card. Very few have access to health care. Small businesses are being driven out. Uh, we have the Democrats control everything. Veto proof majority.
▶ 2:05:29uh in and they have done nothing to create or protect a a solution for our seniors, for anyone in our state. Uh and is why we have the highest out migration, the worst healthcare outcomes, uh all kinds of problems. And it is not because we're not putting enough money into it. We put more money in than anybody else. And so uh to me, I just especially when it comes to Medicaid and and the essential plan, we're not being uh fair to our constituents or being fair uh to u to the taxpayers on what we're doing. and we're not getting good outcomes for the money we're spending.
▶ 2:05:59But I would like to see us improve uh the opportunities we have for our our health, our seniors and especially in the preventative medicine area. Diabetes, health uh you know, heart disease, obesity, those things are really becoming uh really serious in our communities. And um one of the themes that we keep seeing is maybe payment models allowing the clinicians to move from from reactive care to proactive management.
▶ 2:06:22something that uh the chairman loves to talk about uh especially you know preventative care getting people healthier how do we get those outcomes I want to ask my first question for Dr. Hoben and if you could talk to um you know how an afford an accountable care organization or valuebased incentive can encourage early identification of risk and intervention for patients with some of the multiple chronic diseases we described and how these ACOs um how has their participation with these models helped
▶ 2:06:52with hospitalizations hospitalization costs readmissions uh ER visits you've done this in both rural and and uh and urban areas How what what would what would your be your opinion be on this and how can we access this more under this model to make less less expensive but more
▶ 2:07:12Yes ma'am thank you for the question. I think first and foremost to your point is a focus on prevention and screening. So having those incentive incentives there not only on the care teams that are providing it but also on the patients to get it. So the more incentive they have to participate in their health care and be active participants in that, we will lead to better outcomes. I think as it comes to thinking about the affordability around the chronic disease management, it's again back to the the team carebased model.
▶ 2:07:38And when you look at team-based models where patients are getting care from top oflicens partners throughout that team, we see better outcomes. And so physicians and providers can spend more time with the more complex patients and other ancillary team members can spend time in their areas of expertise. And what we've shown in those models is a significant reduction in hospitalizations, readmissions, use of the emergency room.
▶ 2:08:03And I think the MSSP data speaks for itself as 2.5 billion when you look at what MSSP has done from a cost reduction. We've experienced that in our ACOS.
▶ 2:08:12That's great. Like I love the model, but um and also, Mr. Chairman, I just want to briefly flag an issue that was raised during the committee's field hearing on rural health uh last March. at the hearing. Members on both sides of the aisle, this was bipartisan, heard from our ground and air ambulance providers that have not seen a meaningful uh update to their reimbursement rates in more than 25 years. Over that time, costs for fuel, staffing, technology, uh vehicle replacement, all those things have increased significantly yet. Reimbursement hasn't kept pace.
▶ 2:08:41Uh so, and unlike many services, emergency medical services must be ready to respond 24 hours a day, 7 days a week. Uh whether they are ultimately reimbursed or not is going to be a real problem. also a particularly important in a rural and suburban district like mine that spans the shoreline of Lake Ontario and all across New York State. Um this is an urgent issue and I just wanted to point that out for the uh for the chairman and for uh decision makers on this committee that we need to address that issue. Thank you so much. I yield back.
▶ 2:09:08Thank you, Mr. Bean. You're recognized.
▶ 2:09:10A very good afternoon, Mr. Chairman, to you and good afternoon Ways and Means Health Committee. It's an honor to be on here, Mr. Chairman. Thank you for letting me uh be a part of the committee. to our all-star panel. Welcome. You will always have the the chance to say that time I testified before Congress. How about that? Uh listen, before I go, I got questions. I do have questions, but first I got to correct the record because the other side keeps saying Trump Care and they point to Republicans saying we broke it.
▶ 2:09:40Uh let's be clear and let me correct the record. Obamacare was created 100% by Democrats. You remember that? Oh, you can keep your doctor. Remember that. it's going to it's going to lower cost. None of that was true. And here we are after dumping billions upon billions of dollars into it to prop this uh system up. U we find ourselves wanting more and more for a mediocre system. Of the 24 million people on Obamacare right now, 50% up to 50% have never made a claim.
▶ 2:10:10Uh yes, they were signed up without their knowledge. It's not working. Uh they don't have a choice. The insurance companies can raise prices. The premium tax credits are based as a percentage of what the insurance company charged. It is broken. The last thing that we want to do is put more money into a broken system. These premium tax credits were done during CO. Y'all remember CO? It was a temporary thing. COVID is over. It's over. As should be these premium tax credits.
▶ 2:10:39Now, Obamacare doesn't go away. If you're a fan, it doesn't go away. Just the premium tax credits. 93% of Americans on this program will still be eligible to receive a subsidized health plan. But we can do better, America. We can do better because right now we are paying $4.5 trillion for health care. Uh that's a lot of money. It is.
▶ 2:11:01And when you compare us to other civilized uh gradea countries, we uh we pay sometimes double and triple per capita what other countries pay. And yet we are getting mediocre results. mediocre. Uh, America, we are sick. We're sick. Maybe it's because we overeat or drink too much or smoke or don't exercise. Our food is lousy. Whatever it is, 60% of Americans have some type of chronic condition that just eats our lunch financially.
▶ 2:11:3142% have two or more. We've got to do better. We've got to do better. And Miss Riker, I've heard you say so many times, it's awesome. we are underutilizing health care professionals like you uh a pharmacist who have that interaction every uh every day with your patients. I know in my area northeast Florida, the greater Jacksonville area, there's a program called Age Well. It's by Baptist Health.
▶ 2:11:55Uh it specializes in senior health care uh for ages 65 or older and it just has a wraparound approach to uh deliver care and coordinate it which we uh which we struggle with. Uh we've got work to do but the answer can't be more money. We've done it. We're out. We're 38 trillion in debt. But we could do so much better by coordinating care by using technology. Uh Mr. Riker, what should we do right now?
▶ 2:12:23the the gateway the gateway uh disease. It seems like it triggers so many other things and it's it's an horrendous disease. It's diabetes and it leads to so many other things. What should we be doing? Uh the answer is not more money. You can't say that. But what can we do, Miss Riker, to better coordinate diabetes care?
▶ 2:12:43Yes, thank you for this question. And and as we said, pharmacists are our most accessible health care provider and our most underutilized. And so in chronic disease management like in diabetes or whatever the disease is, I feel by allowing pharmacists to be part of that integrated care team, we would be able to help improve in outcomes. So in the in my pharmacy every day, I'm already taking vital signs. I'm monitoring patients adherence.
▶ 2:13:13Um I am checking for drug drug interactions, all of those sorts of things. And with diabetes, I have patients come in and I'm monitoring their continuous glucose monitor with them. I'm helping them interpret that.
▶ 2:13:25And you're giving them the advice right there at the uh at the window. I have to rush because I've got to get to Dr. Periq. Uh so that's good. And and that's uh that means something that you can tell them uh take it twice a day with food or not with food, whatever it is. And not eat so much. I know we need to do that. Put the fork down. I think is probably what I need to hear. I think some of that Dr. Dr. Peri, how do we get I know you got I got 20 seconds left. It's a it's a big question. How do we First of all, you would agree choice and competition should be part of any healthcare solution.
▶ 2:13:55Would you agree?
▶ 2:13:57Yes, [laughter] you would agree. How do we get there? I know that's I guess a question. Would you agree with that though? Yes. Choice and competition.
▶ 2:14:05Choice and competition for
▶ 2:14:07healthare for letting the individual decide which way they go.
▶ 2:14:12What's best for the individual? You would. So with that, that's a conversation for another day. That's where we need to start. Instead of rebuilding or instead of building onto a broken system, Mr. Chairman, we have work to do to rebuild uh a system that utilizes choice and competition and puts the patient first. With that, I yield back, Mr. Chairman. Thank you.
▶ 2:14:32I wish my friend had a little more What a great to have him on the team. Let me just say kind of doing the wrapup uh you know he mentioned it 4.5 trillion I was looking at today it's almost5 trillion dollars we're spending on healthcare and you can make the argument there's a lot of sites out there you can look at our health's getting worse kids 20% obesity young adults 31 and under in terms of serving the military 31% adults in general 40 to 50%
▶ 2:15:03uh obesity and all the things that kind of comes come with that and you mentioned a little bit about education What are you doing to try to educate people there? I read a book and it said you need to be the CEO of your own health. I think some simple things like I don't want to make simp too simple but like screening everybody getting a physical if they want.
▶ 2:15:23If they don't that's your their choice but getting a test getting the screen at the beginning of the year January or something where you get a a physical and you I got to say I got a couple of tweaks here and get something done. But I'm curious about that. And then the other question I was going to ask, so I'll throw it out there, you think about it, is the pay plan. I had 1,200 employees before I came here. The pay plan is the most important thing or one of the most important things you got.
▶ 2:15:50There's a lot of other things, but you know, the whole thing on fee for service, is that the way we should go or should we be looking at alternatives? Because the tendency, whether you like it or not, the propensity is to move you in that direction to do more, to make more money. I'm not saying anybody's taking advantage of it, but my point is I do really do think that there should be some consideration. Some firms I know I've got a doctor I work with and he he does he says he pays you pay him so much a year and he says I want to see you less.
▶ 2:16:21So, but that's the right incentive is treat people, treat their health, their conditions, get them better so they don't need to be running to the doctor every couple of weeks. So, doc, what do you think? M. Holden, what's your thoughts on Dr. Holden? Yeah, go
▶ 2:16:39Yes, sir. I So, thank you for the question. I I think you're I think you're right. I think there will always be there will likely always be a fee for surface component and a value component. There are certain things in the healthcare that are transactional and they will probably stay transactional, whether that's cataracts or ear tubes or things like that.
▶ 2:16:56I think when you look at the major cost in health care, it's really around this chronic disease management and the way we can approach that and be successful is using comprehensive care teams, top oflicens work, reducing some of that regulatory burden to make it easier, offload the providers, allow them to do their job and create the right access points. And if we can get irregardless of what the payment model looks like, if we can get patients to the right level of care at the right time, we will see cost reductions in maintaining quality.
▶ 2:17:24And we've shown that in many programs over the years um that we've been involved with and others here have been involved
▶ 2:17:30Yeah. Someone said like heart disease and cancer and some of these things. If you can catch it early, good chance you'll be able to deal with it and to work out. Is that your sense? Is that what you've seen? Is that the case? I I I feel bad for my mother after she passed. But she by the time she went in and got got addressed, it was stage four colon cancer and never knew she had you know was in that situation. she thought she had the flu.
▶ 2:17:55So I just in the back of my mind I thought to myself and I had another friend, a young person at 40 years old had the same scenario. But it just seems if you catch things early there's a good chance between diet and exercise. So what do you do with your employees uh for example to educate them or or your patients? Educate your pa patients because one thing I do see a lot more than it was 20 years ago. I got 10 grandkids and two sons, but the do they're into health.
▶ 2:18:25They don't bring it the bad stuff into the house. Now, as papa, I get chance to take them out for an ice cream. But the bottom line is I said, "Don't bring it into the house." And, you know, vegetables, fruit, and all the other stuff, but it seems like the younger generation because we got access to so much good information, they're watching it, listening to it, and a lot of it they're not bringing in the house. are making a lot better decisions than even we did when we had kids many years ago, my wife and myself.
▶ 2:18:53Any other thought what this record this
▶ 2:18:59Yes. So I I I agree um preventative medicine saves lives and it reduces cost just like with ECAPS. ECAPS is is earlier testing and treatment um of disease. And so I think by, you know, really implementing pharmacists into those care teams, we can we can help to produce those better outcomes.
▶ 2:19:21Yeah, that seemed pretty exciting about the idea of working together as a team. Anyway, I'd like to thank our witnesses for appearing before us today. Please be advised that members have two weeks to submit written questions to answer later in writing. Those questions and your answers will be made part of the formal hearing process. With that, with that we stand adjourned.