Copyright 1999 Federal News Service, Inc.
Federal News Service
MARCH 17, 1999, WEDNESDAY
SECTION: IN THE NEWS
LENGTH:
5401 words
HEADLINE: PREPARED STATEMENT OF
NANCY-ANN DEPARLE
ADMINISTRATOR
HEALTH CARE FINANCING ADMINISTRATION
DEPARTMENT OF HEALTH AND HUMAN SERVICES
BEFORE THE
SENATE FINANCE COMMITTEE
BODY:
Chairman Roth, Senator Moynihan, distinguished Committee Members, thank
you for inviting me to discuss the Health Care Financing Administration's (HCFA)
progress in implementing Medicare payment reforms enacted under the Balanced
Budget Act of 1997 (BBA). I would like to also thank the Medicare Payment
Advisory Commission for its advice for ensuring that Medicare continues to make
appropriate payments and protects beneficiary access to care.
Medicare is
the nation's largest insurer, covering some 38 million of our nation's elderly
and disabled. Medicare processes about 900 million fee-for-service claims each
year, is the nation's largest purchaser of managed care, and accounts for 11
percent of the federal budget.
We have implemented more than half of the 335
BBA provisions affecting HCFA programs, and many more are partially implemented.
In the past year, we published 92 regulations and Federal Register notices
implementing important Congressional directives, beneficiary protections, the
Medicare+Choice program, and savings in the BBA that are critical to extending
the life of the Medicare Trust Fund. We have made major strides in fighting
fraud, waste and abuse, and cut our payment error rate in half in just two
years. We also have converted the vast majority of Medicare HMOs to the new
Medicare+Choice program and implemented a carefully planned National Medicare
Education Program to help beneficiaries make informed health care decisions.
At the same time, we are tackling one of the most difficult Year 2000
computer challenges in government. This must be our highest priority.
Unfortunately, meeting the Year 2000 challenge has forced us to make difficult
decisions involving some BBA provisions. The vast majority of BBA provisions do
not have to be delayed. However, on the advice of independent computer experts,
we made the difficult decision last year to delay projects that could interfere
with Year 2000 work. This included BBA provisions such as the hospital
outpatient prospective payment system that we very much want to implement. We
will make every effort to implement these provisions as quickly as our Year 2000
obligation allows.
I have brought a new team of leaders to HCFA to help us
meet our BBA and Year 2000 challenges.
- Gary Christoph, Ph.D., a computer
scientist and security expert from the Los Alamos National Laboratory, serves as
our first-ever Chief Information Officer and heads our information technology
team and Year 2000 efforts.
- Robert Berenson, MD, an internist who helped
establish a private sector preferred provider organization health plan, now
leads our Center for Health Plans and Providers.
- Jeffrey Kang, MD, a
geriatrician who was a private sector managed care plan medical director, is our
Chief Clinical Officer and heads our Office of Clinical Standards and Quality.
- Carol Cronin, Ph.D., a gerontologist who ran a private sector firm devoted
to helping corporations educate their workers on health care, is leading our
Medicare beneficiary education program.
- Marjorie Kanof, MD, a physician
who has worked as a Medicare contractor medical director, is in charge of
implementing much stronger oversight of Medicare claims processing contractors.
FEE-FOR-SERVICE BENEFITS AND PAYMENT REFORMS
The BBA includes important
new Medicare fee-for-service preventive benefits, as well as payment system
reforms that are critical to extending the solvency of the Medicare Trust Fund.
We are making good progress in implementing these changes.
For the new
preventive benefits, we have:
- expanded coverage for test strips and
education programs to help diabetics control their disease;
- begun covering
bone density measurement for beneficiaries at risk of osteoporosis;
- begun
covering several colorectal cancer screening tests;
- expanded preventive
benefits for women so Medicare now covers a screening pap smear, pelvic exam and
clinical breast exam every three years for most women, and every year for women
at high risk for cervical or vaginal cancer; and,
- begun covering annual
screening mammograms for all women age 40 and over, and a onetime initial, or
baseline, mammogram for women ages 35- 39, paying for these tests whether or not
beneficiaries have met their annual deductibles.
We have made solid progress
in implementing fee-for-service payment reforms. For example, we have:
-
modified inpatient hospital payment rules;
- established a prospective
payment system for skilled nursing facilities to encourage facilities to provide
care that is both efficient and appropriate;
- refined the physician payment
system, as called for in the BBA, to more accurately reflect practice expenses
for primary and specialty care physicians; and initiated the development of
prospective payment systems for home health agencies, outpatient hospital care,
and rehabilitation hospitals that will be implemented once the Year 2000
computer challenge has been addressed; and,
- begun implementing an
important test of whether market forces can help Medicare and its beneficiaries
save money on durable medical equipment. We are prepared to begin a test in Polk
County, Florida of competitive bidding as a way to get the best quality and
price for durable medical equipment and supplies. A toll-free hotline (888-289-
0710) is available to answer beneficiary and provider questions about the
project.
Inpatient Hospital Payment
We have implemented 74 percent of
the inpatient hospital-related changes included in the BBA in updated
regulations. These include substantial refinements to hospital Graduate Medical
Education payments and policy to encourage training of primary care physicians,
promote training in ambulatory and managed care where beneficiaries are
receiving more and more services, curtail increases in the number of residents,
and slow the rate of increase in spending.
We also froze inpatient
hospital payments in fiscal year 1998, as required under the BBA, resulting in
substantial savings to taxpayers and the Medicare Trust Fund. We notified
Congress last year that we may need to postpone the payment update scheduled for
October 1999 because of the Year 2000 challenge. However, if we sustain our
current rate of progress in meeting that challenge, we may be able to implement
the October 1999 update on schedule.
Physicians
As directed by the BBA,
we have taken concrete action to refine and implement the resource based system
for practice expenses under the physician fee schedule. We published the final
regulation in November 1998, and began implementing the new system in January
1999, with a transition to full implementation by 2002. We were required by the
BBA to implement the new system in a budget-neutral fashion. This will
inevitably cause some physicians to see payment increases while others see
decreases.
The methodology we used addresses many of the concerns raised by
physicians and meets the BBA requirements. We used the American Medical
Association's actual cost data to reflect all of a specialty's practice
expenses, not just those linked with specific procedures. Our expert accounting
contractor, KPMG Peat Marwick, attests that our methodology followed reasonable
cost accounting principles. The General Accounting Office also is largely
supportive of our methodology. We fully expect to update and refine the practice
expense relative value units in our annual regulations revising the Medicare fee
schedule. We welcome and encourage the ongoing contributions of the medical
community to this process, and we will continue to monitor beneficiary access to
care and utilization of services as the new system is fully implemented.
The
Balanced Budget Act also requires that we implement a resource- based system for
malpractice relative value units. We currently are in the process of developing
the system and plan to include it in this year's proposed rule.We notified
Congress last year that, in order to ensure that all Year 2000 work is done
correctly we may need to freeze our computer systems during a critical period of
Y2K work, and would therefore have to delay the January 1, 2000, physician
updates. We will know more about whether we may be able to do these updates on
schedule after we have reached the government's March 31, 1999, Year 2000
compliance deadline. We share physicians' concern about these possible delays,
and we want to work with physicians and Congress to evaluate our options and
ensure that any necessary delays do not create a hardship and that any interim
measures fairly reimburse physicians.
Skilled Nursing Facilities
We have
made substantial progress in implementing the new skilled nursing facility
prospective payment system. The old payment system was based on actual costs.
The new system uses mean-based prices adjusted for each patient's clinical
condition and care needs, as well as geographic variation in wages. It creates
incentives to provide care more efficiently by relating payments to patient
need, and enables Medicare to be a more prudent purchaser of these services. The
BBA mandated the implementation of a per diem prospective payment system for
skilled nursing facilities covering all routine, ancillary, and capital costs
related to covered services provided to beneficiaries under Medicare Part A. In
accordance with the BBA, we implemented the new payment system July 1, 1998.
We fully understand the concerns raised by providers about this new system,
particularly those related to outlier and non-therapy ancillary services. The
new payment system is complex, and we are working with providers to address
these concerns. We know that this is not a static system and that it will
require ongoing refinements.
We strongly believe the Resource Utilization
Groups (RUGs), which are a key component of the system, must be periodically
evaluated to ensure they appropriately reflect changes in care practice and the
Medicare population. We are working closely with an expert research contractor
to examine potential refinements to the RUGs model, particularly those
associated with medically complex patients and non- therapy ancillary services,
such as medications. We expect to have the results of this research by January
1, 2000, and to be able to make refinements shortly thereafter.
In addition
to this research effort, we plan to host a Town Hall meeting next month with
interested industry and consumer stakeholders to seek their first-hand advice on
refining the current RUGs model. We will take the suggestions of the industry
and the results of our contractor's research into consideration as we make
necessary refinements. I want to assure beneficiaries, providers, and Congress
that we appreciate the importance of this task and are committed to fairness and
ensuring continued access to care.
Home Health
The BBA mandated a number
of changes in the way Medicare pays for home health services to curtail
unsustainable spending growth and fight what was widespread fraud, waste, and
abuse. These changes are vitally important and have been a long-standing
priority for HCFA and this Administration. Medicare spending on home health more
than tripled in the 1990s, while the number of beneficiaries receiving home
health services doubled. The new payment systems create incentives to provide
home health care efficiently as well as control spending growth.
Congress
wisely postponed the final implementation date for the home health prospective
payment system because of our need to address the Year 2000 computer problem. We
are working hard to develop the prospective payment system and believe that we
are on track to meet the October 1, 2000 implementation deadline. This October,
we expect to publish a proposed regulation for the prospective payment system so
we can begin receiving and evaluating public comments. We anticipate that the
final rule will be issued in July 2000.
We know some providers continue to
have concerns about the home health interim payment system. Last year, Congress
made important changes to the interim system to address some of these concerns.
However, given the magnitude of the changes in home health payment, it is
understandable that other concerns remain. We are committed to working with
providers and Congress to ensure fairness and protect access to appropriate home
care services covered by Medicare as we proceed toward prospective payment. We
are monitoring the impact of these changes on beneficiary' access to care and,
thus far, do not have evidence on whether access to care has been compromised.
Hospital Outpatient Departments
The Balanced Budget Act empowers us to
move away from charge-based hospital outpatient coinsurance, which has long been
a priority for the Clinton Administration. The increased costs the current
system imposes on beneficiaries are unfair. Regrettably, implementation of the
prospective payment system as originally scheduled would have required numerous
complex systems changes that could substantially jeopardize our Year 2000
efforts. Therefore, we have postponed implementation and are working to
implement this system as quickly as the Year 2000 challenge allows. In the
meantime, we are willing to work with the Congress to sec if an alternative
solution can be developed that might more quickly move us toward our shared goal
of reducing beneficiaries' out-of-pocket costs for these services.
We issued
a Notice of Proposed Rule Making in September 1998 outlining plans for the new
system so that hospitals and others can begin providing comments and
suggestions. We are making data files available to the industry, and we have
extended the comment period until June 30, 1999 so the industry and other
interested parties will have sufficient time and information to comment.
We
have also implemented a BBA provision that eliminates an anomaly in the law,
known as the formula-driven overpayment, which caused taxpayers to pay too much
for certain surgical, radiological, and other hospital outpatient services. We
implemented this change just two months after the BBA was enacted.
Rehabilitation Hospitals
We are in the process of developing a prospective
payment system for rehabilitation hospitals as required under the BBA. We have
contracted with Muse and Associates, Dr. Brant Fries at the University of
Michigan, and Dr. John Morris at Hebrew University to conduct research and aid
in development of a case mix classification system for rehabilitation hospitals.
Tiffs new system is scheduled for implementation over a two year period
beginning October 1, 2000. We are currently analyzing the positive and negative
aspects of both a per-episode and a per-diem payment system based on a
comprehensive assessment of each patient's condition and resource requirements.
We have not ruled out either approach at this time. Our primary concern is to
ensure that the system we adopt allows our beneficiaries to get the care they
need and treats providers fairly. We appreciate the technical suggestions we
have received from the industry in this regard, as well as the evaluation and
advice provided by the Medicare Payment Advisory Commission and the General
Accounting Office, and we will continue to work closely with them and Congress
as this system is developed and implemented.
MEDICARE+CHOICE
Medicare+Choice allows private plans to offer beneficiaries a wide range of
options, similar to those available in the private sector. Medicare+Choice and
other changes enacted in the BBA require a massive and important new beneficiary
education campaign. Medicare+Choice includes important new protections for
patients and providers, as well as quality assessment and improvement
requirements. And it initiates a fairer and more accurate payment system.
We
are very committed to successful implementation of Medicare+Choice. We believe
that managed care and other private plans are important voluntary options next
to original Medicare. Medicare managed care enrollment has nearly tripled under
the Clinton Administration, from 2.3 million when the President took office to
6.8 million now. We now meet regularly with beneficiary and industry
representatives to discuss ways to improve Medicare+Choice, and have begun
making refinements based on these comments and discussions.
We have
converted the vast majority of former Medicare HMOs to the Medicare+Choice
program and published all BBA-mandated Medicare+Choice regulations. Last month
we published initial refinements to these regulations which improve beneficiary
protections and access to information while reducing plans' administrative
workload.
We launched a national education campaign and participated in more
than 1,000 events around the country to help beneficiaries understand
Medicare+Choice and other important changes to Medicare. And we are establishing
a federal advisory committee to help us better inform beneficiaries.
Beneficiary Education
As mentioned above, we have launched the National
Medicare Education Program to make sure beneficiaries receive accurate and
unbiased information about benefits, rights, and options. The campaign includes:
- mailing a Medicare and You handbook to explain new benefits and health
plan options; - a toll-free "l-800-Medicare" call center with live operators to
answer questions and provide additional print information on request; - a
consumer-friendly Internet site, www. Medlcare.gov, which includes comparisons
of benefits, costs, quality, and satisfaction ratings for plans available in
each zip code; - an alliance with more than 100 national aging, consumer,
provider, employer, union, and other organizations who help disseminate
Medicare+Choice information to their constituencies; - enhanced beneficiary
counseling from State Health Insurance Assistance Programs; - a national media
publicity campaign;
- more than a thousand individual state and local
outreach events around the country in senior centers and town halls, on radio
call-in shows and other venues, and in languages ranging from Vietnamese to
Creole; and,
- a comprehensive assessment of these efforts.
In 1998, we
tested the whole system in five states -- Arizona, Florida, Ohio, Oregon and
Washington. Unfortunately, the decisions by some plans to withdraw from the
program or reduce their service area significantly complicated our task. We
learned a great deal in this "dry run," and focus groups indicated that a
majority of beneficiaries found the information in the Medicare & You
handbook to be informative and useful. We are also conducting cases studies to
evaluate the education campaign in five communities in the five pilot States and
one community outside the pilot States. Preliminary results from our assessment
efforts are already suggesting ways to make Medicare & You easier to use,
and links we can add to help users find key information faster on our website.
These and other findings will help us to refine efforts for a full-scale,
national campaign before the November 1999 open enrollment period.
As
mentioned above, we are establishing the Citizens Advisory Panel on Medicare
Education, in accordance with the Federal Advisory Committee Act, as a formal
mechanism to obtain public input for improving our education efforts. The Panel
will meet quarterly to help:
- enhance our effectiveness in informing
beneficiaries;
- expand outreach to vulnerable and underserved communities;
and
- assemble an information base of"best practices" for helping
beneficiaries evaluate plan options and strengthening a community infrastructure
for information and counseling. Panel members will include representatives from
the general public, older Americans, specific diseases and disabilities,
minority communities, plans and insurers, providers, and other groups.
We
are also working to standardize plan marketing materials that summarize benefits
so beneficiaries can make apples-to-apples comparisons. Our goal is to complete
this work before the first annual coordinated open enrollment period in November
1999.
Reaching Out to Plans
We have taken several steps to encourage
health plan participation in Medicare+Choice.
In addition to converting the
vast majority of Medicare HMOs to the new program, we have added 12 new plans
and expanded service areas for another 11 plans since last November, including
the first provider sponsored organization with a Federal waiver from State
licensure requirements. We are reviewing 24 new plan applications and 18 service
area expansion applications.
Last summer we held outreach sessions attended
by more than 1,500 plan representatives, and we continue to strengthen lines of
communication with plans. We have named a senior official within HCFA, Tom
Gustafson, whom plans can call directly if they have trouble resolving issues
through normal HCFA channels.
As mentioned above, last month we published
initial refinements to the Medicare+Choice regulation. The new rule:
-
clarifies that beneficiaries enrolled in an M+C plan that withdraws or is
terminated from Medicare are entitled to enroll in other remaining locally
available M+C plans;
- specifies that changes in plan rules must be made by
October 15 to ensure beneficiaries can make informed choices during the November
annual open enrollment period;
- waives the requirement for an initial
health assessment within 90 days of enrollment for enrollees who stay in the
same plan when they age into Medicare and for enrollees who switch plans but
remain under the care of the same primary care provider;
- allows plans to
choose the form of the initial health assessment;
- allows coordination of
care to be performed by a range of qualified professionals;
- limits the
applicability of provider participation requirements to physicians; and
-
aligns requirements for terminating specialists with the process for other
providers. We intend to publish a comprehensive final rule with further
refinements this fall.
To further facilitate plans participation, the
President's budget includes a proposal to give plans two additional months to
file the information used to approve benefit and premium structures.
This "Adjusted Community Rate" data would not be due until July 1,
rather than May 1. July 1 is the latest we can accept, process, and approve
premium and benefit package data, have the data validated, and still mail
beneficiaries plan information in time for the November open enrollment period.
Given legislative schedules and the need to act immediately, we informed plans
that the required filing date this year will be July 1. We look forward to
working with you to enact legislation necessary to support this change that is
so important to Medicare+Choice success.
Payment Reform
The BBA requires
Medicare to "risk adjust" Medicare+Choice payments starting January 1, 2000.
That means we must base payment to plans on the health status of individual plan
enrollees. Data on individual beneficiary use of health care services in a given
year will be used to adjust payment for each beneficiary in a Medicare+Choice
plan the following year. Risk adjustment represents a vast
improvement over current payment methodology. It helps assure more appropriate
payments and curtails the disincentive in the current payment system for plans
to enroll sicker beneficiaries.
Risk adjustment will help
beneficiaries feel more confident in their Medicare+Choice options. It assures
beneficiaries that Medicare pays plans the right amount to provide all necessary
care because payments take each enrollee's health status into account. That will
help people with serious illnesses, such as cancer or cardiovascular disease,
who can benefit most from the coordination of care health plans can provide.
Risk adjustment will help taxpayers by addressing the main
reason Medicare has lost rather than saved money on managed care. Many studies
show that health plans enroll beneficiaries who, on average, are much healthier
and less costly than those who remain in traditional Medicare.
Risk
adjustment will also help level the playing field among Medicare+Choice
plans. It tempers the risk of significant financial loss when plans enroll
beneficiaries who have expensive care needs. And it focuses competition more on
managing care than on avoiding risk. It also will help plans by alleviating
concerns among beneficiaries that plans have financial incentives to deny care.
The law requires us to proceed with risk adjustment starting
January 1, 2000, and does not specifically call for a transition. However, we
believe we must implement these changes in an incremental and prudent fashion,
and are, therefore phasing in risk adjustment over five years
to prevent disruptions to beneficiaries or the Medicare+Choice program.
It
is essential to stress that risk adjustment will not and cannot
be budget neutral. Risk adjustment was required in the BBA
because of substantial evidence that Medicare has historically overpaid plans
because managed care enrollees tend to be healthier than beneficiaries who
remain in fee-for-service Medicare.
If risk adjustment were
budget neutral, Medicare and the taxpayers who fund it would continue to lose
billions of dollars each year on Medicare+Choice. Budget neutral risk
adjustment would cost taxpayers an estimated $200 million in the first
year of the phase-in, and $11.2 billion over five years if health plans
maintained their current, more healthy mix of beneficiaries. Actual savings to
taxpayers will depend on the extent to which less healthy beneficiaries enroll
in plans. Total payment may be higher for some plans than it would be under the
current system if their enrollment becomes more representative of the entire
Medicare population. Overall, we project plan payment to change on average by
less than 1 percent the first year. The phase-in substantially buffers the
impact. The federal government is forgoing an estimated $1.4 billion in savings
in the first year and as much as $4.5 billion over the full five years because
of the phase in. Impact on plans will be further buffered by an annual payment
update for 2000 of 5 percent, and by blended payment rates that we estimate will
be paid to 63 percent of counties in 2000 and in many cases will be greater than
5 percent.
Competitive Pricing Demonstration
We will soon begin a test
of competitive pricing for managed care, as called for in the BBA. This test
will provide objective data and actual experience that is needed to evaluate
Medicare reform proposals that assume savings from competition among plans.
Managed care plans will compete to offer benefits at the most reasonable cost. A
bidding process, similar to what most employers and unions use to decide how
much to pay plans, will be used to set Medicare+Choice rates.
To ensure
broad community involvement, a Medicare Competitive Pricing .advisory
Committee,chaired by General Motors Health Care Initiative Executive Director
James Cubbin, has made recommendations regarding key design features. It also
has selected the markets of Phoenix, Arizona and Kansas City, Kansas and
Missouri, as initial demonstration sites. We are establishing local advisory
committees in these communities, and they will hold public meetings to ensure
that local beneficiaries have a voice in how the test program will operate.
Ensuring Quality The BBA raises the quality bar by requiring most plans to
monitor and improve quality so beneficiaries can compare plans based on quality
and we can use Medicare's substantial market leverage to be a prudent purchaser.
We are working to incorporate quality assessment and improvement into original
Medicare, as well. And we are committed to making measurable quality
improvements throughout the Medicare program as part of our Government
Performance and Review Act objectives for fiscal 2000,
All Medicare+Choice
plans must report objective, standardized measurements of how well they provide
care and services. They have been using HEDIS, the Health Plan Employer Data and
Information Set, for reporting purposes since 1997. We also are using CAHPS, the
Consumer Assessment of Health Plans Study, to objectively measure beneficiary
satisfaction. We began requiring Medicare HMOs to conduct CAHPS surveys last
year. This fall, we will conduct a CAHPS survey of beneficiaries who disenroll
from plans, asking about the beneficiary's experience and why they left their
plan, to give beneficiaries the perspectives of both those who left and those
who stayed. And next year we will conduct a fee-for-service survey to provide
beneficiaries with data on all options.
HEDIS and CAHPS results are being
formatted so beneficiaries can make direct, apples-to-apples comparisons among
their plan options, and are posted on our Website at www.Medicare.gov.
Beneficiaries may also request HEDIS and CAHPS information through our
1-800-Medicare call center, and we will include this information in the 2000
edition of Medicare & You.We recognize that it takes time for plans to adapt
to the quality improvement requirements, and that a learning curve is involved.
Therefore, we made several changes from our draft proposal to help plans comply.
For example, we are:
- requiring plans to conduct two performance
improvement projects per year, which is
comparable to standards of private
sector accrediting organizations;
- giving plans three years to achieve
demonstrable quality improvements; and,
- giving plans discretion as to
where they conduct site visits for provider credentialing. Appropriate
flexibility will be provided so plans with networks that are less structured
than traditional HMOs, such as PPOs, can meet these requirements. Our quality
improvement systems will be sensitive to different plan structures and their
different abilities to affect provider behavior.
We are extremely impressed
with the quality improvement project outlines submitted by plans. Most are very
thorough and thoughtful. Many include detailed benchmarks and timetables. They
make clear that plans are very capable of achieving what Congress envisioned in
the BBA. Market Volatility
As you know, some Medicare HMOs did not convert
to the Medicare+Choice program, and others reduced their service areas last
year. While we are concerned about the impact on beneficiaries who were left
with no other managed care options, it is important to put those business
decisions in context. Some of the plans that withdrew had market positions or
internal management issues that made it hard for them to compete. And they faced
rising prescription drug prices and other commercial pressures. Many of the
disrupted beneficiaries had several other plans to choose from, and all but
50,000 had at least one other plan option.
It is our understanding that the
Federal Employees Health Benefits Program experienced a similar rate of plan
pullouts, often affecting the very same counties. The vast majority of Medicare
HMOs converted to Medicare+Choice, and we have approved several new plan and
service area expansions. This suggests that plan withdrawal decisions have more
to do with internal plan and larger marketplace issues than with Medicare rates
or regulations. In fact, a certain amount of market volatility must be expected
when relying on the private sector.
To buffer against such market
volatility, the President's budget includes proposals to protect beneficiaries
from such disruption by broadening access to supplemental Medigap polices if
beneficiaries lose their plan option and allowing enrollees with end stage renal
disease to move to another plan. We also provided for earlier notification of
plan withdrawals in our recent refinement to Medicare+Choice regulations.
CONCLUSION
We are making substantial progress in implementing the many
Medicare changes in the BBA. They expand options and improve services to our
beneficiaries, create better payment systems, and extend the life of the
Medicare Trust Fund. Clearly, more work remains. We are committed to continuing
to work to ensure that we are fair and prudent as we implement payment systems,
and above all do not compromise beneficiary access to care. I am grateful for
the advice and assistance this Committee and the Medicare Payment Advisory
Commission have provided. I thank you again for holding this hearing, and I am
happy to answer your questions.
END
LOAD-DATE:
March 18, 1999