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
