Reforming Medicare Provider Payment and Bolstering Health Care Cybersecurity

Provider Reimbursement Stability Act is another bill that aims to update the underlying structure of the physician fee schedule to improve predictability for physician payments and it is being led by Representative Murphy of North Carolina and Representative Schneider of Illinois. MACRA tried to move away from the traditional fee-for-service payment structure which requires recurring legislative dock fixes to prevent scheduled payment cuts to doctor reimbursements. While MACRA perm permanently repealed the older sustainable growth rate formula that caused significant payment challenges, Congress still has to consider short-term legislative patches to stabilize fee-for-service payment rates. By the end of this year, we and Congress will again need to look at a potential doc fix, and these bills try to get at some of those challenges. Another bill before us is the ensuring community access to pharmacist services act. or E CAHPS led by Representative Smith of Nebraska and Representative Schneider of Illinois. This legislation would expand Medicare coverage for certain pharmacy, pharmacist services, such as pharmacists uh providing testing. Community pharmacists are often among the most accessible providers in rural areas, Mm-hmm. which makes this legislation important for communities such as my district, These are my favorite. where many patients consider the pharmacy a critical point of care. Additionally, the Alzheimer Screening and Prevention Act, or ASAP Act, is led by Representative Buchanan of Florida and Representative Tonko of New York, and it would create a pathway for Medicare to cover FDA-approved blood-based biomarker screening tests for early detection of Alzheimer's and other related dementias. Further, I look forward to continuing the work on the Rural Obstetrics Readiness Act, which aims to help prepare rural hospitals and practitioners for obstetric emergencies. It is led by Representative Kelly of Pennsylvania and Representative Kim of California. We often hear about the challenges women and families face in accessing maternal health care particularly in rural areas such as my district. Many communities face shortages of obstetric providers, limited access to local maternity services and growing maternity care deserts. And it is important that we continue to look for ways to address the maternal health care crisis that is facing our country. Two other bills before us today are the Kidney Care Access Protection Act and the Keeping Individuals with Dialysis Needs Equipped Through Through Year-Round Remote Monitoring Act which both aim to improve care access for individuals affected by kidney disease. Among several several other Medicare payment reform bills, we will also discuss bills related to therapeutic shoes for those with diabetes, as well as legislation to mo that modernizes and expands access to cyber resources to help combat com growing cyber security threats. I am looking forward to our conversation and thank you to the witnesses for being here today. I now recognize acting ranking member uh Representative Fletcher of Texas for a five minute opening statement.

Well, thank you so much uh Chairman Griffith and um I'm glad to be with you here today because many of the bills that we are discussing today are important pieces of legislation for my constituents and for communities across the country and this hearing provides us the opportunity to continue important conversations about reforming Medicare payments for providers and to discuss policies aimed at imp at improving the security of Americans' health data something that is critically critically important. Many of the other bills we're discussing today are also toward expanding access to care for people across the country. And while I hope that today we are able to discuss some thoughtful recommendations and ideas, I once again caution everyone that these are not normal times, and we cannot have a hearing on the legislation aimed at reforming our health care system without discussing the ways that this administration and this Congress are actively harming providers and patients with the policies that this Congress has enacted over the last two years. So I know how important it is to pass legislation that will address the cuts to Medicare physician payments and ensure that physicians are receiving adequate reimbursements that will allow them to keep their doors open and to continue treating Medicare patients. In fact, it's one of the top issues I hear about from uh providers that I represent and many, physicians live and work in my district. But at the same time I'm hearing about this issue, I've also spent all of this Congress hearing from so many providers about the devastating effects of the so-called " one big beautiful bill". And I can't get into all of it, but between the cuts to Medicaid and the expiration of the Affordable Care Act, enhanced premium tax credits, it's estimated that nearly fifteen million people will lose access to health care. And the loss of coverage estimates don't even include the additional number of people who are forced to shift their health care plans who get health care plans that are not as good because they can't afford the ones that they had as the costs get shifted throughout the system. And what we know is that that is leaving millions and millions of Americans underinsured, uninsured, and unable to access care. When more people are uninsured and underinsured, it drives up costs. It drives up the cost for uncompensated care. It drives up the that increases the costs for not just the providers, but every single participant in our health care system, especially patients. Our health care system works as an ecosystem. If costs increase in one part of the system, those costs are incurred in other parts of the system. Providers are forced to make cuts elsewhere in the health care system to make up for the increasing uncompensated care costs. And we've already seen providers across the country begin to lay off staff, reduce health care services, and even close their doors altogether. It's expected that these cuts to jobs and health care services will become even more drastic once more of the provisions in that, so-called one big beautiful bill, take effect. They all haven't all taken effect yet. But we know that since it was signed into law, the Trump administration has issued a series of rules to implement the provisions of the bill that go even further than the statutory requirements in the bill, further reducing access to care and placing even more strain on health care providers and our health care infrastructure overall. And with providers forced to cut services and staff, this means that it's not only those who are on Medicaid or who received the enhanced premium tax credits who will lose access to care or see their health care costs increase. It will be more difficult for all Americans to access the care that they need. This will likely result in many Americans delaying or forgoing care altogether. And when people delay or forgo care, that is harmful for their health and for the health of our communities. And physician after physician has told me this, public health expert after public health expert has told us this, it's time for us to respond to it. For an administration that claims it wants to make America healthy again, actions prove the opposite, that it is doing everything but that and not making us healthier, but making it more difficult and more expensive to access health care. So I welcome the discussion today on pieces of legislation that will protect and expand access to care for Americans all across the country, but we on this committee also need to address the ways that policies that have been recently enacted have cut off access to care and have driven up health care costs for millions of Americans and I hope that the committee We'll take the opportunity to do that in future hearings.

Channel E yields back. Now recognize the Chairman of the full committee, the gentleman from Kentucky, Mister Guthrie.

Thank you, thank you, Mister Chairman. Thank you for Chair Griffith for holding this hearing. I'll be brief, as the committee has already done extensive uh work examining the provider landscape and subsequent payment reform. Earlier this year we heard from witnesses as part of our affordability series, followed by a hearing this spring focused on Medicare position payment reforms. Today we will build on that work by considering a range of legislative proposals aimed at strengthening the ability of our nation's providers to deliver enhanced care for Americans. Additionally, we are considering two pieces of legislation to address cyber security threats in the public and private health sectors, and pose serious risks to patient safety and and privacy. H R nine nine zero eight, the Rural Hospital Cybersecurity Enhancement Act, led by my colleagues, Representative Halchen and Schreier. Representatives Halchen and Schreier would support rural hospitals' critical cyber security infrastructure by requiring HHS to establish a comprehensive workforce development strategy that addresses the need for cyber security professionals in rural hospitals. The bill also requires HHS to publicly publish materials for rural hospitals to train their staff. Similarly, the Healthcare Cybersecurity and Resiliency Act of twenty twenty-six would expand resources for preventing and responding to cyber security incidents across the health care system, require health care providers, and plans to include the number of individuals affected when notifying them of a breach. I thank all of our witnesses for being here today. I look forward to hearing from your testimony. I thank the Chairman and I will yield back.

The Chairman yields back. I now recognize the ranking member of the full committee, Representative Colon, for five minutes for an opening statement and a point of personal privilege over and above the five minutes. Mister Quon.

Well, thank you, it's uh good to see you today. I don't know, you've been chairman of two committees since I saw your last rules in here today. But this is our last health subcommittee hearing before House Republicans send us back to our districts until after the election. And it's important as we discuss these legislative proposals today, that we not forget the Republicans' big ugly bill cut American health care cut American health care by more than a trillion dollars, the largest cut in our nation's history. And these massive cuts will result in fifteen million Insurance premiums spiked for twenty million people in the beginning of the year because Republicans refused to extend the ACA tax credits. And while Republicans are holding a hearing to discuss the challenges that providers face in the Medicare physician uh fee schedule, hospitals and clinics are closing in record numbers across the nation because of Republicans' health care cuts. Approximately ten thousand health care workers have already been laid off, and another three hundred hospitals, clinics and home care providers are closing down altogether or reducing services. So that's the health care environment that we face today. It's a disaster in my opinion. But let me get to the bills that we're considering today. We'll discuss a number of bills that would reform and modernize the Medicare physician fee schedule. What con when Congress passed the Medicare access and chip reauthorization act, or MACRA, there was hope that it would stop that roller coaster of payment cuts and create a system for reliable Medicare fi- payments to health care providers based on the quality of care that patients receive. A fundamental portion of MACRA was the merit-based incentive payment system. That system was intended to provide better pay for health care providers who provide better care. In reality, this system has appeared to create additional administrative burdens for providers without producing significant improvements in patient care, in my opinion. I believe any reforms to the Medicare physician payment system needs to ensure that Medicare remains viable while ensuring that patients receive quality care and doctors receive fair compensation. Any changes to the payment system should also improve how we evaluate the quality of care seniors receive without imposing burdensome administrative requirements on physicians. At the end of the day, Congress must prioritize access to to high quality care for all Medicare beneficiaries when and where they need it, and we must ensure any changes that we are considering today do not result in increases in Medicare beneficiaries' premiums or out-of-pocket costs. We will also consider legislation that would require Medicare coverage of Alzheimer's disease early detection screening tests. These tests have the potential to offer a transformative approach to early Alzheimer's screening. Any further changes to this bill must ensure it does not hinder the Center for Medicare and Medicaid Services' ability to collect data and real-world evidence real-world evidence in or to inform coverage determinations and must also treat all Medicare bef- beneficiaries equally. We're also considering two health care cyber security bills. They're intended to enhance health care privacy and better protect our health care infrastructure from cyber attacks and intrusions. And I continue to believe that we should address on-line, pos- hol- holistically, look at this holistically, of which health care privacy is an integral and essential aspect to these efforts. But I'm looking forward to the discussion today and I believe we must find bipartisan solutions on this issue. I also believe that Medicare beneficiaries should have access to routine services they need in the most accessible locations, including their local pharmacies, and I believe that H R three one six work can help us to do that. Now turning to public health, we'll consider a bill that would help prepare prepare rural providers to handle obstetrics emergencies, and another bill that would help develop a comprehensive strategy to prevent, diagnose, treat, and cure epilepsy, one of the most common neurological conditions that we have here in the United States. So, uh, I thank Mr. uh, Chairman Griffith. Let me just uh add, if I could, I know I'm going over time here, but I wanted to take a moment to to thank you Nalini for her more than eleven years here at the Energy and Commerce Committee, most of those years serving as Chief Counsel for the Health Subcommittee. She's played a critical role in every major health care bill that has been signed into law during that time. That includes the American Rescue Plan during the COVID pandemic and the bipartisan No Surprises Act, which ended the practice of surprise medical bills for patients. And has also led the health team during passage of the Inflation Reduction Act, which finally empowered Medicare to negotiate lower prescription drug prices for America's seniors. And this legislation is saving seniors billions of dollars on the drugs that have already been negotiated. And there'll be more negotiations this year and in years to come building on those savings. So, Junette has been a trusted advisor, she's going to be missed here at the committee, uh very seriously missed. And I wish her nothing but the best in her future endeavors. I wish she wasn't leaving, but I usually say that about anybody leaves who's good. But in her case it's even it's even more of that uh that uh I wish she wasn't leaving. But I wish her best on her future endeavors and congratulate her for her tremendous work of making health care more affordable and accessible for every American. So all the best, Junette, and thank you for everything you've done. Thank you, Mr. Chairman, I yield back.

Thank you and I I would be remiss if I didn't say that and I think most people who watch us know but without the team behind us uh we couldn't get anything done uh it's very helpful to have their input their knowledge and their advice so thank you. Alright we want the uh oops, skipped a paragraph. We now conclude with member opening statements. The chair would like to remind members that pursuant to committee rules, all members' opening statements will be made a part of the record. We wanna thank our witnesses for taking their time to be with us today, and to testify before this subcommittee. Although it is not the practice of this subcommittee to swear in witnesses, I will remind our witnesses that knowingly and willfully, making materially false statements to the legislative branch is against the law, under title eighteen, section one zero zero one of the United States Code, you will have an opportunity to give an opening statement, followed by questions from members. Our witnesses today are Mr. Greg Garcia, Executive Director for Cybersecurity, Health Care and Public Health Sector Coordinating Counsel, HSCC, Doctor Anthony Pudlow, uh, PharmD, MBA, MS, Chief Executive Officer of the Tennessee Pharmacists Association, TPA, and and are you keeping Ms. Harshbarger in line? I'm just saying.

Uh-huh.

Yeah. Uh, Doctor uh uh Murat Alam, MD, MSCI, MBA, FAAD. President, American Academy of Dermatology Associates, AADA. Doctor Rebecca Andrews, MS, MD, MACP, immediate past chair, board of regents, uh American College of Physicians, ACP and Doctor Eileen Atwood, MD, MPH, immediate past chair of the Committee on Health Economics and Coding, American College of Obstetricians and Gynecologists, ACOG and Miss Gabby Koeniger. Thank you. Uh, M MPH, Co-founder and Executive Director decoding developmental epilepsies. Uh, per committee custom, each witness will have the opportunity for a five minute opening statement, followed by a round of questions from the members. The light on the timer in front of you will turn from green to yellow when you have one minute left. I now recognize Mister Greg Garcia for his five minutes to give an opening statement. Mister Garcia.

Thank you, Mister Chairman and members of the committee, thank you for inviting me to testify. Uh, today I will discuss cyber threats to the health care system and patient safety and what we can do about it. Uh, the Health Sector Cybersecurity Working Group is an industry-led advisory council of almost five hundred health care organizations and government agencies and we work together to identify and mitigate systemic threats and vulnerabilities that affect the delivery and support of health care. At the heart of this work is the guiding principle that cyber safety is patient safety. Twenty-five years ago last Friday, the United States suffered the worst attack on American soil in the nation's history. It resulted in the deaths of more than three thousand people on that day and in its aftermath. While I watched archival news coverage of that event last weekend, I pondered how many souls, how many more souls might have been lost had those terrorists added to their arsenal with simultaneous cyber attacks on the neighboring hospitals. This blended attack could have disabled clinical IT systems and medical devices, and providers' ability to care for the many people burned and injured on that day. you should harbor no doubts that this is a very real scenario. Five years after those September eleven attacks, twenty years ago this coming Friday, in fact, I was appointed as the nation's first DHS Assistant Secretary for Cybersecurity. This new role was created in part to counter the prospect of that kind of devastating blended attack. In reminding me last week about the linkage between those two September days, colleague made a trenchant observation. She told me, " You know, since your appointment, the same technology that has put a cardiologist beside a patient's heart hundreds of miles away has also handed a criminal on another continent a weapon to hold for ransom her life support." This is the challenge before us in the health sector and before this committee. For our part, the many cyber security professionals in our membership have since twenty nineteen produced almost forty healthcare cyber security best practices by the sector for the sector, and some jointly published with HHS. Um, I would commend to my clinical colleagues here, we also have produced a cyber security for the clinician video training series. Forty minutes of your time well spent. Um, and that's available free on our web site. Implementation of these tools will measurably improve the security and resiliency of the nation's healthcare system if we can get them to the stake stakeholders who need them, with the government's help, at scale. And this is especially important for the nation's rural and resource constrained health providers. They are the most vulnerable to evolving malicious cyber threats, and this calls for a concerted, multi-pronged combination of government programs, assistance, and funding, coupled with market-based mutual support, community defense, and a safe harbor when they take appropriate steps to protect themselves, but still get attacked. Today the committee has two cyber security bills pending before you, and while the HSC has not formally considered these bills, I can say that they represent a welcome indication of this committee's attention to this complex and evolving challenge. Together these bills direct cyber security coordination across HHS, CISA, and the healthcare sector, and provide specific targeted assistance to the nation's small rural and resource constrained health providers. clarifications and refinements are needed in certain provisions, we stand ready to work with the committee to consider appropriate recommendations. Some of our suggestions would include the need to, one, direct HHS and CISA to formally involve the council in cyber security deliberations, threat information sharing, and incident response advisories to the community. Two, clarify section four of the Cyber Resiliency Act to require that the HHS designee for internal and external cyber security coordination, be at the deputy assistant secretary level or above, with the appropriate authority to influence policy and programmatic decisions. Three, ensure that grant funding is available to the broadest community of resource constrained health providers, and allow use of those funds to replace legacy medical devices that are too old to secure. And finally, four, Avoid congressionally prescribed technical solutions such as multi-factor authentication and encryption. These might be correct today, but technology is constantly evolving in ways that will change the meaning, the implementation, and effectiveness of technical products and methods. Such technical guidance in our view is better left to evolving industry security frameworks that are widely recognized and referen and referenced in law and operations. Mr. Chairman, that concludes my remarks and I'll be happy to answer any questions.

Appreciate it. And the gentleman yields back. Now recognize Doctor Anthony Pudlow for his five minute opening statement.

Thank you, Chairman Griffith, Ranking Member Fletcher, uh Vice Chair Harshbarger and members of the subcommittee, thank you for the opportunity to testify today. I especially want to thank uh Vice Chair Harshbarger, a fellow Tennessean and pharmacist, for her leadership in expanding access to timely, affordable health care. My name is Anthony Pudlow and I serve as the Chief Executive Officer of the Tennessee Pharmacists Association. Today, I'm here because too many seniors are still being denied timely access to care that may be available just minutes from their homes. You have a bill before you to address this issue that has strong bipartisan support among among members of this committee with thirty-eight co-sponsors among its members including twenty Republicans and eighteen Democrats. Now, Picture a senior who wakes up on a Saturday morning, struggling with respiratory conditions. Her physician's office is closed. Obtaining a timely appointment may be difficult, whether she lives in a rural community or a busy urban area. And waiting could allow a manageable illness to become far more serious. But her trusted pharmacy is open. Her local pharmacist is nearby, trained, and authorized by state law to provide the care she needs. Yet, because she relies on Medicare, coverage for those services may not be available. That is the gap HR thirty-one sixty-four, the Insuring Community Access to Pharmacist Services Act, or ECAPS, would help close. Throughout my career I've viewed health care from many perspectives, as a practicing pharmacist caring directly for patient care, As a leader, developing innovative pharmacy practice models, and as an advocate, working with policymakers and other healthcare professionals. All those experiences reinforced a simple truth, pharmacists are among the most accessible healthcare professionals in a patient's life. For many seniors, the pharmacy is more than a place just to pick up a prescription. It is often the most accessible point of entry into the healthcare system. Patients trust their pharmacist because the relationships buil built over years and often decades of care. Now, consider the Medicare beneficiary in rural Strawberry Plains, Tennessee, who wakes up with those respiratory symptoms but cannot reach a physician office who might be miles away. Or consider the senior in an urban neighborhood of Memphis, Tennessee, who may live near medical facilities but still cannot obtain a timely appointment, or easily travel across the city for care, even though that trusted community pharmacist is nearby and available. Too often, these seniors are faced with a difficult choice, wait and hope that they get better, or seek care in a higher cost setting, such as an emergency department. In Tennessee, pharmacists are authorized under state law to order testing and uh provide treatment for common respiratory illnesses. Tennessee, along with twenty-seven other states, already authorized their Medicaid and commercial health plans to cover such services. Medicare beneficiaries, however, they are often the only patients unable to access coverage for the same pharmacist-provided services. Ecaps would address this disparity by covering pharmacist-provided services under Medicare Part B for common respiratory conditions, under state scope of practice, and as part of the patient's health care team. America's pharmacists are ready. On behalf of the seniors, families, and caregivers who should not have to wait until a manageable illness becomes a medical emergency, I respectfully urge this committee to swiftly advance the in ensuring community access to Pharmacist Services Act. And let us give seniors access to the care that is already close to home, and help them remain where they most want to be, healthy, independent, and with the people they love. Thank you for your leadership and for the opportunity to testify, and I welcome your questions.

Thank you very much. Now recognize uh Dr. Murad. Alam, for his five minutes of opening statement.

Thank you, Chairman Guthrie and Griffith. Ranking members, Poulon and Fletcher, members of the subcommittee. My name is Doctor Murad Alam and I'm president of the American Academy of Dermatology, which represents eighteen thousand physicians nationwide. I'm also the vice-chair and a professor in the department of dermatology at Northwestern University Feinberg School of Medicine in Chicago. In my practice, which focuses on skin care, skin cancer care, I treat patients who travel from far away, including rural areas and adjoining states, because they cannot find care closer to home. Many of these patients return again and again because they depend upon me to catch cancerous spots. Perhaps it is a new growth on their back that the patient cannot see, or a suspicious sore on their nose that the patient isn't quite sure was there before. Skin cancer is the most common cancer in the United States, with most skin cancer patients sixty-five or older. Dermatologists are expert at evaluating skin lesions, distinguishing benign from malignant disease, and treating skin cancer when it is localized and most treatable. Most of this care is in private practices rather than in hospitals. Prevention, early detection, and access to high-quality, dermatologic care is particularly important for Medicare beneficiaries given their elevated risk of skin cancer. When detected early, ninety-nine percent of skin cancers can be cured, commonly with a single in-office procedure. When detected later, skin cancers that have advanced or spread typically require treatment with expensive and toxic medications and only thirty-five percent A disheartening part of practicing medicine is discovering a lesion that had it been found earlier could have been treated more easily. We saw this repeatedly during the pandemic. I told my staff, I know you are scared, but we have to see patients. We cannot let time pass without them being checked. We stayed open and we prevented suffering and likely saved lives. Unfortunately, between Medicare physician payment cuts and mounting administrative burdens, physicians are facing death by a thousand cuts, a slow erosion that is driving burnout and threatening patient access to care. Every close practice, every delay in care, every unfilled position that further hampers care delivery, threatens the long-term utility of Medicare. While I continue to encourage my medical residents and fellows to start independent practices in underserved areas, it is increasingly difficult to make that case. Between payment cuts, consolidation, and administrative burdens, they fear they cannot survive on their own, even when the desire to serve these communities is there. Congress must act to reform Medicare physician payment by establishing positive annual inflation adjustment and increasing the budget neutrality threshold. In addition to the expiration of the two point five percent update Congress provided only for twenty twenty-six, CMS's proposed rule for the twenty twenty-seven Medicare physician fee schedule includes cuts of eleven percent for dermatology's medically necessary services cuts that cumulatively rise to at least sixteen percent when fully phased in. thereby further destabilizing private independent practices. These proposed reductions directly threaten skin cancer prevention and treatment. If these cuts become reality, physicians would be forced to reduce staffing and limit the number of Medicare beneficiaries they can serve. We extend our gratitude to Representatives John Joyce, Greg Murphy, and Kim Schrier for their leadership in introducing H.R. ninety-six ninety-three, the Patients First Act. While physicians have long advocated for inflation updates tied to the full Medicare Economic Index, the inflationary update policy in the Patients First Act would be a vital building block towards long-term sustainable and predictable annual adjustments. I thank you for holding this hearing and for your commitment to ensuring patient access to life-changing dermatologic care. We must stop draconian cuts to Medicare physician payment. The price of delaying critical legislation, like the Patients First Act, is lives. The Academy looks forward to working with the committee as it considers the challenges facing physician private practices. Thank you.

Thank the gentleman for his testimony and now recognize Doctor Rebecca Andrews for her five minute opening statement.

Good morning, Chairman Griffith and Ranking Member Fletcher, the distinguished members of the subcommittee, and thank you for the opportunity to testify today. Who will take care of me? That was a question that I never thought of ten years ago, but now I worry almost daily when I imagine my future health. I'm Doctor Rebecca Andrews, an Internal Medicine Physician, Primary Care, and the immediate past Chair of the Board of Regents for the American College of Physicians. We represent more than a hundred and sixty-three thousand physicians, nearly half of the nation's primary care physicians, along with those in hospital medicine and the internal medicine subspecialties. Primary care is the foundation of every high functioning health system. A primary care physician is your health guide over the course of your life, and the longitudinal relationships that we build produce the trust for better outcomes. Yet somehow, the US health outcomes still trail other nations. My testimony today is a tale of numbers. One third of our country, one hundred million people, do not have a primary care physician. In my home state, it takes a year to get a new primary care physician. Of my sixty graduating residents each year, Very few choose primary care. This year it was six. That was a good year. And while the average medical student debt, when they graduate, is two hundred and twenty-three thousand dollars, Medicare payments have declined by thirty-three percent since two thousand and one when you account for inflation. This has hit primary care the hardest, since we lack the procedural revenue that cushions other specialties from the same cuts. Medical students and residents must weigh their school debt against their significantly lower earning potential in primary care, compared to other many other subspecialties. In other words, they simply cannot afford to go into primary care. Two years into practice, I personally saw the tangible evidence of the power of primary care. A twenty-nine year old woman called me, concerned about a breast lump, so I made her patient number twenty-six that day. And I have now cared for her for twenty years, through her cancer treatment, its recurrence, and her second remission. It took me ten years to convince her to treat her depression, but that allowed her to go back to work. For the past five years, I've treated her diabetes. And just two weeks ago, with the help of my resident, after years of discussion, I finally convinced her to take a medicine that would protect her against heart disease. This is primary care. The comprehensive care that is undervalued and built over years that produces the health outcomes we all want.

Mm-hmm.

Adding ten primary care physicians to every hundred thousand patients adds an average of two years of life expectancy. And for all of you, adding ten primary care physicians means that your cons- constituents will double their life expectancy by adding them compared to any other type of physician. And yet, we're losing this practice area. Still, I'm buoyed by hope. The Patients' First Act of twenty twenty six is part of that hope, and I thank doctors Joyce, Murphy and Schreier for leading the effort. Our written testimony has more detail, but I wanna highlight the potential. A permanent inflationary update would ensure physician payment never again goes three decades without an increase. A five-year hybrid payment pilot would provide independent primary care practices, in addition to fee for service, a per-member fee, recognising that primary care happens on the phone, through care coordination, and certainly beyond the office visit. I use a similar model in my practice, and we are able to have integrated social work, behavioral health, and a pharmacy team. But this must not be offset by broad cuts. or cost sharing by patients. So who will care for me in the future? To get more medical students and residents into primary care, invest in primary care through a mechanism not beholden to budget neutrality, support coding policies that appropriately value and recognize the time to provide longitudinal comprehensive care, use quality measures that are evidence-based, such as the Quality Reform Task Force and the Patient First Act, And build safeguards against physicians so they're not penalized for their patient complexity and social risks. Friday my resident asked me about the future of medicine. He wants to go into primary care. The future doctors are watching what you decide. But with input from physicians and professional medical organizations, you have the power to build a system that puts the physician in front of the patient rather than behind mountains of paperwork. Thank you for the opportunity to testify. I look forward to your questions.

Thank you very much, and now I'll recognize Doctor Eileen Atwood for her five minute opening statement.

Chairman Griffith, Ranking Member Fletcher, and distinguished members of the subcommittee, thank you for inviting me to speak with you today on behalf of the American College of Obstetricians and Gynecologists. My name is Doctor Eileen Atwood. I'm a practicing OBGYN in Providence, Rhode Island, where I also serve as the Co-Medical Director of the Emergency Department at my primary hospital. as well as hold privileges and work clinically at two other low-obstetric volume hospitals in the state. I am also the immediate past chair of ACOG's committee on health economics and coding. ACOG, with more than sixty thousand members, is the leading physician organization dedicated to advancing women's health. Our mission is to support our members to improve the lives of our patients, their families, and communities. Key to realizing that mission is ensuring sustainability of physician practice and patient access to affordable, high quality, and safe health care. One in three US counties have no obstetric clinicians or birthing facilities. More than two point four million women of reproductive age live in these communities, and nearly one hundred and fifty rural hospitals have stopped or planned to stop providing obstetric services between twenty twenty and the end of this year. This rapid increase in closure has reached crisis levels. In rural areas, loss of hospital-based is associated with higher rates of outer h out of hospital and preterm births, as well as lower rates of prenatal care, with the maternal mortality rate in the United States remaining unacceptably high with notable disparities by both race and rurality. This is why ACOG is proud to support HR one two five four, the Rural Obstetrics Readiness Act. This bill would create an obstetric readiness training program for rural facilities without a dedicated labor and delivery unit. provide new federal grants for those facilities to purchase the necessary equipment, and create a pilot program to support a warm line, connecting OBGYNs with clinicians in rural facilities in need of urgent teleconsultation. And this work is not just theoretical. We have done it informally in Rhode Island and with significant positive effect. Whether working in the emergency department or as serving as the hospital's Paranatal Safety Officer I am frequently on the receiving end of obstetric emergency transfers. including those from facilities without a dedicated labor and delivery unit. For example, I recently took a call from a regional hospital that had a patient in her second trimester present to their emergency department with dangerously high blood pressure. Through our t phone consultation, I was able to recommend the appropriate medications to minimize her risk of stroke or seizure and help determine if they could safely transport the patient to our facility, nearly an hour away, where we have the necessary resources for this patient and her baby. Additionally, we have grown our emergency department training programs with other specialties, including emergency and family medicine. We work alongside non-OBGYN residents and faculty to become more comfortable with obstetric emergencies that may present to their local and rural hospitals, to become more agile in safely managing these patients locally and best practices when transferring to a higher level of care. With this in mind, we urge Congress to pass the Rural Obstetrics Readiness Act this year. I also want to express my support for efforts to fix the flawed Medicare physician payment system. More than eighty percent of OBGYNs accept Medicare, affirming the role we play in caring for patients across the lifespan. Medicare patient payment policies reach beyond the Medicare program, with Medicaid, TriCare, and private insurers often following Medicare's lead on physician payment rates. The current system is not sustainable and has contributed to the consolidation of physit physician practice. As you just heard, adjusted for inflation, Medicare physician payment has declined nearly thirty-three percent over the last twenty-five years. The lack of inflationary update, the outdated budget neutrality threshold, and the recent misguided efficiency adjustment policy threatens not only the future of private practice, but access to care writ large. We need a payment system that recognizes the value and complexity of surgical care, as well as primary care, and adjusts for inflation to ensure that payment reflects the cost of providing that care. that updates the budget neutrality cap, and that allows for adjustments based on actual utilization. We are urging Congress to pass both the Provider Reimbursement Sustainability Act and the Patients First Act. Together these bills will add much needed stability to the Medicare program and preserve the low volume threshold necessary to enable OBGYNs like me to remain in the program while maintaining the shared priority of advancing access to high quality care. We are nearing the end of this Congress, but there is still time to pass.

Thank you very much, and and now recognize Ms. Gawby Hynekker for her five minute opening statement.

Thank you so much, Chairman Guthrie and Ranking Member Fletcher and members of the Uh my name is Gaby Koeniger and I'm the Co-founder and Executive Director of the Epilepsy uh excuse me Decoding Developmental Epilepsies and serve as a founding member of the Epilepsies Action Network but most importantly I am Elliot's mother, a child with a rare and catastrophic epilepsy who joins me today along with his sister Vega and my mother Jayetta epilepsy is always a family matter. I am here today to ask you to pass the National Plan for Epilep Epilepsy Act, H R eleven eighty nine, which has generated significant bipartisan support with ninety-seven representatives and twenty-eight senators who have cosponsored the National Plan for Epilepsy Act and the Senate recently unanimously passed a modified version. Nearly three point four million Americans live with epilepsy, rough and roughly half a million of those are children. We have made extraordinary scientific progress, but our system has not kept pace. We need a national plan to translate that progress into better care and outcomes for those living with epilepsy. My son Elliot began having seizures within days of being born. They were dismissed for months, and we were delayed in accessing a neurologist. What followed was a year and a half diagnostic odyssey with more than a dozen doctors, spinal taps, skin biopsies, MRIs, EEG_s, hundreds and hundreds of seizures. and many, many hospitalizations. In twenty fourteen, genetic testing revealed that my son has an SCNA-related disorder, a rare genetic condition that wreaks havoc on every system in his body. I speak on his behalf and for the countless others who cannot. Elliot is thirteen and he is my pride, my joy. But he suffers immensely. Elliot cannot hold up his hand in head independently, grasp a toy, eat by mouth, tell me what he's why he's hurting. or what he likes. Every day I live in fear that that day could be our last. And despite everything we know now, after about a d decade uh since the discovery of the disorder, he has tried and failed nearly every anti-seizure medication uh and excuse me, he has failed nearly every seizure medication that he has tried, and his treatment is still largely trial and error. Elliot's story is one of a catastrophic rare but there are so many others who live with profound uh effects of epilepsy. The veterans who have suffered TBIs, elder onset epilepsy, those with epilepsy that cannot get pregnant or live in deep depression. For far too many children I've seen pass away from drowning, respiratory distress, multi-system organ failure. In fact, one in every thousand people who live with epilepsy will pass away quietly in the night from SUDEP sudden unexpected death in epilepsy. The terrible reality is that one in twenty-six people will develop epilepsy in their lifetime. That equates to roughly one in one child in every classroom. Families across the country are navigating delayed diagnoses, disconnected care, inadequate data, and treatments that far too often remain guesswork. As you all likely know, more than a dozen federal agencies are currently working in epilepsy, NIH, CMS, CDC, FDA. Department of Education, Veterans Affairs. We have made incredible, incredible progress in epilepsy research, and there's incredible work happening in this country, yet too little of that knowledge is really translating into quickly available treatments and outcomes for patients. At least one third of adults who live with epilepsy do not gain seizure control. About a quarter of children, and for with a disorder like SCNA that my son has, more than sixty percent of those children never gain seizure control. We do not systematically track enough patients, their care, and outcomes to meaningfully learn from each person. As we've heard repeatedly today, clinicians are under strain. They are managing complex, lifelong conditions amid workforce shortages, administrative burdens, and limited tools to predict what treatments will work and when. And as we know, precision medicines are on the horizon, but uncoordinated systems and delaying um are delaying the promise of these lifesaving opportunities. This fragmentation also has uh consequences for affordability. Uncontrolled epilepsy drives significant health air care costs, and it is estimated that the total health kill bur care burden for those living with epilepsy is at least fifty-four billion dollars. Better coordination can help us get patients to the right diagnosis and the treatments sooner improving outcomes reducing avoidable costs and giving care providers better information and tools to care for their patients. Families like mine should not have to build the infrastructure ourselves to find patients, collect data, develop c guidelines, and push science toward treatments. The good news is is that the epilepsy community has come together, a hundred and fifty organizations have endorsed the legislation, and we have already come together to develop consensus priorities for what could be conclude c can be included in a national plan for epilepsy, And when it is passed, we stand by ready to support uh Congress and the Secretary-Gerent advance this lifesaving work. In the world of epilepsy, I'm almost done, I promise, there is a saying which is that time is brain. The longer we wait, the more damage that is done. It may already be too late for my son, but we have the chance with the National Plan for Epilepsy Act, take a ha historic step toward ending decades of fragmentation and ensuring that scientific progress more rapidly reaches the people who are desperately needed. We need to act now. And on behalf of Elliott, my family, and the millions of Americans and their families who uh live with epilepsy on a daily basis I respectfully ask you to pass H R eleven eighty-nine this year, to give families like mine a future defined not by fear and lost potential,

Mm. Thank you.

but by progress and possibility.

Thank you for your thank you for your testimony today.

Thank you.

Uh we will now begin questioning. I'd ask that members not begin a new question to our witnesses as their five minutes is about to expire. and would encourage members to submit written questions for the recoc record. I now recognize myself for five minutes of questioning, first with uh I would ask for unanimous consent to present for the record a letter from Congresswoman Jen Kiggins a Nurse Practitioner who writes in support of HR sixteen sixteen the promoting access to diabetic shoes act. Without objection? So ordered. Alright, Doctor Atwood. In my district we have a limited number of O OBGYN specialists and many are considered uh many areas are considered maternal health care deserts. Outside of payment stability, what are some other ways we can look to build the maternal health workforce pipeline, especially in rural communities, where a lot of times it's not that the hospital's not willing, they just don't have providers.