Panel 4: Health Policy Academy Deep Dive: Unlocking Expertise of Congressional Agencies

Speaker 1 (00:04):

Okay, well I’m now pleased to introduce our final panel of the Day Health Policy Academy’s Deep Dive, unlocking the expertise of Congressional Agencies. After the panel, be sure to stick around. We’re going to have some drinks and some light snacks. I will warn you, they’re our catering crew is going to be setting up during this panel, so you might see that. And then as soon as the panel ends, we’re going to shift some of the tables over. So just want to give you a warning for folks on this side of the room. But with that, I am thrilled to turn it over to our moderator, Dr. Melanie Goran. Melanie Anna Goran is a nationally recognized strategic and innovative health policy expert with over 25 years of experience, including as a Senate confirmed HHS executive. Dr. Goran most recently served as assistant secretary for legislation at HHS during the Biden Harris administration.

(00:57):

Prior to being confirmed by the Senate to serve as a SL, Dr. Gordon was deputy staff director for Health subcommittee and professional tax staff for the committee on Ways and Means in the US House of Representatives. Dr. Gordon started her federal career as a senior analyst at Government Accountability Office focusing on a range of public payer health policy issues. She holds a bachelor’s and master’s degree from Emory University and a PhD from the University of California, San Francisco, originally from Baltimore. And Dror lives in DC with her husband, two children and dog. And so with that, I will hand it over to you.

Dr. Melanie Goran (01:31):

My dog would say he’s probably the favorite child. First, thank you guys for being here. I know it has been a long day and I really appreciated the questions and engagement that you brought to the last panel. So keep that energy up. We promise that we will be short and we will make sure because we want to answer your questions, help you be the best health staff that you can be. I was in your shoes very recently or feels very recently, and as introduce our various speakers, I’m going to give you a little snapshot of how I use them so that it gives you some context to think about why all of these congressional support agencies are there, why Congress funds them, which is incredibly important and the valuable work that they do. I will say, I probably would not be sitting, I know I would not be sitting here if I didn’t start my career at GAO and people like Leslie helped me understand where federal payment systems were if Jim wasn’t patient and who asked about Medicare Part C in the last round, right?

(02:30):

I mean, Jim and his team literally drew a map for me and explained to me market penetration when I took over the Medicare Advantage portfolio for ways and means. CVO and CRS taught me how to think like an economist. So I understood scores when they put out reports and math pack was so important when I did the DOLs work. So think about how you can use these resources in your job, not just now, but throughout your career because it’s incredibly important. So we’re going to have each of the presenters talk about what they have done and then we will answer your questions. But I think what I want you to walk away with, and maybe I’ll start there, is if you walk away with knowing there is a whole community of really smart, committed, and this is the important part, non-partisan bicameral, right? They don’t preference the Senate over the house.

(03:28):

They work confidentially with you to provide you the expertise and help that you need. Now, I will go to my ways and means committee moment and say, but before you go totally rogue, please talk with the committees of jurisdiction. Because the worst thing and the worst calls I ever had to make was when I had to call staff and be like, so I hear your boss is working on this. Do you understand? That goes against the chairman? And I know that sounds silly, but that’s my other piece of advice. Work on policy, be smart, get smart, go to everything you can do, talk to the experts, but also really work with those experts at the committee. Debbie Curtis, who was sitting here right before here was on the committee when I joined as a detail E from GAO Neil, who’s now hiding in the corner, was my fellow, right? The health community is small.

(04:19):

I looked at her, I’m like, we’ve all worked together in different roles, in different iterations throughout our career. So as you think about what you’re learning today, really think about it for right now and where you are, but also where you’re going to be in 20 years when you’re still working on the hill. You’re still working in public service. So with that, I’m going to just go down the line and introduce folks, and then you’re going to hear from the smart people who continue to teach me. First we have a DT Send. She serves as the Chief Health Policy Studies Unit at CBO, the Congressional Budget Office. Previously, she was the director of research and policy at the Healthcare Cost Institute and assistant professor in the Department of Health Policy and Management at Johns Hopkins Bloomberg School. She previously held positions on the staffs for the Assistant Secretary of Planning and evaluation.

(05:08):

A P is also really important. They’re at HHS. They are the smart economists that drive policy, the White House Council of Economic Advisors. Your boss one day will ask for an economic advisor’s report, know those people are really smart and know where to find those reports. The US Agency for International Development, she holds an undergraduate degree from Yale and a PhD in health economics from the Wharton School in the University of Pennsylvania. Next we have Leslie Gordon, who is a director at the US Government Accountability Office where she leads the agency’s work on the Medicare program. Leslie and I started our careers together. We did. We did. And one of the things I can say about GAO is it really builds expertise and a knowledge of federal systems. Leslie’s led work on Medicare Advantage Hospital, price transparency, limb loss, end stage renal disease, private equity, ownership of nursing homes and telehealth and a whole bunch of other things. If you ever want to get smart on an issue really, really quickly, read the background sections of a GO report. They’re designed to be succinct. They’re designed to teach you what you need to know to understand that report. I’m going to tell you about MedPAC in a second, but the geo background reports and the staff spend a ton of time making sure that that is understandable for everybody. Sorry if I’m stealing your thunder.

Speaker 3 (06:26):

No.

Dr. Melanie Goran (06:26):

Okay. This is my dream panel, even though I’m a total health nerd. So prior to joining GAO, Leslie was a project director and research instructor for the National Center for Education in Maternal and Child Health. She holds a master’s degree in public policy from Georgetown Small Court School of Public Policy and a bachelor’s degree from the University of Notre Dame. Leslie is also a family, is a caregiver for an HN disabled family members and an avid hiker. Next we have Jim Matthews as again, Jim taught me everything I needed to know about Medicare Advantage. Jim joined Health Policy Alternatives in January of 24 after 30 year federal career and public policy. He was executive director of the Medicare Payment Advisory Commission. MedPAC. Ooh, if you want to have fun, go to the MedPAC Commission meetings. Good time. They’re a good time. If you’re interested in learning about how really smart experts debate issues, right?

(07:24):

The MedPAC and Macpac boards are there to advise Congress and they’re made up of appointed experts from across disciplines and advocates, and it is a fascinating conversation and the analysts are amazing. Okay, now I’ll keep going. So Jim served as the executive director after having served for nearly a decade as the Commission’s deputy director in these leadership roles, Jim provided policy advice to Congress people like me as well as to CMS that informed major developments Med PAC’s recommendations under Jim’s leadership to help shape the change of Medicare policy for drugs, hospitals, and post acute care in the Bipartisan Budget Act of 2018. I will also say that one of the best things that Jim did was make, and MedPAC in general is approachable for staff. They make a payment basics book if it is not printed and sitting on your desk. It was the thing I gifted every new LA it weighs a means.

(08:19):

So, okay, ready? Write this down. MedPAC Payment Basics. MedPAC Play with basics has a beautiful flow chart of how hospitals are paid. And I’m slightly embarrassed to say that I had that hanging on my desk as a SL 25 year career. Still had the payment basics and still kept it as a reference on my desk because it explains the nuances of payment. So when that lobbyist comes in or your boss asks why this hospital is paid differently than that hospital, you have that in front of you. It also explains all of the other payment system and they’re like One page super easy. Great. Okay. Sorry Jim. So Jim earned his bachelor’s and master’s and doctorate degree from the University of Chicago. He also holds a scuba rescuer certification from the National Association of Underwater Instructors. I did not know that

(09:10):

Jim, also Jim Children gave him the best piece of jewelry ever. You can ask him about that later. Finally, we have Kate Massey, who’s the executive director of the Medicaid and Chip Payment and Access Commission. Macpac like MedPAC, Macpac incredible resources. Go find the explainer. I will admit Medicaid’s a challenge, right? Because if you’ve seen one state, you’ve seen one program, you’ve seen one program, you just heard about 1115 waivers. But in the current debates and reconciliation, use their resources to get smart to understand what’s being discussed so that you can understand when CBO puts out their report, what they’re talking about. You need to triangulate all of these resources together. Before joining macpac, Kate was the senior deputy director for Behavioral and Physical Health and Aging Services. I’m sorry, Kate, behavioral and Physical Health and Aging Services Administration at the Michigan Department of Health and Human Services. Kate has over 20 years of operational and policy expertise in Medicaid, Medicare, and the state children’s health insurance programs, CHIP and private market health insurance. She is Medicaid managed care experience previously serving as the Chief Executive officer for Magellan Complete care of Virginia and Vice President for Medicaid and Medicare and government relations at Kaiser Permanente of the Mid-Atlantic States.

(10:32):

I’m going to make sure we get to time. So Kate has had a long career and has led a team focused on Medicaid chip and private insurance at the Office of Management and Budget. Yet another they’re, they’re that way at the end of the street, OMB and their analysis, the president’s budget. If you want to talk about president’s budgets and proposals and congressional justifications, which you guys should all learn to read. Yeah, right. Triangulating your data, thinking of policies for your boss. It’s not one source, it’s all of them coming together. So with that, I’m actually going to hand it over to dei.

Speaker 4 (11:07):

Great, well thank you. Thanks for having me back. I’m excited to be here. Lemme see if I can, okay. Alright, great. Okay, perfect. So the goal for me with my 10 minutes is to give you kind of a high level overview of CBO, including a bit about what we do, about what we don’t do and the kinds of services and information that we provide to the Congress. So for those who don’t know, CBO, the Congressional Budget Office was created by the Congressional Budget and Impoundment Control Act of 1974. And the goal is really for CBO to give Congress a stronger role in budget matters and in particular provide the data and the analysis to help the Congress make effective budget and economic policy. So the agency, we provide analysis of budgetary and economic issues. All of the analysis that we provide is objective and impartial.

(12:09):

We are strictly nonpartisan, and you’ll hear me say this again later. We do not make policy recommendations. We follow processes that are all specified in statute or that have been developed in concert with the budget committees and congressional leadership. And our chief responsibility under the Budget Act is to help the budget committees with matters under their jurisdiction. In addition to the budget committees we work, we support other committees and particularly appropriations ways and means the finance committees as well as the leadership. And I just want to emphasize and we can talk more about this, but it’s really Congress that sets CBOs priorities and you’ll see how that flows through what we produce and give to the Congress as I go through.

(13:00):

So with this objective in mind, we provide a variety of different types of information to the Congress. Some of that information like what are commonly referred to as baseline projections are statutory requirements. So those are projections of federal spending and revenues under current law that help Congress formulate its budget plan. Some are, a lot of what we do are of course cost estimates. Those are estimates of legislative proposals effects on the federal budget that help Congress stay within its budget plan. CBO is required by law to produce a cost estimate for nearly every bill that is approved by a full committee of the House or the Senate and their advisory only. So as I said before, CBOs job is to do the best analysis that we can and give that information to the Congress and then it’s really up to the Congress kind of what they want to do with that information so they can be used to enforce budgetary rules or targets, but that enforcement is really the purview of the budget committees and not of CBO. And then the last one I want to highlight on the slides is we do also a lot of analysis of policy options. Those are often housed in the big CBO reports that you’ll find on our websites. A lot of that, those reports come out of the program divisions, which is where I sit in the health analysis division. In addition, there’s the budget analysis division and they’re the ones who are responsible for doing all the cost estimates.

(14:43):

So our assessments are based on detailed analytics. We have a look and build a strong detailed understanding of federal programs and revenue sources. We spent a lot of time looking at the literature and talking to outside experts to inform our assessments. Of course, we do a lot of data analysis ourselves in-house using data that is reported by federal statistical agencies and other groups and we have a panel of health advisors and a panel of economic advisors who we also consult with. And I think for all of you, one thing that we always like is when staffers who are particularly interested in issues recommend people for us to speak with on topics so that we can keep our network broad and well-balanced and get input into the work that we’re doing.

(15:40):

We really prioritize transparency. So we’re committed to documenting and sharing the basis of our findings. That’s often why we write these really big reports or have a lot of accompanying information along with the cost estimates we provide. We try to explain the revisions to budget projections and estimates. We do that in writing. We do that in conversation with staffers. Our director does that. He goes up to the hill and testifies. We report on the accuracy of our projections. Again, we seek a lot of external review and we do a lot of informal talking with staffers and members about how we’re getting to our assessment. So what they mean, okay, what do we not do? As I already said once we do not make policy recommendations, we are nonpartisan. We don’t make any judgements about the merit of the legislative proposals and that’s really important for how CBO operates and the kind of information that we give and our role in what we provide to the health.

(16:55):

We do not write legislation. We again analyze different proposals and options. We don’t implement programs or regulations or enforce budget rules, budget committees, other federal agencies, the Office of Management and Budget are responsible for those roles and we don’t conduct audits or operations of government programs. That’s Leslie. So she’ll go, she’ll talk about that. Next, just a little bit about our organization and staffing. The agency has about 270 full-time staff, our director Phil Swale. Currently he’s appointed the director’s appointed jointly by the speaker of the house and the president pro temp of the Senate and all staff. All of us are appointed by the director solely on the basis of professional competence with no regard to political affiliation. And about 80% of CBOs professional staff hold advanced degrees in their economics, public policy, public administration, or related field.

(18:04):

Let’s see. So let me just wrap up by giving you some kind of numbers about how much we do and what the kinds of materials we’re producing. This kind of follows from the earlier slide where I was describing the kinds of work that we produce. So in a typical year, CBO publishes about 80 reports, working papers, testimonies, and interactive tools. Some of the reports like the budget and economic outlook are specified in statute, others are also required by law or they’ve become kind of a traditional CBO release over time. A lot of our analytic reports are written at the request of the chair or ranking member of a committee or at the request of the leadership of either party. And I’ll just say I’ve been at CBO for almost two years now, and one thing that I have experienced is that often a lot of those requests are we don’t get a letter out of the blue.

(19:06):

We’ve never heard of this report or interest in this topic before. In most cases we have a relationship with the committees and we hear we are particularly interested in this kind of a topic, what could CBO do? How could we work together? These are the most important questions for us. And so it’s more of a joint process of figuring out the topic and scope of reports. Often in those reports we’ll present a set of options for changes in federal programs or tax rules under consideration and assess each options budgetary and economic effects. And again, no policy recommendations. So it’s really sort of a comparison of budgetary effects. We also produce about 700 cost estimates, and as I’ve been mentioning throughout, we fulfill thousands, a lot of requests for technical assistance, for example, consulting with committee staff as they are drafting legislation and kind of throughout the process. So it’s been really before coming to CBOI did a lot of executive branch work and it’s been really one of the pleasures of CBO to work closely with staff and get to know staff and see how we can most effectively inform or meet their needs and inform their decision making.

Speaker 5 (20:29):

I think that’s it.

Speaker 4 (20:31):

Awesome. I’ll give you my 45 seconds. Okay,

Speaker 3 (20:35):

Good afternoon. It’s a real pleasure to be with you this afternoon and I’m here to represent the GAO. Go GAO. You’ve heard of us. We’re the investigative Armed Congress, the congressional watchdog. We help Congress with their oversight responsibilities for the executive branch. So we examine where the federal dollars are spent and how federal programs, policies and operations work. We also provide lawmakers and agency heads with objective, nonpartisan, professional fact-based recommendations and help government save money, improve operations and work efficiently for the American people.

(21:21):

And we support Congress in carrying out constitutional duties. And one other thing that you’ll notice at the bottom of the slide, so among all of our work and our analysis and the reports and things we put out the comptroller General, the head of the agency is also responsible for appointing several healthcare related commissions. Oops, I went the wrong way. We provide a number of services to the Congress. You probably read a few of our reports. Last year we did 718 reports with over 1500 recommendations on how to improve the government. We have a few different formats for our reports. There are letter reports, there are short correspondence. We now have a new q and a format and there’s a healthcare capsule, which is a two page format. But with our longer reports, everything gets boiled down into a one page highlights page. So if you don’t really have time, the high key points are on that highlights page and you can reference it there.

(22:25):

The technical assistance that we perform. We certainly like to get calls from staff to help them think about what they’re going to request work of GAO, how it should be structured, what makes sense for us to look at. So we definitely respond to those information requests, but we also can provide updates on what are the open geo recommendations about a program, what’s the status of the agency’s progress? Can you give us some background information? What does this new rule say? And we can summarize other reliable sources of information. Our technical assistance generally does not involve anything that would mean that we have to interact with the agency staff. And last year we did about 1100 technical assistance touches with the staff. We have science technology and cybersecurity expertise in house. This is sort of new like the last 10 years. We think 10 years is new at GAO.

(23:21):

We’ve been around a while, but the science and technology folks will do a technology assessment that’s a new kind of product that GO does and our cybersecurity folks are in their evaluating controls of the IT systems across the federal government. Our legal teams support legal decisions, federal bid protests, appropriations law, and then we also look at how federal agencies comply with certain laws like the Congressional Review Act and the Federal Vacancies Reform Act. Our team did 1800 bid protests last year and 550 legal decisions. Those are on the website with respect to supporting testimonies and hearings. Geo staff can be witnesses. We can write statements for the record to supplement other points of view or other facts. We can prepare questions for your panelists even if you don’t want geo at the table. We can help you think about questions to ask those panelists and questions.

(24:21):

And we develop questions for confirmation hearings as well. And we can provide you with again, summaries of GAO findings and recommendations of the status update to supplement and help inform where you want to take those inquiries. Last year, GA’s work yielded 67.5 billion in financial benefits, a return of $76 for every dollar spent on the agency. And I got to plug our six year average, which is $123 return on investment. Our work is directed 96% by Congress. It comes to us through mandates in the law or committee reports and through direct requests generally from committees and subcommittees. The chair ranking member, Melanie said, you got to reach out and talk to the chairman. Anyone can request work from GAO, but we have priorities and we have a lot of work to do. And so if a chairman or ranking member is not signed on as a requester of the work, it’s very, very unlikely that we will get to that request there about, I think there anyway, I won’t talk about the queue.

(25:35):

It’s not a pretty picture. We do do 4% of our work is based on the Comptroller General’s authority. He initiates the work independent of our request. These are very broad areas, mainly they’re sensitive topics or other topics that it might be hard for someone to request. But then when as we’re developing the work, we do reach out to staff and we let them know it’s coming down the pipeline and members can sign on as addresses if not requesters, and they can get that work. Just a summary of the healthcare team. We really look at every all areas of healthcare delivery and financing. So I lead the Medicare portfolio work, but my colleagues, there are other directors. We do all of ’em.

(26:27):

Our work is directed by Congress and we don’t forecast or estimate spending or what costs are going to be in the future. We don’t make policy recommendations, but we do make recommendations to improve operations. So we will evaluate program, we’ll look at programs, assess them and evaluate them against clear applicable criteria, which can be like the agency’s own program requirements or the rules or the statutes associated with it. Project management practices, internal controls are other widely known standards and practices. I lead the Medicare work, as I said, there are 64 open recommendations to improve the Medicare program currently. Seven of them we consider to be high priority recommendations. And an example of one of those is we have an open recommendation that CMS fully validate the Medicare advantage and counter data because it’s needed to understand what services are being provided in Medicare Advantage and it’s being used as a basis to risk adjust payments.

(27:35):

When we have, we find deficiencies or gaps in the performance of programs and the agency doesn’t have the authority to conduct or to make the change, then we will make a recommendation. That is we consider a matter for congressional consideration. It’s directed at Congress to say Congress that you would need to act to address this deficiency. An example of one of our recommendations related to that is where we have recommendation on site neutral payments. You might’ve heard a lot about site neutral payments and equalizing payments between hospital outpatient departments and physician offices. Well, GA is right there with the same. I want to plug another one of our matters for congressional consideration that recently came through our team in 2018 reported on the amount of money, 5 billion that was being spent on critical incidents related to poor quality care in skilled nursing facilities. So we have a matter for congressional consideration that they implement additional reductions in payments to SNS when they generate spending.

(28:40):

That is on potentially preventable critical incidents. And I have a little word cloud for you. This is generated from the reports that the GA healthcare team put out in 2024. And I just want to point, I didn’t know what was going to happen when I did this and I did take out the small words and would’ve been really big, but you’ll notice improve information, veterans Oversight Medical Monitor network of our 67 products that the healthcare team put out last year, they ranged from VA appointment timeliness, suicide prevention programs, DOD, VA transition programs, conditions of the Indian Health Service facilities, public health workforce, maternal health, OCS response, FDA, foreign drug manufacturing state’s, regulation of pharmacy benefit managers, Medicare hospice program hospital’s, use of supplemental nurses during the pandemic, Medicaid managed care state directed payments and Medicare and Medicaid program integrity. This slide, if you have access to it, it’s a list of all of the healthcare directors. You don’t have their email addresses attached here, but these are the folks who are my colleagues who handle everything except Medicare and just Farb as our managing director who leads all of the work. I really look forward to your questions and I yield my 30 seconds.

(30:27):

You’re going to have to advance a bit.

Speaker 6 (30:33):

Alright, thank you everyone. I appreciate the invitation to come talk with you today. Before I get into my formal remarks, I do want to say that while my previous position was executive director at the Medicare Payment Advisory Commission or MedPAC, I am not speaking for the commission, it is their April public meeting today. And the leadership was otherwise engaged. But the Alliance asked me to come in and speak about the commission. And I think based on my 16 year tenure there, I have some basis for being able to say a few things and I am 98% confident that everything I’m about to say is still true and current.

(31:17):

I’ll leave it to you guys to figure out the 2% that is not. But let me talk a little bit about MedPAC. We are, I’m going to be saying we a lot. I apologize in advance. MedPAC is an independent nonpartisan congressional support agency that has the very narrow mission of providing analysis, policy recommendations, and technical advice to the Congress on issues related to the Medicare program. I say narrow, but those of you who are familiar with Medicare realize the scope of what those few words actually touch on. And we, sorry, again, MedPAC will cover everything related to Medicare payment is in its name, but also access to care, quality, beneficiary issues, provider issues, how Medicare interacts with other aspects of the healthcare system. It is a fairly broad portfolio within a fairly narrow legislative parameter. MedPAC, as I think Melanie mentioned, is staffed by or it’s composed by 17 commissioners who are appointed from different walks of the healthcare community.

(32:34):

We have providers, payers, beneficiary advocates, actuaries, and these are appointed by the comptroller general at GO and GAO does an amazing job given the constraints of trying to find broadly representative expertise by appointing 17 individuals to sit on the commission. So I appreciate all of the good commissioners you’ve sent our way and I have other things to say about all the bad ones. Okay, but the commission meets in public seven, eight times a year to discuss the deliberations and discuss an analytic work that is produced by the staff. My role was to lead the staff when I was at MedPAC. They are composed at any given point in time of 25 to 30 analysts, most of whom are national experts in their fields. When MedPAC takes on an issue, the agency keeps three principles in mind no matter what it is that the commission is evaluating, whether it’s post-acute care, hospital care, physicians, beneficiary access to care, clinical laboratories, whatever it is, there are three things that guide med pack’s analytic work.

(34:00):

First, the commission always strives to make sure that whatever it is doing ensures beneficiary access to high quality care in an appropriate setting. Second, MedPAC tries to ensure that Medicare is making the best use of the tax dollars that fund the Medicare program from taxpayers and beneficiaries who pay premiums. And then lastly, the commission tries to make sure that all of its policies give providers an incentive to deliver care efficiently, appropriately, and equitably. In the course of the commission’s work, there are basically two broad buckets of work. One is fairly public facing. There’s the commission work that the staff supports. Again, these are the public meetings where the commissioners gather to discuss the analytic work produced by the staff. There are the analytic work that is published in the two standing reports to Congress that MedPAC produces every year in March and June, as well as a whole bunch of other mandated reports that the Congress has a propensity to throw at the commission.

(35:17):

MedPAC produces comment letters to the Secretary of Health and Human Services on proposed regulations related to the Medicare program. They also produce contractor reports. And then lastly, on a very limited basis, some of the MedPAC staff will produce material for a peer review health services research journals. But the primary role of the commission is to support Congress. And over the years there has been an interest among the leadership in engaging more in the health services research community. I have always resisted that and kind of kept blinders on with the notion that our primary role was to support the Congress. That leads to the second bucket of activities that the commission engages in. This is responding to congressional requests for information analysis of background. And a lot of this takes place behind the scenes. Probably 75% of med pack’s work is related to these congressional requests that come in and literally there can be 20, 30, 40 in any given week. And some of these are big requests that result in the dedication of a lot of staff work to a formal written report or it can be quick inquiries. How many uninsured people with red hair live in Montgomery County, Maryland on this census tract?

(36:50):

But it’s a constant flow of information and like my colleagues, that is all handled on a confidential basis and it is handled on a nonpartisan nonpolitical basis, irrespective of whether the requests are coming from the house or the Senate MedPAC with the limited resources that it has does its very best to handle all of these requests timely, objectively and in a nonpartisan way. MedPAC also does a hill staff briefings. So in advance of each public meeting that the commission holds, the commission will get on the phone with the committee staff with jurisdiction over Medicare and say, here’s the agenda, here’s what we’re going to talk about, here’s why. Here’s where we’re going with this. And the idea is no surprises. The Congressional committee staff hate it when you surprise them with something and they will chew you out. You wouldn’t believe. Not that I have ever experienced that.

(37:59):

MedPAC like our colleagues here, GAO and Macpac also will serve as witnesses to congressional hearings. Preparing testimony. I’m going to skip over the payment basics just for a second here. MedPAC also produces a data book each year that is tremendously valuable as a quick reference. And then since Melanie did give this some airtime, the payment basics, again, I highly urge you to take a look at those. They are two to four pages each and they will give you a working knowledge of whatever payment system you happen to be interested in. And over the years, it had been my understanding that these documents were also a favorite of Wall Street analysts who needed to come up to speed on an issue and were happy to take information produced on the public’s dime in order to help enrich the hedge funds that they represented. So this is the benefit of me not being at MedPAC and I say a lot of stuff that would’ve got me in trouble two years ago.

(39:04):

So MedPAC has a broad leeway to conduct the work that it does. And here again, there is a benefit to being a congressional support agency in that MedPAC is not subject to things like the administrative Procedure Act, foia, things like that. So it can conduct its work, very nimbly, agilely, and with a great amount of confidence, both with respect to the people who request the work, but also the people who are providing MedPAC with information. It is a tremendously powerful thing to be able to go into a room talking with extremely important and influential people in the healthcare sector and say, I’m going to be candid with you. I need you to be candid with me. Let’s talk. And you would be surprised at how often that happens when you set those kind of ground rules. So MedPAC is able to go out and do site visits with providers.

(40:01):

They will do focus groups with the beneficiaries and providers. They will get input from other stakeholders on a confidential basis, convene expert panels. But where MedPAC strength lies is the quantitative analysis that it does. I mentioned on a couple of slides ago that the staff are experts in their fields and MedPAC sits on vast amounts of Medicare data. When I left, we were in the ballpark of 200 terabytes of data, and I couldn’t tell you what a terabyte looks like, but I think it’s bigger than this. But they are really sharp people, very dedicated to their work, and I would put them analytically against anyone out in the field in terms of the work that they do and the recommendations that they produce with respect to the data and analytic work that they look at. This gives you some sense of the kinds of things that MedPAC produces.

(41:07):

One of the standing jokes in DC is that no one pays attention to MedPAC, that Congress will go for years and years and years without paying attention to MedPAC until they do and when they do. Here’s one of the things would’ve never said when I was on the job, but MedPAC recommendations can lead to major overhauls in federal legislation related to the Medicare program. And the one I want to point to on this slide is the redesign of the Medicare Part D drug benefit. That largely came from 2, 3, 4 years of analytic work, two years of technical assistance with the congressional committee staff, and it did indeed become the law of the land. For the record, we had nothing to do with the price negotiation components of the IRA, but the Part D redesigned that with us MedPAC the value of MedPAC. You’ve heard Leslie talk about return on investment for GAO.

(42:09):

We used to do a similar exercise at MedPAC, but since I left, they took out the dollar estimate of the savings that the commission produces and now sort of like McDonald’s, billions and billions in savings for $14 million annual appropriation. And those of you who operate in the federal budget world, that’s not even budget dust, that’s budget molecules. And so for the amount of work that the commission produces for that amount of investment, the highlights, what a rare and valuable entity MedPAC is. With that, if you do have any questions, need anything from MedPAC, go to MedPAC. Don’t come to me if you want to feed me good Kentucky Sour mash whiskey for an hour. You’ve got my email address on the slides here. Happy to talk at any length, particularly about Medicare Advantage. But with that, I will turn things over to Kate.

Speaker 7 (43:11):

I knew Jim was going to be a tough act to follow. So I will talk about macpac, but I won’t necessarily focus on the things that the commissions share in common because we really are sibling commissions. So things like the 17 commissioner appointees that are facilitated by GAO, that’s the same. The way that we approach our work is generally the same. I think that there are several questions that I usually get when I’m speaking about the commission questions about, for example, how we develop our analytic work plan and what work is in the pipeline and also what happens to our recommendations. So I’ll just point out two things that might be of interest to you. When it comes to Mac pack’s analytic work plan, we’re informed by several different inputs. So first is as a congressional support agency, we want to make sure that what we’re providing is helpful to congressional deliberations.

(44:07):

So similar to MedPAC, we are talking with our contacts on authorizing committees. We’re also very carefully watching what’s happening on the hill in the way of hearings, proposed legislation. We track our technical assistance to see what trends are emerging so that we can try to position the commission to be proactively helpful. So Congress and all of the members and the staff that are asking us questions, we’re kind of internalizing that and trying to pivot to make sure that we’re of help and support. The second input is obviously our commissioners. So we have 17 subject matter experts and we want to make sure that we’re leveraging their time and effort and support of the commission. So we’re constantly asking them throughout the analytic work cycle, what are you interested in? From your perspective, what would you advise? We focus on, we want to make sure that while we’ve got them on the commission, their input can really help shape our work.

(45:08):

We also do a lot of work with states. So we are somewhat different from MedPAC in the sense that our statutory authority instructs us to make recommendations to Congress, the HHS secretary as well as the states. And because states are equal administrators in that federal state partnership when it comes to the Medicaid program, we want to make sure that we have a really good understanding of what they are confronting as they go about their daily work. So we will have private confidential listening sessions with the National Association of Medicaid directors. We talk with behavioral health directors, we talk with long-term care directors, we talk with disability directors, and we’ll talk with other subject matter experts that have a deep embedded relationship with states like the National Academy for State Health Policy. Bless you. We’re also talking with program integrity units and their leadership. So we really want to make sure that we’re drawing on all of the different stakeholders that comprise the Medicaid program to understand what policy barriers and obstacles they deal with so that we can try to help them mediate what those barriers and obstacles are.

(46:22):

And then of course, our staff are subject matter experts. They’re highly qualified in the areas of Medicaid and chip, and so we want to make sure that we’re honoring their contributions to the organization as well when it comes to areas where we have been focusing from a research perspective that are directly tied or dovetail well with congressional priorities. Let me give you a couple of examples to see if I can kind of hook you guys in. So first, we’re working on a project this year that will span into next year focusing on automation in prior authorization for Medicaid managed care. And automation is inclusive of artificial intelligence. So we are talking about and talking with experts. We have a panel conversation that includes an academic perspective, a provider perspective, a consumer advocate perspective about how AI is being leveraged in Medicaid managed care and what some of the cautions are.

(47:22):

We’re also supplementing that with a policy review, a literature review, as well as qualitative interviews we’ll be conducting over the summer with states health plans and others to really understand how this new technology is intersecting with the Medicaid program. We have a project that we conducted to help Congress in their deliberations for the Support Act reauthorization. So we similar to MedPAC, have access to a lot of Medicaid administrative data, which is essentially claims data and we use those claims data to do a state by state assessment of utilization across every medication for opioid use disorder. We also conducted a regression analysis to see how beneficiaries demographic characteristics may help or hinder their access to MOUD. And we did a quantitative assessment to try to capture what the effect the support act had on access to MOUD. So all of that will be included in our June report to Congress.

(48:23):

Let me also just touch on one last topic, which I feel like is a hot topic right now and that is Medicaid financing. We do a lot of work on Medicaid financing. So here are some examples. We are one of the only folks around town who are carefully tracking what the aggregate amount of Medicaid state directed payments are in the program. These are payments that go to different classes of providers through the Medicaid managed care delivery system to help supplement base rates. So we have published issue briefs and we update those issue briefs so that everyone has current data available to them. We have also looked at the targeting of Medicaid dollars to different classes of hospitals like rural hospitals. So we’re able to provide different breakouts of how rural hospitals may benefit from state’s decisions about how they direct Medicaid supplemental funds. And we’re also working on a project right now tied to hospital pricing, which is trying to index what hospitals are paid, which you would think would not be that difficult, but it’s actually taking us several years because hospital pricing and hospital financing is just as confusing on the Medicaid side as it is on the Medicare side.

(49:42):

And so we want to do something that will facilitate state by state comparisons as well as comparisons to other benchmarks like Medicare because that’s usually something that’s discussed in the context of Medicaid financing. Are you at 80% of Medicare, a hundred percent of Medicare or possibly above? I could go on and on, but let me stop there. Let’s talk about the resources that Macpac offers. I would put them into three major categories or buckets. The first is tied to the independent nonpartisan research that we do, original research that is captured in the two statutorily required reports to Congress that we submit in March and in June. In addition to those reports, we actually also issue different types of issue briefs. And so that will usually summarize work that we do that is a bit more contained that may not need the same level of commission deliberation or that may be timed to the hot topic of the moment.

(50:51):

So we just want to get it out and we don’t want to have to wait for a March or June report to Congress. So we’ll use the issue brief as the vehicle. Today we released two policies in brief that I would draw your attention to tied to structural Medicaid reform. So in June of 2016, the commission thought about a framework for evaluating Medicaid financing and thought about different types of considerations that policymakers would need to take into account regardless of the specific proposal, even though we talked about different approaches such as block brands, per capita caps, cap allotments, et cetera. So the policy and brief provides a high level overview and a link to the underlying report so that you can look at the source documentation similar to GIOI was so glad that Leslie raised this. We do include key points at the beginning of every chapter so that you understand what the key takeaways are and what the recommendations are with a brief summary in addition to the first category of reports, issue briefs, et cetera.

(51:54):

The second category I would say is data. Data. So we will put out on an annual basis what we call our MAX stats publication, which pulls from all of the data that we receive that is not widely available. It can be claims data. We will sometimes put Medicaid in the context of other payers when it comes to total expenditures. We will give breakouts of enrollment spending utilization, et cetera. It’s a really rich resource. We also publish in partnership with MedPAC, a duals data book. We will also put out and summarize for you survey data that speaks oftentimes to access that Medicaid provides, especially compared to other types of payers like Medicare, private insurance or the uninsured. And we’ve engaged in several projects that try to clean up data because sometimes you’ll hear the phrase dirty data. It’s sometimes hard to Melanie’s point given the variation in Medicaid programs to compare across states.

(52:57):

So a benefit in state A might have a different name or a different code than a benefit in state B. And so what we’re trying to do is facilitate comparability. So we did some data cleanup on LTSS data so that we could look at different health disparities. All of that information is on our website. We’re doing the same thing with behavioral health data because there’s been a lot of questions that we’ve been on the receiving end of to try to understand what behavioral health utilization looks like in the Medicaid program. And then the last category is references. So there’s a secret reference on our website. It’s an annotated statute for titles 19 and 21. It gives a plain language interpretation of the underlying statutory language and flags where there have been congressional changes to the statute. We published that in 2023, but it’s generally up to date and people have found it really helpful as a quick reference guide. And we will also record some of the presentations that we’ve done and posted on Mac pack’s YouTube channel. So we provide technical assistance to the hill. All of our technical assistance is confidential. If you do have any questions, I recommend that you go to Catherine Rogers. I did talk to Catherine before I made this presentation. She knows that her email address is made publicly available. And then I would just leave you with a link to our macpac email distribution list in case you’re interested in signing up. All of our information is pushed out there. And then you’ll also have the link to the public meetings that we make available and stream virtually. Thank you.

Dr. Melanie Goran (54:37):

I thank everyone and I hope that this has been helpful. I’m going to pull up three points then I want to make sure we’re answering your questions. The first is congressional support agencies have access to data across all of the programs. When you get a meeting and you’re like, Ooh, this doesn’t seem right because using data only from their hospital, their organization, the 5% data sample in Medicare, and you’re like, what does it really mean? Look to the congressional support agencies because they have access and the technical expertise to look across industries to answer those technical questions. And their best interest is in the taxpayer and the American Citizens receiving services. So they come at this as a place, and you heard everybody say, we really looked for what is Congress paying for? What is the value of the program? What are we getting for the dollars we are investing? And that should be the question of policy. Are we getting what is best from there? The second thing I want to talk about, because Jim brought it up, was nobody pays attention to MedPAC and Macpac recommendations or GA recommendations. It’s not true. Okay? There’s a socialization cycle that people don’t talk about, and I want you as your thinking about what work you’re going to do in advance on behalf of your boss. It’s not going to happen tomorrow.

(55:58):

There’s a GA recommendation I worked on when I worked at GAO. It still hasn’t been implemented, but people are still talking about it. We’re talking about how to make dual eligibles work, be better integrated to make that seamless. So the conversations, conversations are important, but it is go back and read past reports. Don’t expect things to sort of happen. And one day dual eligibles are going to get care with one card. It’s a big policy goal. And the last I want to speak about some agencies that aren’t here. We didn’t hear from the Congressional Research Service. They’re incredibly valuable. They are super smart. They offer a different component of background research. If you haven’t taken their appropriations and budgets class and the training they provide to staff, they have a different mission. Really use those resources also. You can borrow any book from them and they’ll deliver it to your office.

(56:55):

Hot tip for being a Hill staffer. We talked about OMB, the Office of Management budget. That is the executive branch of main policy shop. There is a presidential budget that goes out every year in the spring, but there are congressional justifications that go behind it. They’re a little bit more in depth. There’s also the budget in brief, which is like the easily digestible version. They will do briefings on the hill facilitated by each department about the president’s budget. Go and listen. You’ll also be shocked, much like how MedPAC macpac GA recommendations sort of linger. There are things that show up in the president’s budget year after year after year, but it talks about where that policy is. And the last I want to talk about is technical assistance from the agency that’s the assistant secretary for legislation. The various legislative components within HHS, but really across the government are there to make sure that your policy, drafters intent, that is you as the staff working on behalf of your boss.

(57:58):

What you are visioning can actually be implemented. Let me tell you, the worst thing to do, and my first GAO report I ever worked on was a mandate. So it was included in statutory language that Joel, who was sitting here drafted and it was wrong. It talked about add-on payments in part A for new technologies. Part A being hospitals, they don’t exist in Part A, but I still had to write a GA report. We were legally obligated to do it. So please go get technical assistance, talk to GAO. If you’re going to include a mandated report, talk to the various other components, including the department, get that technical assistance because it is important that if you make sure that it’s right, if it is wrong, it’s really hard to fix mistakes and statute. Everybody’s like, all right, we did that. Let’s move along. Let and clearing out that dead wood, including geo reports for programs that no longer exist is actually a really big legislative lift and it shouldn’t be. So do your homework at the beginning. Okay, so that was my soapbox from my former A SL space. But people are here to help and they want to make sure that legislation is good and it can be implemented and that it’s technically correct. And all of these organizations, as they said, do not come with a partisan or house for Senate opinion. It really is like what is the goal of the policy vision, that two sentences, and how do you move it forward?