Chairman Bilirakis, Chairman Greenwood, Congressman Brown, Congressman Deutsch, distinguished Subcommittee members, thank you for inviting me to discuss our physician and provider education efforts with you. Medicare is vitally important to senior citizens and disabled Americans, and our partnership with physicians and other providers plays a critical role in providing quality care and services to beneficiaries. Our goal is to ensure that beneficiaries get the care they need without imposing unnecessary burdens on beneficiaries, physicians, and providers. The Administration is reviewing regulatory and legislative changes that may be needed to enable us to better focus our efforts on achieving this goal. It also is clear that we must reimburse physicians and other providers in a timely, efficient, and fair manner. We know we need to continue to improve in this area, and we are working to address this through the host of activities I will describe today.

Over the last few years we have made great efforts to improve our relationship with physicians and providers. Working with our contractors, we have taken a number of steps to ensure the information we share is consistent, clear, and unambiguous. We are making materials available in print and on the Internet, by toll free telephone request, and via satellite broadcasts, and we are developing new materials to provide updates and clarifications about Medicare. We are reaching out to physicians and providers with mailings and local and national educational seminars. And, we are listening to them, so that the information we convey is sensible, reality-based, and supportive of the care they give to Medicare beneficiaries.

While we have made substantial progress, we know we still have important work to do. We are looking to physicians and other providers for their input so that we can better focus our education efforts and make the rules required by Medicare more understandable. We have formed a special team that is helping us to pinpoint problem areas for physicians and develop suggestions to simplify Medicare requirements. For example, we have been working closely with the physician community to develop new guidelines for billing physician office visits under Medicare. We are rewriting our manuals to clarify billing instructions and enhance education. We also are improving the physician and provider enrollment process so it will be easier to participate in the Medicare program.

We share a common mission with our physicians and providers -- ensuring high quality medical care for Medicare beneficiaries. We look forward to our continued partnership with the physician and provider community, and Congress, to further improve the education, outreach, and streamlining efforts that we will discuss today.

BACKGROUND

Medicare pays for the health care of almost 40 million beneficiaries, involving nearly one billion claims from more than one million physicians, hospitals, and other health care providers. As the administrator of this program, the Health Care Financing Administration (HCFA) must strive to ensure that Medicare pays only for the services allowed by law while making it as simple as possible for qualified health care providers to treat Medicare beneficiaries. We have to carefully balance the impact of Medicare's laws and regulations on physicians and providers with our accountability for more than $210 billion in Medicare payments, and we are committed to finding the right balance.

The Health and Human Services Inspector General recently reported that Medicare pays virtually all claims correctly based on the information submitted; however, improper payments do occur for reasons such as insufficient documentation, lack of medical necessity, and improper coding. During the past five years, we have worked with physicians and providers to improve their understanding of the process. As a result, Medicare has reduced its payment error rate by half, from 14 percent in fiscal year 1996 to 6.8 percent in fiscal year 2000, meeting our 2000 Government Performance Review Act goal and keeping us on track for continued improvement. However, we realize that the volume of laws and regulations covering Medicare's responsibilities is substantial, so the need for balance has never been more compelling.

Over the last five years a number of new laws have dramatically altered the Medicare program and the health care arena, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Balanced Budget Act of 1997 (BBA), Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA), and Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. Combined, these laws contained hundreds of provisions that we have the responsibility for implementing, such as new prospective payment systems for numerous segments of the health care industry, including home health, skilled nursing facilities, and emergency departments; new preventive benefits; and new health plan choices for Medicare beneficiaries. The number and complexity of these changes were greater than any we had ever before experienced.

We are continuing to pursue an open process as we implement these new programs and policy changes, seeking insight and recommendations from physicians and providers, their associations, and other members of the public. This is far different from the way many private insurers conduct their business, and greatly benefits everyone as we incorporate stakeholders' recommendations into our new policies and regulations. But, as we implement these legislative and regulatory changes, we have had to undertake the most extensive education program in our history, including outreach to beneficiaries, physicians, and providers to help them understand how the changes affect them.

OUTREACH THROUGH OUR CONTRACTORS

We primarily rely on the private insurance companies, who by law process and pay Medicare claims, to communicate policy changes and other information to the physicians and providers they serve. We recognize that the decentralized nature of this system can result in inconsistent communications, and we have taken a number of steps to improve the educational process.

These efforts include:

• Centralizing our focus for Medicare education. We have centralized the majority of our educational efforts and their oversight in our Division of Provider Education and Training, whose sole purpose is educating and training our contractors and the physician and provider community regarding Medicare policies.
• Providing consistency through contractor train-the-trainer sessions. We are providing contractors with a standardized training manual and in-person instruction regarding their education of physicians and providers. These programs ensure that our providers speak with one voice on national issues. For example, coordinating with the Blue Cross/Blue Shield Association, we developed train-the-trainer sessions for the Home Health Prospective Payment System regulations. We then developed a satellite broadcast, which was rebroadcast several times prior to the effective date of the regulation. Following the train-the-trainer sessions, we coordinated a town hall meeting; and we participated in weekly conference calls with regional offices and fiscal intermediaries to monitor progress in implementing these changes and answer questions. We performed similar activities for the Outpatient Prospective Payment System (OPPS). We continue to refine this process on an on-going basis by monitoring the training sessions conducted by our contractors.
• Improving contractor responsiveness. Our new Customer Service Initiative is aimed at improving contractors' responsiveness to the concerns of physicians and other providers. We are evaluating contractors' customer service efforts and surveying physicians and providers this year to see how the initiative is progressing, and where we can make further improvements.
• Working to improve contractor outreach. We also are strengthening and standardizing the way in which our contractors carry out education and customer service activities. We require all contractors to provide information via printed bulletins and newsletters, as well as via the Internet. This includes requiring each contractor to link to our website from its own website, giving physicians and providers immediate access to our Medicare learning network. And we are exploring the possibility of complementing our national e-mail listservs, which deliver valuable information as a broadcast email to thousands of providers, by making listservs available at the contractor level to address local as well as national concerns.

OUTREACH THROUGH OTHER CHANNELS

In addition to our contractors, we have a number of other channels for communicating with physicians, providers, and their professional organizations. We are:

• Using our Regional Offices. The ten HCFA regional offices are another key component of our outreach to physicians and other providers of healthcare in this country. Our regional offices oversee our contractors, assuring that contractual agreements are met and helping with solving problems between the contractor and physicians or providers. Most of our regional offices now have a Chief Medical Officer. These physicians serve as a liaison between HCFA and the local physician and provider community. And most importantly, the regional offices directly communicate with physicians, providers, and their professional organizations on a daily basis. Via organized meetings and through individual problem solving, they share information about the Medicare program and bring the issues of the physicians and providers in that region to the attention of the Agency.
• Conducting monthly conference calls with physicians. Each month, we conduct conference calls with physician organizations across the country to provide information and obtain feedback. The calls are open to the representatives of more than 100 national, state, and specialty associations. Participating associations often share information from these calls with their physician members. HCFA staff, including our physicians, also attend national, state, and local medical society meetings to talk with physicians, to hear their concerns, and to explain Medicare policies in greater detail.
• Establishing toll-free information lines. In 2000, we established toll-free lines for physicians and providers at our Medicare claims-processing contractors. The numbers are listed at www.hcfa.gov/medlearn/tollfree.htm. Each contractor also maintains a Website and electronic bulletin boards to provide information to physicians, providers, and their staff.
• Distributing Medicare & You handbooks. Responding to physician requests, we sent copies of the Medicare & You 2001 beneficiary handbook to more than 500,000 individual physicians and group practice offices this past winter. The handbook is updated and mailed to all of the nearly 40 million Medicare beneficiaries as an easy-to-understand guide on Medicare's benefits and policies. In addition, we worked with the Interamerican College of Physicians and Surgeons to coordinate the mailing of Spanish versions of this handbook to more than 49,000 physicians.
• Preventing errors through compliance guidance. We worked with the HHS Inspector General to develop guidance for physicians and providers on how to comply with Medicare policies, and invited public comments on this guidance. Additionally, we are sharing feedback with physicians and providers, both on an individual and community level, about how to correct and prevent the types of errors identified in medical review of claims. This will help to reduce the number of improper claims among the vast majority of physicians and providers who make only honest errors.
• Focusing on Medicare+Choice Organizations. We also are working with managed care organizations that serve Medicare beneficiaries. We are holding numerous educational training conferences around the country for these organizations, as well as attending industry conferences to learn first hand where problems may be occurring and where there are areas of concern. Additionally, we are sponsoring conference calls with managed care organizations on specific subjects to provide guidance on emerging issues and facilitate additional training. We are reaching hundreds of managed care staff who participate in these calls from their work sites. And we consult extensively with the industry on the guidance we provide. For example, we are sharing our draft manual chapters and other policy guidance with our Medicare+Choice contractors to ensure that we fully consider their concerns before final publication.
• Publishing articles in the Journal of the American Medical Association. We highlight news and issues of interest to practicing physicians and others in the health care industry in quarterly articles published on the Federal Page of JAMA. These articles help to inform physicians on such topics as Medicare's new preventive benefits, Medicare+Choice encounter data collection, and Evaluation and Management Documentation Guidelines.

MEDICARE EDUCATION AND TRAINING: A PRIORITY

Through our contractors and a variety of other communication channels, we work hard to get providers the information they need to be reimbursed for caring for our beneficiaries. We communicate this information through a number of different products that employ the latest technologies and respond to the varying learning styles and needs among physicians and providers. These include:

• Creating a Web-based Medicare education site. We have a variety of resources available on the Internet at the Medicare Learning Network, www.hcfa.gov/medlearn. This Network provides timely, accurate, and relevant information about Medicare coverage and payment policies.
• Providing free computer-based training courses. Doctors, providers, practice staff, and other interested individuals can access a growing number of informational computer-based courses at the Medlearn website. Some courses focus on important administrative and coding issues, such as how to check-in new Medicare patients or correctly complete Medicare claims forms, while others explain Medicare's coverage for home health care, women's health services, and other benefits.
• Issuing e-mail updates. As of February 2001, almost 10,000 listserv subscribers are receiving timely updates about the two new prospective payment systems implemented in 2000 for outpatient hospital services and for home health services. We are exploring ways to provide similar listserv updates to physician and provider organizations.
• Sponsoring satellite broadcasts. We sponsor live, national satellite broadcasts for physicians and other clinicians about Medicare topics such as women's health, preventive benefits, and preventing billing errors. The broadcasts can be viewed in hospitals, medical schools, and virtually any other location across the country through satellite television.
• Creating a Resident Training Program. We are reaching out to new physicians, making Medicare information available to residents at teaching hospitals and medical schools to introduce them to Medicare and ensure they have an understanding of the program's policies early on in their careers. This program, which is currently being pilot tested and refined, includes an in-person training session, a video, a computer-based training course, and a comprehensive manual
• Creating a Frequently Asked Questions resource. We are developing a system to capture and compile the many individually answered physician and provider questions that come into the Agency. We will incorporate them into an ongoing compendium of Frequently Asked Questions (FAQ), and make them widely available via our website, publications, speeches, and other channels.
• Creating a manual of Medicare basics. We are developing an easy-to-use handbook of Medicare basics, which will be produced both on paper as well as CD-ROM. It also will be able to be downloaded from our website. The handbook will guide physicians through relevant Medicare laws and regulations. We are aiming to finalize and release the handbook by the end of this year.

PROGRAM REQUIREMENTS THAT SUPPORT PHYSICIANS

The efforts described thus far highlight our communications efforts with the physician and provider communities. Additionally, we understand that the particular Medicare policy we are communicating must be sensible and supportive of physicians in caring for patients. In 1998, we created the Physicians' Regulatory Issues Team (PRIT) to improve the agency's responsiveness to the daily concerns of practicing physicians. This team is an agency-wide effort, and members include our leadership, HCFA physicians, technical experts, and regional office staff. The PRIT works in three broad ways. First, it has been invaluable to the agency in amplifying the voice of practicing physicians. The team has articulated for us the problem of excess Medicare burden as seen through the eyes of practicing physicians. Moreover, it has developed a vision for the agency in which Medicare requirements are not only less burdensome, but truly supportive of physicians in caring for patients. The strategy team members bring to dozens of discussions across the agency every week is that improving the integration of practicing physicians' input into our decision-making will result in better policies.

Second, the team members work within the agency to serve as catalysts and advisors to policy staff as changes and decisions are discussed. Examples include:

• Simplifying evaluation and management guidelines. These guidelines are cited frequently by physicians as excessively complex and fitting poorly with the way they provide care. Therefore, in cooperation with the American Medical Association, which develops the guidelines, we have undertaken a major initiative to simplify them. Since sharing new draft guidelines in a town hall meeting last summer, we have been seeking and receiving broad input from organized medicine, practicing physicians, and the Practicing Physicians' Advisory Council (PPAC), a formal committee comprised of practicing physicians who provide the Agency with a doctor's "bedside" perspective. We continue to refine the guidelines and are preparing to pilot test them later this year. Prior to implementation, we will educate physicians about the changes.
• Streamlining Medicare forms. With extensive input from physicians, providers, and their staff, we are developing better procedures to reduce the burden of the Medicare enrollment process on the large number of physicians and providers who provide health care to our beneficiaries. And we are exploring ways that we can use today's technology to further facilitate the enrollment process. Additionally, we are working to improve other Medicare forms, including our Advance Beneficiary Notices and Certificates of Medical Necessity.
• Improving operational policies. We are working to facilitate physicians' care through supportive policies. For example, we recently issued changes that allow physicians to fax their orders and "initial" changes for patients to receive wheelchairs and other needed equipment.
• Paying for important services. One of our overarching goals is to "pay it right," and that includes making sure physicians and other providers are compensated for the care they provide as allowed under law and regulation. For instance, as of January 1, 2001, we now pay physicians separately for their work determining patients' eligibility for the Medicare home health benefit.
• Clarifying oversight policies. Last year we issued a Program Memorandum that brings together in one place the processes for contractors to use in conducting medical review. The Program Memorandum responds to the comments from many practicing physicians, including that physician education and feedback are essential to the medical review process. In particular, we describe the expectation for communications between contractors and providers, noting that decisions to conduct medical review need to be data driven, and highlighting that the amount of review be only that necessary to address an identified problem.
• Identifying and changing excessively burdensome requirements. In a current initiative, the Physicians' Issues Project, we have identified some specific Medicare requirements that physicians frequently cite as problematic in their day-to-day practices. We received extensive input on these issues from the physician community at a recent PPAC meeting, and as a result, have chosen seven requirements for immediate review. We intend to change these requirements or reach out to physicians and providers to improve the supportiveness of the Medicare program.
• Leveraging current channels of input from practicing physicians. The PPAC is a valuable resource for information regarding the impact of our regulations on practicing physicians. Our staff has re-focused and re-energized our efforts and the open forum this group provides. We ask for their advice on specific issues in areas where we can benefit from the 'bedside' perspective of PPAC members, other practicing physicians, and physician organizations.

Finally, the PRIT is responsible for several new initiatives aimed at increasing agency understanding of the reality of practicing physicians.

• 'Shadowing' physicians. Working through our Kansas City regional office and the Medical Society of Johnson and Wyandotte Counties in Kansas, the PRIT has arranged for approximately 12 senior HCFA staff to spend three days next month observing primary care and specialist physicians. This same regional office is working with the Nebraska Medical Society and the National Rural Health Association to design a similar program with a rural focus for our staff.
• · Sentinel Clinicians. We are designing a new process for querying practicing physicians from time to time, which will add to and complement our other information gathering efforts. We will use this process to listen to practicing physicians, asking them about aspects of their daily 'bedside' experience of caring for patients while trying to satisfy the requirements of the Medicare program.

NEXT STEPS

We are continuing our efforts to strengthen and improve our physician and provider education programs, including the channels we employ, the products we generate, and the underlying policies of the program. We are delivering the information they need in a timely and consistent fashion, but we need to do more. We are:

• Developing a national network of "Medicare Learning Centers" to serve as host sites for satellite broadcasts, where physicians, providers, and their staff can come to view our satellite broadcasts in central locations.
• Developing a Medicare Learning Network faculty, to be available to develop and enhance our training resources. This faculty will feature nationally recognized experts on distance learning, professional education, and customer service.
• Continuing to improve our Medlearn website by offering convenient, one-stop information for Medicare physicians and providers.
• Developing special strategies for specific populations such as new physicians and providers, those who submit a high volume of claims, first time callers, and repeat callers.
• Attracting a wider audience of clinicians by integrating clinical topics with the billing and payment education aspects of our training tools.
• Upgrading our current computer-based training tools; including continuing education credits for completing certain training programs; and developing new web-based training tools.
• Developing focus groups, surveys, and other evaluation measures to help us understand how many physicians and providers use our education tools, confirm what they gain from the experience, and help us to improve continually.

CONCLUSION

Physicians and providers play a crucial role in caring for Medicare beneficiaries, and communicating clearly with them is an important aspect of administering the Medicare program. As we all know, strong communication entails both delivering and receiving information. We recognize that there is considerable concern regarding the way in which HCFA interacts with its providers and contractors. Many of these concerns are well founded. However, we hope that our new processes will improve our administration of the Medicare program. In addition, we hope that we can improve our relationship with physicians and providers. We have tried to improve our education efforts and share important information so it is easier for physicians and providers to follow Medicare's requirements. We have more work to do to ensure that we are paying physicians and other providers timely and fairly, and that they can understand Medicare's requirements. So we are actively seeking the health care community's input, paying attention to their concerns and suggestions, and working closely with our contractors to ensure we listen and explain effectively. I appreciate the opportunity to discuss our physician and provider education efforts with you today, and I look forward to answering your questions.