Lobbying Disclosure Act of 1995 (Section 5) - All Filers Are Required to Complete This Page

9. Check if this filing amends a previously filed version of this report

LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code BUD

16. Specific lobbying issues

The Budget Control Act of 2011(PL 112-25) required mandatory across-the-board reductions in Federal spending effective January 1, 2013, known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months, but after this time elapsed, President Obama issued a sequestration order on March 1, 2013. Under this order Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment.
Consolidated and Further Continuing Appropriations Act, 2013, HR 933. Funding for the federal government was set to expire on March 27, under the terms of a six month continuing resolution (HJ Res 117) approved September 28, 2012. The Continuing Resolution kept in place spending targets established in the 2011 debt limit deal known as the Budget Control Act. It also left in place provisions calling for mandatory sequestration of federal spending applied to domestic and discretionary spending.

The House Republican fiscal 2014 budget blueprint, (H. Con. Res. 25), called "the Path To Prosperity" written by Rep. Paul Ryan. The fiscal year 2014 budget resolution (H. Con. Res. 25) would turn Medicare into a premium support system beginning in 2024 for those born in 1959 or later. In addition, the House proposal would block-grant Medicaid and cut program spending by $810 billion over 10 years and repeal large parts of the Affordable Care Act. It would keep the taxes associated with the health care reform law, however, as well as the $716 billion in Medicare cuts it contains.

The Senate Budget Resolution (S. Con. Res. 8) written by Senator Patty Murray, (D-WA) chair of the Senate Budget Committee would reduce Medicare spending but does not include structural program reforms. The Senate resolution contains $275 billion in largely unspecified healthcare cuts over 10 years, calling for accelerating delivery system and payment reforms, reducing waste and fraud, and encouraging greater provider engagement. The Senate budget would also repeal the Medicare physician sustainable growth rate, but offers no replacement mechanism. The Senate budget would cut $1.85 trillion from the federal deficit and replace the sequestration required by the Budget Control Act until 2021 by raising $975 billion in new tax revenue over the next 10 years while enacting new spending cuts, including the healthcare cuts.

HR 2775 The Continuing Resolution that makes continuing appropriations through January 15, 2014, thus ending the government shutdown, and increases the debt limit through February 7, 2014.

The Bipartisan Budget Act of 2013 (BBA) (H.J. Res. 59), which Maintains the 2 percent sequestration cuts to Medicare providers; Provides modest sequester relief to discretionary programs, including medical research at the National Institutes of Health; a three-month extension of expiring Medicare provisions (GPCI floor; therapy cap exceptions, Ambulance add-ons, hospital payment adjustment for low-volume hospitals, and Medicare-dependent hospital program), which are important to hospitals; Prevents a 21% physician payment cut for 3-months and also provides a 0.5 % payment update during that time; covers the ~$7 billon 10 year cost of the 3-month SGR fix (physician payment formula) and Medicare extenders package.
AmeriCorps Funding: Afterschool Health Services Program
The primary focus is an Afterschool Health Services Program, which provides the infrastructure for communities to work collaboratively to improve health of youth in afterschool settings. This approach recognizes afterschool programs as a credible venue for health improvement as our nation moves forward with health care reform. This approach also takes into account the research base that demonstrates that a quality education is a number one determinant to good health. Marshfield Clinic will support legislation to implement quality services in afterschool settings that include case management of individual youth to promote academic success, personal/social development and health/wellness. This will include access to clinical services designed to meet the identified needs of enrolled youth i.e. early and periodic screening, well-child visits, immunizations, behavioral health appointments/treatment plan compliance, dental screening and sealants, asthma case management; Evidence-based programs, practices and policies targeting identified health priorities i.e. alcohol and other substance use and addiction, high-risk sexual behavior, intentional and unintentional injuries and violence, overweight, obesity and lack of physical activity, tobacco use and exposure; Release of information forms and written consents signed by parents prior to services.

AmeriCorps Funding: Healthy Lifestyles Program
There is a need for strategic action at the federal level to counter the obesity epidemic in our nation. Chronic diseases related to obesity such as diabetes, heart disease, high blood pressure and certain cancers are the leading causes of premature death and disability. Unless the obesity epidemic can be curbed, the life expectancy of future generations will be compromised. Programs, practices and policy approaches that have been effective in the adult population such as employee wellness and policies promoting physical activity must be implemented early in life to redirect obesity inducing habits and behaviors in children. Marshfield Clinic will support legislation to implement policies that take a comprehensive approach to obesity prevention, addressing nutrition and physical activity in a broad variety of environments including communities, businesses and schools.

Community Health Center Funding Dental Access

Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. In 2010, by matching a $10 million contribution from Security Health Plan, the State of Wisconsin partnered with Marshfield Clinic to build a rural dental education outreach facility. The facility is needed to support plans to develop residency and post-baccalaureate training programs and a dental student programs. This is part of a larger initiative, the primary purpose of which is to improve the oral and general health of underserved residents in rural and small urban communities. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics and has another one in planning. The dental facilities provided access to more than 41,000 predominately low-income uninsured or publically insured residents last year. Marshfield Clinics proposed dental education programs could expand this to over 120,000 low-income patients in our system alone, while helping to train Wisconsins future rural dental workforce.

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Centers For Medicare and Medicaid Services (CMS), Health & Human Services - Dept of (HHS), Health Resources & Services Administration (HRSA), Medicare Payment Advisory Commission (MedPAC), Executive Office of the President (EOP)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

​

LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code MMM

16. Specific lobbying issues

Many aspects of the Affordable Care Act promote changes that are consistent with the mission of the Marshfield Clinic. The following are key elements of the health policy agenda of the Marshfield Clinic:
Medicares Sustainable Growth Rate We believe that the longstanding challenges inherent in fee for service reimbursement under the resource based relative value system, and the financial problems associated with the sustainable growth rate (SGR) formula must be addressed to assure access to Medicare benefits and the future solvency of the Medicare program. We recommend that Congress repeal the SGR formula, and link future updates to measures that reflect the cost and value of providing health care services. Congress must also take steps immediately to create increased incentives for preventative care, care coordination, and primary care services. Physician spending is currently only a fraction of total health care spending but it affects nearly all other aspects of health care delivery. We recommend that Congress utilize the leverage of physician spending to deal with the misaligned incentives in the Medicare program that lead to higher costs and inefficiencies throughout the spectrum of health care delivery. We recommend that new evidence-based measures of quality performance be developed to capture outcomes of care processes. We recommend that Congress fund the work of HHS and CMS to identify and vet better performance measures to support a new physician payment system, especially measures that are focused on outcomes, patient experience of care, care coordination, appropriateness of care, and total resource use.

Medicare Pay for Value Provider accountability for quality and spending growth is an essential element of delivery system reform. Existing law requires that the Centers for Medicare & Medicaid Services (CMS) implement a value modifier that applies to Medicare Part B physician payments for certain physicians and physician groups beginning in calendar year 2015. By 2017, CMS is required to apply the value modifier to all Medicare Part B payments to physicians and physician groups. We recommend that Congress should implement this policy sooner if possible. The Clinic is in CMS's shared savings program as an Accountable Care Organization effective January 1, 2013.

Geographic Adjustment of Physician Payments Recent findings by the Institute of Medicine and the Medicare Payment Advisory Commission have demonstrated significant shortcomings in the data utilized to geographically adjust physician payments. The IOM and MedPAC studies have confirmed that the data sources currently relied upon for geographic adjustment bear no correlation to physician earnings. CMS officials have admitted that the proxies utilized for the purpose of geographic adjustment have never been validated, and there never has been a new data source utilized in the twenty years since the fee schedule was implemented. MedPAC data show that the geographic adjustment reference occupations predict earnings of rural physicians to be 25-30% less than physicians in metropolitan areas. MedPAC data show that earnings of primary care physicians in rural areas are, in fact, 13% higher than physicians in metropolitan areas. Since there is no statistical basis of support for disparities in payment we strongly recommend that Congress require CMS to correct this inequity immediately. Having a source of credible data and a sustainable payment mechanism is critical to maintaining access to primary care services in rural areas for patients who reside in those areas.
Dental Access Wisconsins current record of providing dental care to children from poor households is among the worst in the nation. Marshfield Clinic hopes to improve the oral and general health of underserved residents in rural and small urban communities within the State. Marshfield Clinic in partnership with Family Health Center of Marshfield, Inc. is currently operating 8 dental clinics. The dental facilities provided access to more than 46,000 predominately low-income uninsured or publically insured residents last year.

CBO Scoring of Preventive Health The budget process should be improved to permit Congress to assess long-term health savings that are possible from preventive health initiatives. Recent research supports the premise that the current budget window should be extended and CBO directed to take into account the relevant disease-progression data that exists which demonstrates savings in preventive health. To ensure that CBOs projections on cost savings are tied to scientific data, preventive health analysis must include credible and publicly available epidemiological projection, incorporating clinical trials or observational studies in humans, longitudinal studies, and meta-analysis. This narrow approach will discourages abuse while encouraging a sensible review of health policy Congress believes will further public health.

Comparative Effectiveness/Evidence Based Medical Informatics Research Evidence-based medicine relies upon the judicious use of current best evidence in making decisions about the care of individual patients. Key to effective implementation of value-based purchasing initiatives is the systematic development of data that links the health of populations to the medical services the population receives. The application of health information technology and genomic information in population- and community-based health care delivery systems coupled with the development of wellness programs has the potential to substantially improve health and personalized health care on a national basis. Recommendation: Promote evidence-based medicine as the basis for coverage decisions.

Advance Care Planning Medicare and Medicaid must incorporate advance care planning to respect and inform all caregivers of a patients healthcare choices at the end stages of their lives. It is important that the Federal programs improve the continuity of care and quality of life while maintaining respect for patients wishes. Understanding and honoring patients wishes at the end of life is paramount to ensure they are receiving appropriate care that is aligned with the personal choice and goals. Advance care plans are not necessarily a one-time conversation, but an ongoing dialogue between a patient and health provider. Honoring patient desires and wishes at the end-of-life reduces the burden on family members that would otherwise have to make those difficult decisions. An advance care plan must be easily accessible in their medical record. Research indicates that engaging patients on their end-of-life care and following their wishes and desires may reduce healthcare costs. We urge Congress to incorporate advance care planning discussions with health providers as a covered Medicare and Medicaid annual wellness benefit.

Variations in Health Care Service and Distribution Research conducted the Medicare Payment Advisory commission and the Dartmouth School of Medicine has documented glaring variations in how medical resources are distributed and used in the United States. Medicare pays many hospitals and their doctors much more than what it pays the most efficient and effective health care institutions to treat chronically ill people, yet they still get worse results. The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they actually want or need. Caring for people with chronic disease now accounts for more than 75 percent of all health-care spending. Over-use and overspending is not just a Medicare problemthe health-care system as a whole lacks efficient, effective ways of caring for people with severe chronic illnesses. If the U.S. health care system mirrored the practice patterns of the most efficient/effective health care institutions, Medicare and other payors could save billions of dollars annually.

Medicare Physician payment reform On Feb 7, the House Energy and Commerce & Ways and Means Committees released an outline of a collaborative Medicare Physician Payment Reform Effort. Their leaders are united in a collaborative efforts to repeal the Sustainable Growth Rate (SGR) formula and advance a permanent solution for Medicare physician payment. Their proposal seeks to: Repeal the SGR and provide a period of predictable, statutorily-defined physician payment rates; Reform Medicares fee for service (FFS) physician payment system to reward physicians who provide high quality care; and Build upon the improvements made in Phase 2 by also rewarding physicians who deliver efficient care.

The Senate Finance Committee doc fix bill to replace the Sustainable Growth Rate physician payment formula (S 1871) SGR Repeal and Medicare Beneficiary Access Act of 2013 introduced by Senator Max Baucus would extend or make permanent several of the health payment policies. Both the Energy and Commerce and the House Ways and Means Committee approved versions of a similar bill (HR 2810) Medicare Patient Access and Quality Improvement Act of 2013 introduced by Rep. Michael Burgess.

Medicare Payment Inequities In the traditional fee-for-service system Medicare currently reimburses for units of service, in a manner that promotes service utilization without regard to quality. This has had the effect of economically stimulating growth in the numbers of supply-sensitive services provided by physicians. The Update formula for physician services is inequitable because it treats all physicians and regions of the country alike regardless of their individual volume influencing behavior. If the problem of cost is related to the volume of services provided, shouldnt payment be volume adjusted for specific localities? Why should conservative practices and States be punished for the excessive volume of other localities?

Payment Equity for Physician Work There is no difference in the work of physicians in different locations regardless of where the work occurs. We believe that physician work should not be adjusted for geographic location. What is the rational for paying physicians more in many geographic areas when those same areas have apparently ample numbers of physicians and their wages are trending below physician wages in other areas? Should the Medicare program subsidize physicians who chose to live in high cost areas? Recommendation: the geographic adjustment of physician work should be eliminated entirely on a Budget neutral basis.

Medicare Advantage Performance Measurement The Medicare Advantage program provides a capitated reimbursement to health plans for all Medicare benefits provided to enrolled beneficiaries. We believe that mechanisms for rewarding value in the Medicare Advantage program should offer incentives for those plans that demonstrate superior patient care performance. We recommend that performance bonuses should be provided for plans that: Achieve predetermined quality performance targets; Adopt health information technology; Meet standards for care coordination; and Provide data on comparative effectiveness. The ratings, now available on the Medicare website, are the result of an annual assessment by CMS of Medicare health plans' clinical quality, consumer satisfaction and other beneficiary experience areas. We fully support the continuation of this program, and the financial rewards provided to health plans that perform at the highest level.

Medicare Advantage Call Letter On Feb 15 2013, CMS released the "Call letter"- its annual advance notice regarding 2014 Medicare Advantage and Part D plan rates. In the Call letter: CMS described changes in the MA national per capita growth percentage for aged and disabled enrollees, and change in fee-for-service per capita costs; coding adjustment for MA plans; payment rebate amounts for plans; and an updated model of its CMS-HCC risk adjustment formula to reflect updated data and clinical revisions to diagnoses. Analysts have projected that the combined effect of the many changes could lead to Medicare Advantage payment adjustments netting negative 8-10%. Marshfield Clinic expressed the concern that the combined effect of the slate of reductions in the Call Letter will destabilize the Medicare Advantage program and undermine beneficiaries faith in their plans. The Clinic recommended: that CMS delay implementing any change to the county FFS rebasing methodology; override the SGR formula, consistent with the emerging consensus regarding a shift to payment for value; recommended a delay in implementing a new HCC risk adjustment model; recommended postponement of changes to the star ratings calculations.

Medicare Advantage Improvements H.R. 2753, THE SECURING CARE FOR SENIORS ACT
by Rep. Diane Black (R-TN), provides seniors with more choice and allows flexibility for plans in the highly successful Medicare Advantage (MA) program through common-sense and technical fixes expanding the Open Enrollment Period; Permitting Incentives for Participation in Health Care Improvement Programs; enabling Cost-sharing Variation; making Improvements to the Risk Adjustment System; and making Improvements to MA 5-Star Quality Rating System

Medicaid Block Grants On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, entitled "The Path to Prosperity. Ryan's proposal does not have the force of law but of special interest is Ryans proposal for Medicaid block grants which will come before the Energy and Commerce Committee. Under the Ryan proposal, starting in 2014, the federal share of all Medicaid payments would be paid to the states as a block grant. Chairman Ryan has projected savings to federal government that would result from reduced funding to states.

Premium support On March 21, the House approved Rep. Paul Ryans budget proposal for FY 2014, entitled "The Path to Prosperity. Ryan's budget does not have the force of law but tees up consideration of various reform proposals which may be considered later this year. With regard to health care, the Ryan plan calls for a major withdrawal of the federal government from the financing of health care. One health provision of the proposal calls for conversion of the current Medicare to a premium support program. For those born in 1959 or later the traditional Medicare program starting in 2024, would be converted to a defined contribution program which has been described as a premium support program.

Dual Eligibles Conflicting requirements in Medicare and Medicaid pose a barrier to care coordination for 9 million beneficiaries who are eligible for both Medicare and Medicaid (dual eligibles or duals). The lack of alignment and cohesiveness between the programs can lead to fragmented or episodic care for dual eligibles and misaligned incentives for both payers and providers, resulting in reduced quality and increased costs to both programs. Total annual spending on dual eligibles is estimated to be $300 billion annually. The Patient Protection and Affordable Care Act (PPACA) presents an array of new and enhanced options to improve care for these beneficiaries through better care integration, improved quality measures, and increased access to home and community-based long-term services and support. We would support better alignment of benefits and incentives to improve access to care for dual eligibles and prevent cost-shifting. Changing the incentives to encourage integrated care will result in better health outcomes at a lower cost.

Accountable Care Organizations One important delivery system reform is the Medicare Shared Savings Program under section 3022 of the Affordable Care Act, which promotes the formation and operation of accountable care organizations (ACOs). Under this provision, groups of providers meeting the criteria specified by the Secretary may work together to manage and coordinate care for Medicare beneficiaries through an [ACO]. An ACO may receive payments for shared savings if the ACO meets certain quality performance standards and cost savings requirements established by the Secretary.
Adequate Funding for CMS The problems facing the Medicare program stem from the nations earliest attempts to make health care services broadly available nationwide without disturbing the economic incentives that were then in place. Congress must ensure that CMS has adequate funding to provide oversight of its many programs, including its measurement of resource and input costs and full implementation of the Affordable care Act.
Telemedicine in Medicare Changes to Medicare law and regulation are needed to improve equity in access for Medicare beneficiaries to services delivered via TeleHealth. Medicare beneficiaries should be allowed to receive services in telemedicine sites located in urban areas. The necessary changes would remove restrictions on originating sites by removing the rural requirement and the list of originating sites and allowing any certified Medicare facility to provide the services; current requirements that physician must bill for services from the originating site should be removed; restrictions on eligible practitioners should be removed to allow all Medicare approved practitioners to provide telemedicine services; and there should be no restrictions on which Medicare services may be provided through telemedicine.
GME Funding Models Should Include Non-Hospital Sites and Interprofessionalism As a rural community based GME partner, Marshfield Clinic would welcome an opportunity to collaborate with Health and Human Services and other external GME partners in developing and implementing strategies for effective use of CMS and HRSA funding for expanding graduate medical education programs
Oral Health Coverage for the Medically Compromised and at Risk Populations Shared savings demonstrations should be developed for health systems and co-pay incentives developed for patients engaging in and complying with such inter-disciplinary care.
Simulation Program Development The Accreditation Council on Graduate Medical Education (ACGME) Program Requirements for Resident Education in Internal Medicine has recommended that residency programs need to Provide residents with access to training using simulation. Marshfield Clinic will support legislation to initiate, maintain and grow medical simulation programs through the identification of simulation centers of excellence, advancement of simulation technologies, allocation of grant funds for institutions who train healthcare providers and call together key leaders to discuss the direction of medical simulation.
Meaningful Use of Health Information Technology The accelerating growth in new medical knowledge, coupled with the birth of new sciences, such as genomics and personalized medicine, suggests that physicians, nurses, and other healthcare professionals will invariably continue to fall further and further behind in their ability to keep up with the latest discoveries and approved treatments. Looking to what can be achieved in the future due to implementation of these systems should be our focus, and an ongoing oversight function of the Office of the National Coordinator for HIT which must be closely integrated with Medicare reimbursement.
Personalized Medicine Personalized medicine, the tailoring of medical treatments to patient characteristics, relies upon the ability to classify individuals into subpopulations that differ in disease susceptibility and treatment responses. It allows clinicians to target preventive or therapeutic interventions on those who will benefit, and thereby to spare the expense and side effects of treatment for those who will not, thus making medicine more efficient. If the multiple population groups in the United States and elsewhere in the world are to benefit fully and fairly from such research, a national resource operated as a trust for the public good must be established to conduct a large populationbased cohort study that includes full representation of minority populations. Marshfield Clinic has developed a comprehensive bio-bank, consisting of DNA samples from 20,000+ individuals. The samples, often from extended families, have been linked electronically to medical records for more than 20 years of medical history. The average span of clinical history for PMRP participants is 29+ years. Further development of this public health infrastructure is in the national interest. The Federal government should make critical investments in the enabling tools and resources essential to moving beyond genomic discoveries to personalized medicine services of patient and public benefit.


Community Health Centers Under Health Reform The Affordable Care Act contained a number of key provisions relating to community health centers, including funding for the community health center program and funding to expand the National Health Service Corp. Congress has cut the base funding levels for community health centers and it is possible that they may do so again effectively further diminishing the impact of the reform legislation. As reform is rolled out there are key payment protections and improvements for community health centers. For example, the Act requires that health centers receive no less than their Medicaid rate from private insurers offering plans through the new health insurance exchanges and it requires that these plans must, under network adequacy rules, contract with a sufficient number of essential community providers, the definition of which includes health centers. Other provisions add preventive services to the federally qualified health center Medicare payment rate and eliminate the outdated Medicare payment cap on FQHC payments. This will modernize the health center Medicare payments to insure health centers are able to provide highest quality care to Medicare beneficiaries. ACA recognizes the growing role of health centers in teaching the next generation of primary care providers by authorizing and funding new programs for health center-based residencies. A new Title VII grant program for the development of residency programs at health centers is established along with a new Title III program that would provide payments to community-based entities that operate teaching programs. It directly appropriates $230 million over five years for the new Title III payment program. Marshfield Clinic supports the continuation of this funding.

Dental Access and Integration with Traditional Medicine The Institute of Medicine (IOM) released a report, Dental Education at the Crossroads: Challenges and Change in January 1995 which called for a strong cohesion between medicine and dentistry. The IOM report states that "Dentistry will and should become more closely integrated with medicine and the health care system on all levels: research, education, and patient care. The National Institutes of Health has supported research documenting the importance of oral health in the context of general health and well-being. Studies have demonstrated numerous oral-systemic interactions that underscore the need for more integrated care delivery. As our nation embraces EHR technologies, science underscores the need to fully incorporate oral health within an integrated EHR. Marshfield Clinic is simultaneously addressing the issue of dental access and integration with traditional medicine. Family Health Center of Marshfield, Inc. (FHC) in partnership with Marshfield Clinic has been serving low-income, underinsured and uninsured individuals since March 1974. FHC has been providing on-site dental services since the fall of 2002 and operates eight dental sites with two additional sites scheduled to open in the summer of 2011. As part of this initiative, Marshfield Clinic has developed a comprehensive medical-dental integrated electronic health record (iEHR) environment. CattailsMD, the internally developed electronic health record at Marshfield Clinic in Wisconsin, is one of the oldest electronic medical records systems in the country, with coded diagnoses back to 1960. More recently a dental module, CattailsDental has been integrated and successfully rolled out in all of the seven dental centers across Central and Northern Wisconsin. The latest version of the CattailsDental includes: a dental dashboard, workflow management tools including tooth charting, periodontal charting and treatment planning; access to centralized medications, allergies, special conditions, problems list, demographics and HIPAA forms; access to medical appointments to support better coordination of care; and highly secure remote access supporting alternate devices (laptops and tablets). Using technology to integrate medical and dental health records holds great promise to improve the quality, safety, efficiency, effectiveness and continuity of patient care by enhancing communication and teamwork between physicians and dentists. A comprehensive approach to primary care delivery, demonstrated by Marshfield Clinic and community health centers nationwide, can best be supported with an equally comprehensive EHR infrastructure for both medical and dental records.

GME Residency Expansion Marshfield Clinic is concerned about having a sufficient supply of primary care physicians in order to meet the demands of an expanding and aging population. This is doubly true for patients and health systems in a rural setting. Currently only about 10% of physicians practice in rural areas while 25% of the population resides there. While 36% allopathic residents and 50% osteopathic residents who are trained in a rural residency end up practicing in a rural area, only 4% of the residency training actually occurs in rural areas. As of 2012, there are more US medical students graduating from medical school than there are GME slots. An increase in GME primary care training positions is essential to maintaining high-quality, accessible, and cost efficient care.

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP), Health & Human Services - Dept of (HHS), Health Resources & Services Administration (HRSA)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

​

LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code HCR

16. Specific lobbying issues

Federally Facilitated Exchange Policy Issues
Federally Facilitated Exchanges should take into account quality when serving up consumer plan results beginning with the first open enrollment period in 2013. Rather than waiting until 2016 to show quality ratings, the Federally Facilitated Exchange should display quality data for plans as soon as it is available to assist consumers in making a high quality plan choice.
This aligns with the Triple Aim of improving the quality of care, reducing the cost of care and improving the experience.

Federally Facilitated Exchanges should recognize the marketplace contributions of community-based insurers and should work to ensure regulations do not unduly favor national carriers. Community based carriers ensure a vibrant and competitive marketplace and often have more member-centric service philosophies.
Community Engagement for Healthy Lifestyles
Coalitions, Afterschool, AmeriCorps and Community Organizations

Improving the health of an entire community goes beyond doctor-patient visits, to population health efforts directed at vulnerable populations. Recognizing the complexity of health challenges facing young people and the strong intersection between community coalition efforts, afterschool approaches and improved health, Marshfield Clinic has developed a sustainable infrastructure to unite the efforts of its clinics with grassroots coalitions, afterschool programs, tribal communities and other community stakeholders.

Marshfield clinic believes that high quality afterschool programs are a credible venue to improve the health and education of children and communities. Afterschool programs are poised to assist children to develop and reinforce lifelong healthy habits to stem the tide of chronic disease and to reduce the incidence of lifestyle related disease related to alcohol, tobacco and other substance abuse; high risk sexual behavior; intentional and unintentional injuries and violence; overweight, obesity and lack of physical activity; and, tobacco use and exposure.

There is a critical need for strategic action at the federal level to counter the obesity epidemic in our nation. Chronic diseases related to obesity such as diabetes, heart disease, high blood pressure and certain cancers are the leading causes of premature death and disability. Unless the obesity epidemic can be curbed, the life expectancy of future generations will be compromised. Programs, practices and policy approaches that have been effective in the adult population such as employee wellness and policies promoting physical activity must be implemented early in life to redirect obesity inducing habits and behaviors in children. Evidence shows that physical activity and nutrition policies and programs can decrease obesity levels and promote life-long healthy habits in children. Marshfield Clinic will support legislation to implement policies that take a comprehensive approach to obesity prevention, addressing nutrition and physical activity in a broad variety of environments including communities, businesses, schools and afterschool programs.

To this end, Marshfield Clinic supports federal funding designed to improve the health and education outcomes of youth, children and families. Examples of funding streams that are of particular importance include: Corporation for National Service AmeriCorps Program; Department of Education 21st Century funding; and, the Department of Health and Human Services Child Care Development Block Grant; Center for Disease Control Childhood Obesity Prevention and Community Transformation grants; etc.
Privacy and Security provisions of ARRA

The American Recovery and Reinvestment Act expands current Federal privacy and security protections for health information. Marshfield clinic has specific concerns about:
"Providing transparency to patients by allowing them to request an audit trail showing all disclosures of their health information- including treatment, payment and operations- made through an electronic record. Electronic health record (EHR) users or maintainers must provide requesting individuals with an accounting of protected health information disclosures made during the three years prior to the request (but only for as much of that three year period during which the EHR was in use). Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
"Covered entities must comply with requests to restrict the disclosure of an individual's protected health information if the disclosure is to a health plan for purposes of carrying out payment or health care operations and the information pertains solely to a health care item or service paid for out-of-pocket by the individual. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
"In using, disclosing or requesting protected health information, covered entities must limit themselves, to the extent practicable, to limited data sets or the minimum necessary information. Marshfield Clinic is concerned about the potential costs and administrative burdens of this provision.
"Marshfield Clinic supports provisions strengthening enforcement of Federal privacy and security laws by increasing penalties for violations and providing greater resources for enforcement and oversight activities.
Meaningful Use of health information technology

On December 30, 2009, the Centers for Medicare & Medicare Services (CMS) and the ONC released two regulations required by the American Recovery and Reinvestment Act that lay the foundation for meaningful use of certified electronic health record (EHR) technology. Proposed rules issued by CMS outline provisions governing the EHR incentive programs, including defining the central concept of meaningful use of EHR technology. Final regulations issued by ONC set initial standards, implementation specifications, and certification criteria for EHR technology. Marshfield Clinic is vendor of a proprietary electronic medical record, and closely follows federal developments of the HHS office of the national coordinator and the HIT Policy and Standards Committees to assure meaningful use of electronic medical records and efficient standards for certification and interoperability of unrelated systems.

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Health & Human Services - Dept of (HHS), Centers For Medicare and Medicaid Services (CMS), Executive Office of the President (EOP)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

​

LOBBYING ACTIVITY. Select as many codes as necessary to reflect the general issue areas in which the registrant engaged in lobbying on behalf of the client during the reporting period. Using a separate page for each code, provide information as requested. Add additional page(s) as needed.

15. General issue area code TAX

16. Specific lobbying issues

The Marshfield Clinic has long enjoyed exemption from federal income tax as a venerable nonprofit clinic. As the Clinic has adapted to the changing health care environment, and has begun to more closely integrate with hospitals and other providers serving the same geographic areas, its tax advisors recommended restructuring by creating a new health system parent entity to coordinate activities in multiple subsidiary provider organizations.
After careful consideration, the Clinic formed the Marshfield Clinic Health System, Inc. (MCHS) as a new, community-governed parent entity in October, 2012. The creation of a new tax-exempt parent entity is a standard part of any health system reorganization, of which hundreds have occurred over the past several decades, so obtaining IRS recognition of exemption for MCHS was viewed largely as a formality. Unfortunately for a variety of reasons the IRS is significantly backlogged in its processing of applications. This poses a challenge for the Clinic. To be certain that the Clinic and the new MCHS comply with all applicable tax laws, including provisions governing the use of tax-exempt financing, we are unable to implement our planned reorganization until the IRS recognizes MCHS as an organization described in Section 501(c)(3).

17. House(s) of Congress and Federal agencies Check if None

U.S. HOUSE OF REPRESENTATIVES, U.S. SENATE, Health & Human Services - Dept of (HHS)

18. Name of each individual who acted as a lobbyist in this issue area

19. Interest of each foreign entity in the specific issues listed on line 16 above Check if None

​

Information Update Page - Complete ONLY where registration information has changed.

20. Client new address

21. Client new principal place of business (if different than line 20)

22. New General description of client’s business or activities

LOBBYIST UPDATE

23. Name of each previously reported individual who is no longer expected to act as a lobbyist for the client

ISSUE UPDATE

24. General lobbying issue that no longer pertains

AFFILIATED ORGANIZATIONS

25. Add the following affiliated organization(s)

Internet Address:

26. Name of each previously reported organization that is no longer affiliated with the registrant or client

FOREIGN ENTITIES

27. Add the following foreign entities:

28. Name of each previously reported foreign entity that no longer owns, or controls, or is affiliated with the registrant, client or affiliated organization