Good afternoon, and thank you, everyone, for joining us today. Im mary greeley, president of the Health Care Leadership council. The hlc is a coalition of leaders there all sectors of health care. We have hospitals, insurers, pharmaceutical companies, medical device manufacturers, Health Product distributers and many more sectors represented as well. But today i am also speaking on behalf of a campaign that we call protect my doctor and me. Over 670 organizations from throughout the country representing patients, health care providers, employers, americans with disabilities, veterans and others have formally urged congress to repeal the independent payment advisory board. Today were going to share some information and perspective on ipab and what it means for the Medicare Program, for beneficiaries and for those that provide health care to those Medicare Beneficiaries. Let me begin by introducing our panel. We have dr. Alex [inaudible] president elect of the American Association of neurological surgeons. Hes also chair of the department of neurosurgery at virginia commonwealth university. And he is a director of of the american board of neurological surgery. Bob lancato is the executive director of the National Association of nutrition and aging services programs. Hes also the Board Chairman of the American Society on aging. Bob has spent nearly 20 years in the executive and legislative branches of government including as senior staff of the House Select Committee on aging. And dr. Bill atkinson, he comes to us today from North Carolina where he is a widelyrespected as a champion of health care change and improvement. Hes been a hospital and health care ceo for over 30 years, and most recently of the wake med system in raleigh, North Carolina. Now, im going to turn to our expert speakers shortly, but first id like to welcome erin bill who is legislative director and counsel for congressman roe. Congressman roe has been a leader of the ipad repeal ipab repeal effort. And again this year he is a primary cosponsor of the house legislation that would eliminate the independent payment advisory board. So, erin, would you please share some of your thoughts with us. Thank you, mary. To start, ive got a big pile of business cards up here in case anybody has any questions and you want to reach out to me afterward. As mary mentioned, i work for dr. Phil roe, cochair of the gop doctors caucus, and hes also the sponsor of h. R. 849 in this congress which is aiming to repeal the ipab. Dr. Ruiz, from california, is our democrat lead, and were really excited to be working with their office on trying to make this actually happen this congress. I think we have a good, good shot of doing that. I do want to start out by giving a quick shoutout to the neurosurgeons because they asked that our boss put together a blog post that just went live this morning. So if you go to their twitter page, its neurosurgery, and you can see my boss wonderful blog post. The biggest thing that i have told people when theyve asked me about ipab is that this is not something that would affect just republican beneficiaries, its not something that would affect just democrat beneficiaries, it really is a bipartisan issue that we need to get support behind repealing the ipab. If it goes into effect, it would make drastic and arbitrary cuts to medicare that we would really have no control over any of it. Theres no judicial review. Congress has basically ceded the ability to make medicare cuts to an unelected group of people who arent working in medical practice, arent really doing anything by law. So if we can get this repealed and medicare cuts need to be made, then congress is the group that would be doing it rather than 15 unelected bureaucrats. Beyond that, were really just trying to get as much support as we can. I believe we have 21 cosponsors right now on 849, and we are up to three democrats, so im very excited about that. Think push that you guys any push that you guys can make with your bosses with advocating to other members of congress, wed really appreciate it. I finally have an updated colleague for this congress. It took me a little while, but im happy to the share it with anybody who may want it, so is please feel free to grab a card, reach out to me, and we look forward to, hopefully, having the ipab repealed this congress. Thats really about it. Well, thank you, aaron, for that update. Now, before i turn to our expert panelists today who are going to discuss the potential impact of ipab on patients, physicians and hospitals, im going to take just a moment or two to go over the basics of how ipab actually works and what it would do. So were going to do a little ipab 101 here. Now, im not going to delve into the weeds on this, im not going to go into excessive detall, but we have included the slides that ill be presenting in your Materials Today so you will have those. So even though it has never been activated, ipab has been with us for about seven years now. On paper it is to be a 15member board nominated by the president and then confirmed by the senate. And its supposed to be comprised of people who may not have any other position or employment while theyre serving on the board. There was an early criticism in the fact that this provision would make it extremely difficult to find people with expertise in health care and ask them to, essentially, give up their professions to serve on the independent payment advisory board. Now, the legislation creating ipab established arbitrary growth rates for medicare spending. In 2018 that rate is the gross domestic product, gdp, plus 1 . If the actuary for the centers for medicare and medicaid services, cms, determines that per capita medicare spending will grow faster than that established rate, then the ipab is triggered into action. Now, once that happens the board is charged with developing proposals that will find immediate and i emphasize immediate savings within the Medicare Program and reduce that projected spending growth rate. Now, as you know, president obama did not name any members to the ipab. There has been no sign as yet whether the new administration, president trump, has any inclination to do so either. The law attempted this possibility anticipated this possibility, that the president would not appoint be members to the board. The law states that if the board does not act for any reason, including not having any members, the ipab authority then shifts to the secretary of health and human services. So once ipab is triggered by the actuarial projections from cms, then sec tire price as of now holds all of the authority to act. So that brings us to the real crux of this issue. What would the secretary have the authority to do under the ipab statute. He would have the authority to identify adequate savings to reach this statutory budget target, that gdp plus 1 . There are some constraints in the law. Think proposal could only affect medicare, not think other program. Not any other program. Also no proposal could ration care, raise revenues, raise beneficiary premiums, increase beneficiary cost sharing, restrict benefits or Alter Program eligibility. So i think you can see that that creates a pretty narrow path for any proposal that would achieve those savings. And i should note here that just because the law explicitly forbids rationing of care to medicare men firlies beneficiarieses, it does not preclude actions that we believe could have the same impact as direct rationing. For example, if you with reduce payments to physicians and fewer doctors see medicare patients, then that has a definite impact on Health Care Access even though it doesnt carry that direct rationing label. Now, a couple of additional points about the legislation. Any administrative or judicial review of the boards or the secretarys proposals is strictly prohibited. So no administrative and no judiciary review. And also these proposed spending cuts must achieve savingsing within a single year savings within a single year, so theyre immediate. The organizations that oppose ipab have pointed out this really precludes any thoughtful, longterm initiatives that will strengthen the value of the Medicare Program. But rather, it really limits action to blunt, immediate cuts. In many ways, it reminds me of sequestration. Now, what i havent discussed yet is what is the role that Congress Plays in all of this. Ipab was constructed to largely take medicare Decision Making away from congress. But it left a very small window for the legislative branch to act. Congress may only revise the secretarys ipab recommendations by passing an alternative or an alternate piece of legislation that achieves the same level of savings, again, that gdp plus one growth target. Or the senate can amend the ipab recommendations with a twothirds supermajority vote. And this has to happen very quickly. The secretary submits the proposed cuts by january 25th, and the congressional committees with jurisdiction over this must act by april 1st. So a very short window of time. So here you see again that you have this also in your packets, an ipab timetable which triggers this 2017, and then you can see the implementation of those proposed cuts in january of 2019. So again, i cant emphasize enough that ipabs has now moved from theoretical issue to a very real teenager to medicare danger to Medicare Beneficiaries. Cms actuaries have projected that ipab will trigger for the first time this year and possibly as soon as next month. So at this point, secretary price is charged with finding savings of at least 1. 5 billion to take effect in 2019 once cms makes that projection. And the Medicare Trustees also project that ipab will trigger again in 2022 and 2024, and that would require billions more in cuts to the Medicare Program. So as you heard earlier, here are there are legislative remedies to keep ipab from doing serious harm to Medicare Beneficiaries and access to care. We have the bipartisan bill in the house that you just heard about, h. R. R. 849, that is cosponsored by congressmen roe and ruiz x it is rapidly gaining cosponsors so, thank you, aaron, for the work youre doing on that. We also have two repeal bills in the senate. One, s. 260 by senator cornyn, the republican whip. And also we have one sponsored by senator wyden, s. 250, and he is the Ranking Member of the finance committee. These two are gaining support in the senate. And in particular, were seeing more wisconsin partisan support in the Senate Bipartisan support in the senate than weve ever seen before. I think much of that has to do with the fact that members are now seeing that ipab is an imminent net and that they know that they need to protect their constituents who rely on the Medicare Program. So with that, im going to turn it over to our three experts who are also speaking on behalf of their medicare constituencies; physicians, patients and hospitals. Theyll each present their perspectives, and then well open the floor for your questions. So lets begin. Finish. Thank you, mary, and thank you all for taking time to attend this discussion of this very important issue. As harry said, its going to become a lot more mary said, its going to become a lot more important. Im a neurosurgeon, i treat medicare patients, and from that perspective, i can tell you ipab is one of the most insidious parts of the Affordable Care act, and it needs to go. Now, as you all know since medicares inception, its been congress whos been leading the way in shaping policies to insure our Seniors Health care needs will be taken care of. Ask we all saw this place play out in the last congress when we finally got rid of sgr and was replaced with macra which was signed by the president. Thats how medicares supposed to work, but as mary just summarized very, very nicely, if ipab comes into play, then your elected representatives no longer have any control over how medicare is supposed to work. Instead, well have 15 people with very little accountability, without any day jobs, and many of them have never even touched a patient who will be making decisions about how Health Care Spending new medicare is going to be run. And whats even worse, as she mentioned, if the boards not appointed, it all falls on one person, secretary of hhs. So you have one unelected member of the executive branch who would be performing the job that really historically has been part of the legislative branch. Now, i mentioned macra earlier, and as you all know, for the first time its forcing everyone into a quality, valuebased payment world. And if we do that right, not only will it drive down costs, more importantly, it can actually improve the quality of care that our Senior Citizens get. And the problem is instead of this kind of thoughtful, targeted type of approach, again, to what mary said, ipab would just be a very blunt instrument. Its kind of like instead of using a scalpel under macra, use a sledgehammer under ipab. And to put in this context, remember that medicare doesnt even pay for the cost of taking care of patients right now. The last statistics i saw says medicare picks up 60 cents on the dollar of what it costs me to pick up my patients. So when you already figure its essentially a money loser for my office to keep the practice running, then you layer in all the incredible bureaucracy, ongoing changes to coding and building practices, precertifications, quality reporting metrics that are often not related to what specialists do, you know, for example, my skill and value as a neurosurgeon may be based upon how well my patients cholesterol is managed. It really makes a lot of people wonder about the wisdom of participating in meld care. In medicare. Now, again, this may sound like an argument you all have heard in the pennsylvania. Some physicians just say theyre going to stop participating, and yet most statistics say 90 of all physicians till do. Well, its not black or white. You may be a participant on paper, but maybe you only see one or two patients per clinic session or limit the number you see per week or number you do surgery on. So in effect, that gets into the rationing without calling it rationing issue that mary raised. And mary also mentioned im the chairman of a clinical d. In a medical school. Department in a medical school. And be one issue that really hasnt gotten a whole lot of coverage is the effect that ipab would do to graduate and undergraduate medical education. So, tony, raise your hand. Tony is chief resident who not only is an excellent neurosurgeon, but he has an interest in health care policy. And to turn someone like tony from a fresh medical School Graduate into a highly competent brain surgeon takes about a Million Dollars or more according to our estimates. That moneys got to come from somewhere. Medicare hasnt increased the number of Residency Training spots since 1996, so the subsidies come from either clinical practice plans or from hospitals. And if we just arbitrarily start slashing here and there with ipablike cuts, that will mean we either have fewer physicians or more poorly trained physicians, and neither of those is an acceptable option. So at the end of the day, you know, bad policy is bad policy. Leaving medicare policy decisions in the hands of an unelected, unaccountable, governmental body with minimal congressional oversight will negatively affect access to timely care for our nations seniors and for those with disabilities. Remember that we promised our seniors a medicare system that offers the best care in the world, and bringing an end to ipab once and for all is a vital step towards fulfilling that promise. Thank you, mary, and good afternoon to everyone. Thank you, congressman roe, for your leadership, and senator wyden and senator cornyn. Im bob blancato with the nutrition and aging service program. Really long name, but what our 1100 members do is provide meals to older adults, homedelivered setting meals on wheels is a term you probably know better. Our members helped enroll low income seniors into the Medicare Part d program a number of years ago, and our members are very sensitive to issues that impact medicare because of its direct effect on our participants. And for the past four years, our association has passed resolutions supporting the repeal of ipab. Because ibe pab ipab repeal is the only same answer. Key policy decision on rates and spending that were the purview of Congress Since 1965. Its a dangerous power grab by 15 unelected individuals with no guarantee of consumer or patient representation on the board, and the power could even be more concentrated as the recommendations only need to be approved by a simple majority of a quorum should they with be convened. Ipabs reach is enormous, the entire medicaid program, to be exact. Congress goes from being the driver of medicare policy to a bystander, they can only get 60 votes in the senate to block ipab recommendations or come up with its own proposal achieving equal savings but must do so in an abbreviated period which doesnt always work up here. And lawmakers dont have the authority to pick up specific things they dont like because they must consider all the changes as a single package. The president appointed, but even the hhs secretary unless ipab isnt convened, has no authority to block recommendation ares. Many patient advocate groups expect a 15member panel to recommend fairly significant cuts which could force seniors to pay a larger share of their health care costs. This is particularly troubling when half of the people on medicare earn less than 23,500 a year which is just twice the poverty limit, according to census figures. Any direct cuts to medicare or limits on what the Program Covers could have a dire impact on many of those seniors who depend on medicare and other assistance programs just to survive. For our members and the seniors we serve, medicare provisions such as Preventative Services and reduced cost vaccines have been vital these past few years. So are common straight programs that provide demonstration programs that provide referral services. Important services and innovations like these could be in danger under costcutting measures. This is a volatile time for medicare. Votes will occur throughout the ahca that could impact medicare, and more could follow. But it is Still Congress doing the work with advocates reacting both here and at home about changes that would occur. You have no such luxury on ipab. No one can have a town hall meeting on ipab. There are smarter ways to achieve savings, more utilization of Electronic Health records, greater focus on outcomes. So time for as early a vote as possible on the bipartisan bills, which should have been done seven years ago. We should kill ip ab before it goes anywhere. Thank you. Well, good afternoon, and thank you for being here. Im bill atkinson, again, from North Carolina. Although ipab does not immediately affect hospitals theoretically, let me assure you, everything that affects patients, everything that affects communities, everything that affects doctors impacts hospitals. Theres no way around that, thats the reality of how it works. You would suggest to you when we first came in the room early in this meeting, you heard a siren. And it was an ambulance, let me asheer you, if youve been around it long enough, you can tell the difference. It was an ambulance. And whether ems was going to a call or coming back from one, someone likely by no choice of their own is receiving ailed through emergency medical services. And for the most part, unless thats a patient or someone who didnt need to be treated at the scene and couldnt be released, that persons on the way to a hospital. It could be any one of us in this room. And the question is, are those hospitals available 24 hours a day, 7 days a week, 365 days a year including in the snowstorm tomorrow that supposedly is going to be here. Are the doctors available to be in the that hospital or to come to that hospital. And you dont know what an individual patient is going of to have. And if youve ive had the great pleasure of being president of institutions with level i Trauma Centers for a long time. And let me assure you, when a level i trauma patient the most severe trauma patient comes in, and unfortunately in our world today with the violence thats occurring even in domestic settings, when 20 patients come in or 25 patients come in to a major center, its not a matter of the people that are standing there can do that alone. Youre dependent on a large army of nurses and doctors and specialists in many, many fields and primary care doctors. And you name it, you need it. And all of the surgical technicians and all of the people that run that, it is a very expensive to create a safety net and to actually keep that net in place 24 hours a day, 7 days a week, 365 days a year. And what happens in many Rural Communities and ive run a 50bed hospital in a Rural Community this South Carolina at one point in my early career. When you had a patient that was in trouble regardless of what happened after 5 00, they were going to a hospital in another county because there were only five doctors in that community at the time, and you were going to transfer a patient. And if that patient was serious enough to go, even if it wasnt life threatening and its after five and you send them to another community, if that community doesnt have doctors available to the come in and see those patients even if theyve had a hong day, then that patient has simply been moved from waiting chair to waiting chair to waiting chair, and thats no withdraw to run a ship, as they say. This is a country that one of the freedoms and responsibilities we have is to take care of our neighbor. Its just the right way to do it. Now, im going to suggest to you that we are all responsible for finding ways to reduce the cost of health care. I buy insurance just like you do, you know . My children, weve still got kids in school, in college. Were responsible for the same thing parents are anywhere. Were responsible for each other. My wife and myself are taking care of each other, and it is very expensive to do so in the Health Care World we have today. Ive always been interested on this spot in emergency medical services. I happened to be when i was young and the state of North Carolina along time ago, i still keep those certifications. Ive always been interested in emergency medical services. Its an interesting mood in ems around the nation today and some big cities and small cities alike including North Carolina are working with it. Theyre taking paramedics, some of whom are firefighter paramedics, and training them do Community Health in addition to their ems Emergency Response and an interesting thing i heard in dallas texas from the chief foster theyre not long ago was , who were there trying to set that program up to start . They have to start somewhere and the interesting thing he told me was they were starting with patients who had called 911 50 times in the last year. 50 times. Thats not big users. What theyre doing is having these firefighter paramedics who have additional training go out and see what is the issue . Is it about nutrition . Is it about social services . Drivers licenses . Is it about being lonely . Is it truly i hope problem thats being recycled . The answer to many of those questions if not all of the above, hospitals deal with that all the time. There is a much smarter way to do this instead of cut through Something Like that blindly. It is an opportunity to do smart things, to do innovation. Innovation. And on that day in america when doctor don barwick who you know from the institute stood in florida and said people would be entered in hospitals by accident and by just deeds, things that could be improved, i was standing on the stage with him. Trust me, it does make you a hero in the industry when you talk about hurting people in the hospital but the reality is we know there are issues that need to be improved. We know there are actions that need to be taken across this entire nation to strengthen healthcare. Blindly cutting how we spend money as opposed to where we direct that money is a mistake. Oped is a mistake. Well, thank you for sharing those different perspectives. We will open it up for your questions now. I also have a few i can ask. Anyone in the audience . Yes . [inaudible] so elaborate a bit on why ipab is not a good way to address health care costs. You can think of it as bottomup versus topdown. Topdown, youre on ipab and you see the aggregate spending goes up above a certain line and you push the button and try to shrink it down. Bottomup is somebody whos actually there on the Assembly Line who sees how the work is getting done so you can be in the hospital, clinic and you look for certain ways to decrease inefficiencies, to decrease waste. Its his boots on the ground type of approach. Ipab is this artificial, youve got to cut this much and you may arbitrarily decide if youre running a business , its got to come out of personnel or supplies or insurance, those type of things as opposed to doing the work. You can make money improving quality if we focus on the things that they deal with every day. Does that answer your question . If the unknown. Concerning about what they decide to do to fulfill their mission and where they would choose to take their cuts because as someone said earlier, something overly here as an implication over here if youre on Medicare Beneficiaries so if youre not doing anything about limiting access to healthcare and also driving up costs and theres many unknowns associated with ipab that would make us concern. The suction in ipab is that Everything Else thats being done or could be done hasfailed. Has failed to control costs and i suppose that could happen. The reality is, there are so many approaches very much like i mentioned about Community Paramedics and, its a very small example. There are so many things that are relatively inexpensive and in the end save millions of dollars and take the burden off healthcare and get people in the right place as opposed to absorbing large numbers of resources that are inappropriate for their needs. And inappropriate use of public and private money. Theres so many programs like that should be funded versus talk about, that may take money from one program and move it to another. You could take the burden off Emergency Departments, the most expensive place in america to receive care. If you can take burden of communities by helping the least among us, many of them are people with money who just dont know how. Older patients who dont know how to access the system. And if you come in the right door, if you come in the Emergency Department, its immeasurably complicated what your care cycle will look like and what the cost is so i think we, the smart way to do this is to introduce innovation and change at the starting line of the system, not in retrospect in a dark room somewhere cutting costs. Yes . [inaudible] so if the question here is the statute says consistently that it cannot ration, these cuts cannot ration healthcare for Medicare Beneficiaries. And also you cannot have the tax to increase revenues to the program to offset that growth in spending. You cannot increase costsharing by Medicare Beneficiaries as part of this. The real question here is, and all of this has to be done within a period of one year, what would you expect to see in terms of reduction . How it would affect and then what is the real effect on Medicare Beneficiaries . So if you run a coffee shop or a fast food place and theres a couple items on the menu that you lose money on every time, your company cant survive with you continuing to sell a lot of those so you may sell another certain amount of cups of those coffee but you cant make that a big part of your business. In medicare, every physician of course, we are very devoted to our patients. We want to takecare of them but we also have to pay the bills. As i tell people all the time, even Mother Teresa had to pay her bills and that was your checkbook. You have these competing interests between one, take care of people and especially the elderly, many of whom are your neighbors versus the realities of trying to keep things running so its kind of like slow walking. Im a medicare beneficiary, if i mention im getting paid i cant afford to see more than x number of medicare patients from clinic, per week or do more than a certain number of procedures at the time so that is going to be rationing. It may be a queue for reimbursement but not other types of reimbursement. I think that word needs to be looked at rationally, as many new innovations pointed out that have occurred in medicare in recent years, some of them make it stop in their tracks. They may not expand preventative benefits as the Affordable Care act was able to do, giving you welcome to a medicare physical or osteoporosis or things of that nature so some of the things that are more innovative and newer , thats rationing care and if youre not letting these people in for back to that, thats a word that we have to be careful about. The that may not look like anything beyond that decision but it has ripple effects on medicare down the road. Many innovations are occurring at people 65 or above, a person, a good example is how many patients are transported from new nursing facilities and new ones or other facilities that have a slight fall and the protocol in many locations is you need to go to the emergency room for a fall and its different in any environment but again, in some cases in Wake County Emergency Medical Services in raleigh North Carolina as a protocol now thats been underplayed for a couple years. When theres a fall and ems goes, they can clear that patient with a standard that says either they need to be transported or not. And a vast majority of the patients that have a simple fall in the nursing home do not go to the hospital. And its 100 percent review of each of those patients, they had no fallout from that. The patients that need to really go are the ones that dont clear and the issue historically was the Nursing Homes one a petition where they thought it would be a legal issue if the patient didnt go get checked out. The answer is, they are getting checked out. Theres a physician on the other end of the line and the medics themselves want to make a mistake and they believe theyre not going to do that but theyve been able to save money. Thats a classic example of using innovation and having 100 percent review of those cases to make sure whether theres something thats, thats what its a great system but there are 1 million examples where common sense could be applied to make sure people get the care they need, not the care thats traditional which is not sitting in an Emergency Department where you dont have a true emergency, its not an experience anybody wants including summary of the medicare age or medicare or medicaid age. Yes . So given the critical limitations, especially with respect to ipab, could you the fact that this friday which is, has such a powerful mandate is unelected, not regulated by federal law and half of the constituents asked our Healthcare Providers making these critical decisions which ultimately is going to impact access and questionably, however one prescribes that rationing in terms of access or provision of care, i think the ultimate and result is going to have a profound impact on the time and so i would have concern about underrepresentation from the healthcare arena but its an unelected body with no federal oversight. I think the point here is that its clear as we stay in the statute that the majority of members of this board cannot be those with what i would call realworld experience in providing healthcare. And also, they cannot hold any other jobs wide while they are in this position so whats your reaction to that and what effect you might see from that . We talked about these in maritime and i can tell by the tone of your question where you come down on the side of this. I think youre exactly right. You have someone who presumably has a successful career either as a provider or a healthcare administrator who is supposed to give that up and go work for the government. If nothing else, you cant keep your own previous job on the weekends. And again, not all these members are going to have the real life experience, thats going to be a big problem. Its been said that in the military, the generals and admirals start at the bottom and work their way up through the ranks so they see how the Organization Works at every level. If you parachute people in the top without a lot of that experience or the experience may have been very old, healthcare has changed so much in the last couple years is not the same system your father had. I agree its going to be a big problem. So what it feels like is being dorothy on the yellow brick road. Id like to know whos behind the curtain, to be honest and i think anytime you have to deal with a wizard you dont see and you dont know and you dont know what tasks are being assigned, it doesnt feel very good. Most of us whove been in healthcare a long time are used to coming to this city for our capital to talk about healthcare. And many many times what we asked for or say is important that that happened and thats okay. At least we have an opportunity to Say Something about it and maybe somebody else has a better idea we didnt think of. Thats the great thing about america is the ability to change ideas and see what people do. As ive noted today, the opportunityto do what theyre doing in dallas or baltimore or california, what they are doing in florida impacts all of us. That ability to share information is important. The concept of ipab as i said, its the wizard. It doesnt work. Yes. Is this a catalyst to spur action in congress, it really is not officially eager to cut spending, to pretty much especially Something Like medicare because is there a value in keeping ipab around if only to spur cuts . Will cuts havent realistically not an 80 like that forcing congress was a or that we support that we come up with a better place to do the cuts . The question is whether having an entity like ipab will get stuff done or spur congress to take action and what happens if we dont have that pressure. Ill leave a comment and i will chime in. Well, i think if we were talking about reduction that might take place over a period of years, we would have time to come up with thoughtful innovations on how we could change the delivery of healthcare and providing services. The real challenge with an entity that we see in this is , they have to make recommendations for cuts that will reduce spending within the one year and that in my mind completely maintains the ability to do thoughtful, longterm change as we are trying to turn this huge ship called healthcare delivery. Again, thats a great answer, i agree with that but thats looking at the cost side of the equation but our Current Program has also focused on quality and you could argue thats more important than costs, if you can leave that mother or grandfather there in the hospital so fighting cost is great but thats an incomplete solution. Itwould be interesting to , its a great question but i think that the part of the answer is that its sort of a strange approach to trying to Keep Congress people of ironically spending. Theres a history of making tough decisions onmedicare over the course of time, theres going to be a few more made in the coming months. But the difference i suspect is that the future decisions that are going to be made about medicare, we hope for the most part have bipartisan support. Theres no guarantee of ipab having a bipartisan approach to anything and i think thats one of the compares i would have in addition to the fact that people making those decisions really are not qualified, even if we dont know who they are yet. And again, just a pragmaticresponse , if you want to know how to make healthcare better, 24 seven, 365 asked versus because the only folks who are always there no matter where everybody is, physicians have to be in the middle of it but the people who are dealing with the pragmatic side of how a patient can get in or get out or not be seen or get into a Doctors Office are generally the nurses and every good field both phc would have an ideal of how it fits and i think all of us have to have an ability to sit down and talk to the people who handle the 24 seven movement of patients. Which is at that level and you cannot do it without the physicians and the pas and the other people who do it. They are what make the clock work. The reality is you also have to take the people around the train if you would. And thats the folks that are on the line either in a Doctors Office or the call center or exposed and nursing many times, the sign is at least less silent efficient and i wouldinvite them to the table and i assure you theyre not going to go for the wizard of oz model , kind of a blind ford on a sheet, is not going to happen. That was a very pragmatic answer which i agree with but also back to the 37 feet, theres a philosophical approach, the legislative branch may have trouble going on the budget but that doesnt mean it should see this much power of the executive branch. Thats not on our system. And i cant resist, as a former house staffer, i cant imagine what the fnl would be like. And the answer youd have to give would be agreeable to both so keep that in mind too. I think thats a very good point that this approach really is the antithesis of representative government. In other words, patients, constituents, voters would not have a voice in this process because this is an unelected board. This is dominated by those that are familiar in healthcare. And again, the fact that all of thiswould have to happen in such a short period of time. Which leads me to question all right, if you had to come up with several billion dollars in reductions, what would you have expected to see . What is the likely cost that one would expect that i think would probably be a lot different than the transition you are going through under eight macro, the physician payment reform. What are the types of cuts that this board could make . Im not quite sure what you are asking because what the ipab board might make . Ipab has a partner, youve got to make these cuts in one year. What would hospitals, physicians and others expect to see . I believe and dont quote me on this but theres originally formulated most of the cuts were supposed to fall on providers and sort of other parts of the Healthcare System like hospitals. In the short term. I think that was several years ago and now we are past that but i can imagine ron strokes, the physician provider part gets cut this much, so many billion, hospitals have had this much. Other parts get cut here and there without any more thoughtful and more particular approach to it. I think part of the answer is whos on ipab . Who ends up being put on that and if its the imbalanced a certain way, you can find probably an imbalance in the way they would recommend itself that part of the competition of it becomes important and who was on the, who was on the panel . One would hope that the first lace that they would love as we hope that congress will continue to look at is fraud, waste and abuse in the system. You can extract money and have ithere year after year by me being more aggressive in that front but im sure they wouldbe there. Again, if , look around and talk to people who had experience and Health Settings and not just hospitals because thats a small percentage of people that would be involved in the daytoday access of healthcare but if you talk to people about their time, whats their time for, whats their transportation cost. Whats it mean to have to go to an Emergency Department as opposed to being seen by your doctor, maybe in the middle of the night and so our Urgent Center care centers but not the type weve seen which are driveby centers but the true presence and at the Health Network that might be open around the clock around the patients age and necessary systems. There are many innovations we could do and one of the things we heard earlier was about the importance of training. The training and Education Programs for future nurses, future positions, future pas going down the list, laboratory personnel. Its very important thing to do area we have to be a tremendous shortages in some, especially on nursing in some communities, not all but some and the absence of people who can move the process along the patients that call into work. They move as far through the system or as quickly as they need to be. Its not calling for more technology and in many cases its just a call for the right workforce including physicians, Rural Communities who do not have actual physicians are many times transferred by ambulance to patients on weekends and nights when those doctors are not available so they have to have brakes to once in a while. They cant be on the whole 24 seven in a Small Community or urban community. The urban areas many times have a caseload, its a very expensive prospect. Any other questions from the audience . [inaudible] could somebody explain the difference between the two . The short answer is you have senator wyden who is the ranking democrat on the Senate Finance committee and then you have john cornyn who is the republican with. And in each, from their individual parties have decided to take on the two. And we are just looking to get the Problem Solved and thereal assessment to both of these pieces of legislation is repeal of the ipad so they have the same goals, they have the same effect. Its just each decided to sponsor their own piece of legislation. Its easier for us in the house, we had a bipartisan bill, they started down that path already but at the end of the day, we are trying to get critical mass, make sure this gets done and i might point out the clock really is taking here. Last year, there was an expectation that ipab might be triggered, this year it is pretty darn certain that cms actuary is going to come out with that projection. That a medicare per capita spending will exceed gdp 1 rcent so as we all know, gdp growth has been rather constrained and low so its a pretty low target and it looks like its going to be exceeded and then were going to begin this process. Of having these cuts whether we have a board or not. The secretary will now have that responsibility and must take by statute those recommendations. To achieve those reductions. So we are really looking to all of you in the audience here and whoever may be watching today, please ask your member of congress to sign on to this legislation and to get this legislation passed because it is now imminent threats. And ive been out here for a while but it is now becoming real, its incurred from our panel today, there are real effects that will affect not just the providers, not just physicians and hospitals and those that provide goods and services to Medicare Beneficiaries but its really clear that it will directly affect big beneficiaries and the types of juries they are able to access. So any last comments for our panel . Alright. Thank all of us for joining today, i appreciate it. [applause]. [inaudible conversation]. [inaudible conversation]. [inaudible conversation]. [inaudible conversation] if you missed any of this discussion you can see it in its entirety on the cspan video library