Transcripts For CSPAN2 Key Capitol Hill Hearings 20131216

Postnafta we were doing a tremendous job making something together. We were making pork chops together, but country of origin labeling and impact on livestock trade has dramatically decimated that. Efforts in congress to introduce renewable or a clean energy standard, none of them have passed, not scott mentioned earlier the northsouth flow of the electric grid. But despite that the existence of the grid and existence of the l. Actress degrade trade, the proposals for renewable and clean and g. Standards all would have differentiated between imported and domestic electricity and not given them the same treatment. So a while theres a lot of hope, im wondering how you propose to tackle that . Well, and ill channel Alexander Hamilton and recommend energy to the executive. I think to the extent the president and his administration has an ambitious, active agenda. Congress has a lot less time for mischief and have to deal with so i would encourage the. I think that now is the president pushes hard for the Transpacific Partnership and ttip, we will work a lot less about green cards for cattle from canada. And the other, which always creep in again and always find best audience, so i think given more than they can deal with is probably the best solution we have. I cant local politics is very heavy on this process. If i could just make a comment. Look, having nafta doesnt mean there are not Interest Groups with specific demands, with little clout, with money, and with determination to see through an issue. Thats politics, thats the nature of the beast. It will always be there. Its there with respect to every one of our Major Trading partners, right . The lobbyists for europe and individual European Companies who want certain things, and we can go around the world. So you know i take a very practical view of this, which is if theres an issue that upsets you come you try to get in a fight. As effectively as you can. But these issues that you indicate are not going to go away. And they wont be resolved by agreement. Theres too much or if they are resolved by agreement the resolution will be unsatisfactory i would predict. Because youve got to let steam come out of the system. You have to let people have their say. And a number of these kind of issues have been around a very long time. Prenafta, during nafta, postnafta, and they will be around i think in the future. I dont think there will be an easy fix, i really dont. This is as a practical matter. You can say the administration to take a tougher line. Why . Think about it from their point of view. And all that is on the plate at the administration, not just democrats but republicans, whoever is president. Cattle certification a big issue . No. So i think you have to be realistic about what can be achieved, and do your best to defend your interests and get in a fight. But i dont think the issue will go away because of the nafta or because we like to see nafta renewed further. To pick up on the gentlemans question, i was thinking about, scott mentioned dave ricardo and its always great to mention the great buddy to go back to ricardo, he does we talk about trade. He talks about intercourse among nations. We could get a whole generation focused, dont get in a way of intercourse. This could really [laughter] especially intercourse with cattle. This could be big. I just dialing it back slightly, although i will note on that same key, canada is one of the largest exporters of animal genetics in the world. [inaudible] but on the issue of irritants versus things you can fix with rules. Some of the things the representative from manitoba mentions are things that are resistant to contain it within a rulesbased framework. Im not sure the country of origin labeling could be something that could be dealt with in a nafta, but i know Something Like a by america issue and the issue that canada has with some federal procurement. We were told you guys should have negotiated in 1994. You have your chance, you blew it. This is the problem of having an agreement that isnt upgraded, that isnt evergreen in some way, shape, or form. So sometimes you got to dust up, get in there and fight. And sometimes you can contain some of these problems with an upgraded agreement. Rules are static but the environment is not. Ive been waiting for you. I guess while were having a reality check, if we go back to your comment about former senator obama saying he wanted to renegotiate the nafta, i do think that was a positive i dont think he wanted to renegotiate the nafta by addressing the tpp. But it brings me to the labor issue, and i think, charlene, you might be best positioned to address that. In fact, how do you see that labor issue involving in a positive way . I remember we fought to the now to see that didnt get expanded too much but now its kind of a reality with every trade agreement. I dont believe they will ever get organized labor to support trade agreement, not give cover to members that can support trade agreements. Perhaps you can just highlight how we are moving on the labor issues so that it can be incorporated in a positive way in the trade agreement. And i want to make one brief comment about rules being static. I dont agree with i think rules should be negotiated in a dynamic way so that when congress does rules labeling, we can like we have in the past and will in the future say, no, that isnt a violation of the rule, because the rule is a liberalizing rule. And if you have two strict labeling requirements, you actually violate it, the rule. But in any case, thats another debate. Labor issue, please. If i could come if you dont mind, maybe chris might have something to say on the labor related issues, given supply chains and coproduction and so on. I dont know, scott, i know you previously talked quite a bit about labor. So if i could turn to them first and i can round it out a bit if needed. Let me make a brief comment about the provisions in trade agreements. I think we have come a long way in the treatment of both labor and invited in trade agreement. They were signed agreements and nafta, and every trade agreement has made progress in trying, trying to accommodate the concerns and do a better job of making sure the agreements themselves were robust and offered the degree of protection that was sought. What we havent done is gained support. Although i would note they made positive statements about the ttip. So they are not beyond support and weve made a lot of progress. If you make things together, you tend to make them in a way that enhances the opportunities for labor, if not necessarily the standards from within. I mean, i think that obviously this sort of macro change has happened that plays into this but it is not shifted the dynamic in labor yet is important in the production cycle, imported input. So the extent that companies, industries out large including the workers, depend on imported input better competitive, generating more for trade. I think thats a macro dynamic that is still playing out. I think in the longterm that does, it opens the opportunity for a change in the discussion, but its something thats happening very, very slowly over time. I just wanted to make a quick point that labor unions can also be dynamic. In canada we have a situation with labor shortage, in particular in the oil sands. We have been recruiting workers from the United States. Is relatively easy to come into canada on a temporary basis if theres a demonstrated labor shortage. Whats the difficult is getting certification for recognition skills for particular skilled trades. And so the labor unions, the counterpart unions on both sides of the border, like the aflcio, have said we would really rather that youre using Union Members from canada and the United States rather than nonUnion Members from other countries. So were going to certify the skills that are obtained in wisconsin to help that work to get to work faster in alberta. So they have actually been fairly enlightened on this issue. I think all i would say is you can see from the rhetoric over the immigration debate in the congress, including the use of high Skilled Labor, how difficult these issues are, for members, whatever your view is on the underlying issue. And to the extent their view is that movement of personnel means movement of low Skilled Labor across borders, the concern concluded from big labor becomes even greater. I do think that chris made a very important point, which is given the nature of the Global Economy today, given the nature of competitive strains in the United States as well as in north america, given the rise of the asian economy, which are fiercely competitive, we do have greater room now for discussion of the movement of personnel than we did previously when many of these factors were not so apparent. In other words, the nature of global competition is so fundamentally different now from when nafta was first negotiated that at the time, politicians didnt see the need for the movement of labor. Situation is very different today. So one would hope that the current economic environment would leave space for people to be talking much more rationally about the need to move labor at its best, and execute lee and need for projection production chains for example. Joint r d. Both that highend labor would also regular labor. But i think theres a little more room today for discussion but i think we see from the debate on the hill and comments made that it is very difficult issue politically. It remains difficult politically despite the obvious need given the external environment. With that, let me add my thanks to ambassador barshefsky for her moderating skills, to the panel and all the speakers. And thank you for attending this morning. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] and wrapping up the discussion here at the center for strategic and international studies, a discussion about nafta on its 20th anniversary. If you missed any of the discussion or you would like to see it again, we will have it available shortly online at our cspan video library. Just go to cspan. Org. More life programs across the cspan Networks Later today. Join us at 1 00 eastern for remarks from dan asked them, the chair and ceo of general motors. He will be at the press club today. We will have his remarks live on cspan. Turning to capitol hill, the Senate Returns today at 3 00 eastern. Senators will be picking up where they left off on friday on a series of judicial and executive branch nominations. Votes are expected to around 530 on those nominations. This will likely be the Senate Last Week in session until the new year. Some of the items on the agenda include key pieces of legislation that passed in the house last week. One is the budget agreement that was drafted by paul ryan and patty murray. And the other a bill on 2014 defense programs. Meanwhile, the house has finish all its legislative business for the year. You can watch the house live on cspan and the senate live right here on cspan2. Fcc was the first, provided the first country in the world to fight allocated sector for medical body area networks. This is something that allows monitoring of vital signs without having to have intrusive monitors. It can be a game changer in terms of tracking peoples health. We are a remote wireless remote patient monitoring solution to be able to put devices in patients homes, to be able to monitor and keep them well and have Better Outcomes and keep them out of the hospital. This device is an anticoagulant it devised. Typically a patient that is on coumadin would have to go to have to go to their doctor maybe once a week to get a blood reading and then the data goes into this device and then they can go to our service center, Nursing Center where they can help monitor the patient but if theres a problem that can alert the patients cardiologist. One of the things my office is working on is providing a model notice for health apps. So, for example, when you go to buy a can of food, you know how theres that consistent fda label that lets you look for the things youre interested in. Some people care about sodium, others sugar or fat. Similarly we are developing a tool and we done this for personal Health Records but we are now expand it to address other kinds of mobile and nonmobile apps and tools. This can help you say okay, these folks do not resell my information, or this is how to use it. So again a consumer can help to navigate this newly growing and exploding field. Field. The governments role in supporting mobile Health Care Technology tonight on the communicate is at 8 p. M. Eastern on cspan2. I wish you both a very happy christmas and a bright and prosperous new year. Its a pleasure to meet you, mr. Santa claus, and to help you help on the sale of seals which begins on thanksgiving day. Would you mind autographing some of the christmas seals as a special favor for santa claus . Why, i would be delighted. Its one of the things that i do best. [laughter] thats a good pen youve got, santa claus. Its wonderful, yes, indeed. Must have performed like this before. My father, santa claus, gave it to me. And its got some of the dog hair in it. First ladies influence and image season two. This week Edith Roosevelt to Grace Coolidge weeknights at nine on cspan. Last thursday a group of physicians outlined how the Health Care Law is affecting their patients. They testified before the house oversighoversight and investigas committee. Their concerns included limited access to care and drug cost for those of chronic conditions. Health care policy professionals also testified. Representative darrell issa chairs the committee. Elijah cummings serves as the Ranking Member. The hearing is about three and half hours. [inaudible conversations] could i ask you to please take your seats and ask you to come to order. [inaudible conversations] the committee will come to order. The Oversight Committee exists for key from the principles. First, americans have a right to know that the money washington takes from them is well spent. And second, americans deserve an efficient effective government that works for them. Our duty on oversight and Government Reform Committee to protect these rights. Our solemn responsibility is to hold government accountable to taxpayers because taxpayers have a right to know what they get from the government. Its our job to work tirelessly in partnership with citizen watchdogs to deliver the facts get American People and bring genuine reform to the federal bureaucracy. Today, as we view the continued rollout of the Affordable Care act, we deal with the administrations selling technique, the administrations sold the health law to megapipe with a simple, clear promise. Did you like your plan you can keep your plan. If you like your doctor you can keep your doctor. After aliens of americans received notices that the plans were being canceled, the president was forced to acknowledge just how misleading he had been. The president apologized for his misled sorry, the president apologized for people who were misled by his claim and found themselves in difficult circumstances. And the quote is, i am sorry that they are finding themselves in this situation based on assurances they got from me. Weve got to work hard to make sure that they know we hear them, and were going to do everything we can to deal with folks who find themselves in tough positions as a consequence of this, end quote. Now theres mounting evidence that the president s second promise is also untrue. Americans cannot keep the plan a like. They cannot keep the doctor they like, and its increasingly clear that more needs to be done to keep the president s of assurance that we will do for folks everything we can. Americans deserve to hear the truth. The administration has been stringing them along with promises that every day are being broken. Many of these promises were predictable. Many of these utterances cannot be reversed. Out to the extent that we can bring the American People the truth of whats happening and reversed in any case we can the lowering of access to care, we must do it. Initially, in minnesota, for example, the mayo clinic was only going to be open to people virtually within walking distance. Now it is open because of the backlash to at least people in minnesota. But as a californian, the ability to get reimbursed if im on the California Exchange for the mayo clinic does not exist. This is true throughout the country. Just last month thousands of doctors were terminated from Medicare Advantage plan networks, including 2250 in connecticut alone. Thousands of seniors are facing the loss of physicians they relied and trust on. In florida they are were areas of southwest florida in which no oncologist exists for patients who currently have lifethreatening cancer. Many americans who are shopping for plans on the obamacare, or Affordable Care exchanges, have found that they offer extremely limited Provider Networks that exclude their preferred physicians. Physicians who they have dealt with build relationships with. Many parents are finding out that their child, that their childs pediatrician is no longer covered by their Insurance Plan. We now know that Exchange Plans exclude our nations best hospitals, hospitals like seattles sloankettering, m. D. Anderson cancer center, and the like. Unfortunately, millions of americans are likely to find out early next year that their new Health Insurance plan doesnt cover the doctors who they most value and trust. Such limited plans demand that we ask the question, what quality of care will obama carried actually provide . The axis shock has prompted Many Americans to ask, didnt the president promised me that i could keep my doctor . On november 19, the White House Press secretary explained that the president meant by that, you can keep your doctor, was that if you want coverage from your doctor, you can look and see if they are on your plan. To see if theres a plan in which your doctor dissipates. Clearly in the case of federal and state exchange is, it is unlikely that the best and perhaps the most expensive physicians will ever be available. Just this past sunday a key architect of the law explained, if you like your doctor you can pay more for that doctor. Before the Affordable Care act was passed, you had that right and you have the right to take a plan that suited you and paid for that doctor. In essence, the public is now being told if you like your doctor, then you can try to find a plan that carries them, and then you can pay more for that plan. But you are already playing more for plans that include items you dont want, items you didnt need and likely will not need your this is so unacceptable to the American People that there is no question both through public polls, and if you will, even by democrats no longer touting the main benefit of the Affordable Care act being the improvement of affordability of health care, theres no doubt at all that a few good pass this bill again, you couldnt pass it in this congress. Even if you have not read it and you knew it was going to happen, you would not vote for it. When our government, including the congress, passed this law, we have a solemn duty to honestly inform the American People of what is going to happen. In this case clearly the American People were misled. This duty is no more solemn when it affects americas relationship with their physicians. That is a sacred trust. It is the most important thing in a life or death situation too Many Americans, and it is a trust that has been broken. Today well hear testimony from experts at think tanks and institutions. They will be on our second panel. We have concluded that the first panel should include three doctors who have actual Life Experience practicing with patients and realizing what can or cannot be done, what should or should not be done, and direct experience with what is happening under the Affordable Care act, not just to their practices, but for businesses, but to the patients who are human beings in need of their care. Today, the testimony from these physicians will describe in the most candid and personal terms exactly how the Affordable Care act, or obamacare, has affected these patients in their practice. Im sure these doctors will agree that there were problems in the Health Care System that needed to be reformed. The fact is, america had an imperfect system developed with a number of public and private forms of money, tremendous federal taxes, Insurance Companies that were often difficult to work with, and the like. But a broken system that is repaired by crashing it into a wall is not, in fact, a fixed system. And without i would recognize the gentleman from maryland for his Opening Statement. Thank you very much, mr. Chairman, and thank you for calling this hearing. This week i had a tremendous honor and privilege of traveling to south africa as part of our nations delegation to honor the life of the late president Nelson Mandela. It was an inspirational trip, a life altering trip. Because i had the opportunity to reflect on the amazing changes that one individual working with determination over a lifetime can bring to millions of others. There will always be forces aligned against him progress, against equally come and against basic human dignity. But Nelson Mandelas life reminds us that our mission on earth is to transcend these Destructive Forces and always pursue the betterment of our fellow man. I traveled back yesterday on a 20 hour flight home, i began to think about todays hearing, and i was amazed again at the significance of what our nation accomplished with the Affordable Care act. Before we passed this landmark law, millions of our own citizens could not obtain Health Insurance because they had preexisting conditions. And we allowed Insurance Companies to discriminate against them. They charged exorbitant premiums that were prohibitively expensive. They attached riders that excluded care for these illnesses, and in many cases they denied access to Health Insurance altogether. Think about this. Before we passed the Affordable Care act, they were about 50 Million People in the United States without Health Insurance. 50 million. Thats almost exactly the population of the entire country of south africa. Before the Affordable Care act, we have in our entire nation within a nation of people without coverage. No insurance for doctors visits, Cancer Treatments, prescription drugs, or hospital care. That was a shameful and immoral legacy for a nation as prosperous as ours. Three years ago after decades of inaction, congress and the president passed the Affordable Care act. We finally banned in Insurance Companies from discriminating against people with preexisting conditions. We prohibited Insurance Companies from charging higher prices for women than for men. We eliminating junk plans that collected premiums but then did not pay hospital bills when people got sick. The result today, tens of as a people now have something they did not have before we passed this law. The opportunity and the ability to afford and obtaining quality Health Insurance that will safeguard their Financial Security and recognize their dignity as human beings. Congress understood when we passed the Affordable Care act that these changes would tend to increase premiums for a subset of people who already have insurance under the old discriminatory rules. So we put in place several measures to lower prices and to control cost, including subsidies to help people buy insurance, a requirement that Insurance Companies spend at least 8 of premiums on Health Care Services or offer rebates to consumers, and review proposals might Insurance Companies to raise their rates by more than 10 in a year. The good news is that the actual premium rates have not been submitted by Insurance Companies and they have come in much lower than expected. In september, the department of health and Human Services issued a report explaining that actual premium rates now being offered under the Affordable Care act are 16 lower than projected. Based on this actual premium data, the center for American Progress issued a report in october showing that these lower premiums will say the federal government 190 billion over the next 10 years, meaning 700,000 additional people may be able to obtain coverage. More broadly, the centers for medicare and Medicaid Services issued a report saying National Health spending has slowed to only 3. 9 in the last three years, which is the lowest rate since the government began keeping these statistics in 1960. I understand that we will consider two studies today that i served that premiums are increasing for the majority of people in the exchange is. Both reports have significant, very significant flaws. First, the heritage report completely disregard the subsidies provided by the Affordable Care act, completely. As a result it out to athletes the octal cost of coverage for consumers across the country. Second, although the Manhattan Institute study is better because it includes subsidies, it still compares, and i quote, apples to avocados, end quote, as one commentor explained. It compared five plans under the Affordable Care act with a five cheaper plans offered before the law passed. The obvious problem is that the old plan offered vastly inferior coverage. To me, the most significant problem with comparing premiums before and after the Affordable Care act is that it disregards the 50 Million People who could not get insurance. If someone could not afford a policy that covered a preexisting condition, the price of that are inevitably expensive plan is not considered. Let me close by offering a final thought. One of the things that Nelson Mandela will always be renumbered for is his push for reconsolidation. I respect his viewpoints the viewpoints of my colleagues on the committee as well as those of our witnesses that i stand at the Affordable Care act is not perfect. I have said that many times. In that spirit i hope we can Work Together in a bipartisan way to improve the Affordable Care act, rather than continuing to fight over its very existence. One of the things that the late president mandela said, and i thought about this a lot because it is so true. He said, it always seems impossible until it is done. It always seems impossible into it is done. We are no longer disregard the experiences of 50 million members of our population. We can no longer ignore the pain, the frustration, and the fundamental inequality of this nation within a nation. And with that, mr. Chairman, i yield back spent i thank the gentleman. Members may have seven days is a bit Opening Statements and other extremist material for the record. We now welcome our first panel of witnesses to dr. Patricia mclaughlin is an ophthalmologist in a private practice in new york city. Dr. Eric novak is an Orthopedic Surgeon with the orthoarizona practice in phoenix, arizona. And i would like to recognize the gentleman from georgia, mr. Woodall, to introduce his constituent, doctor english. Thank you, mrenglish. Thank you, mr. Chairman. I appreciate that courtesy. We do have a great pleasure of having dr. Jeffrey english with us today. He has been a tremendous resource to the georgia delegation. I want to tell you just a little bit about his background. He has a bachelor of arts in psychology at Boston College in 1991, and graduated from Dartmouth Medical School in 1995. He served relatively close by here as chief resident in neurology at the university of maryland in 1999 come into the great pleasure of all georgians has chosen to call norcross home where he is now the director of Clinical Research at the multiple Sclerosis Center in atlanta, and president of the georgia chapter of docs for patient care. It is with great pleasure that i welcome debate dr. English, and thank you so much for which do for us, not just on the committee but for us back on. Thank you, mr. Chairman. Thank you. And pursuant to the Committee Rules i would ask all three of her witnesses to rise to take the oath. And please raise your right hands. [witnesses were sworn in] please be seated. But the record reflect that all witnesses answered in the affirmative. Doctor english, the have time in your practice to watch cspan . Well thank him for all of you i will give you the brief. We would ask first of all with and consent all of your Opening Statement in its entire will be placed in the record and in addition to any pertinent or even extreme switcher you would like to spend now or for the next seven days will be included in the record. At least you free to use the entire five minutes on the clock in front of you to say anything you would like to say. But i would ask as that runs down you try to wrap up your doctor english. Mr. Chairman, members of the committee, i want to thank you for inviting me to talk about how the Affordable Care act is going to affect my patients, practicing physicians who see world nations like myself, members on the panel and doctorpatient care who of rental and understand the law have already predicted some of these outcomes that you mentioned earlier. None of what you are seeing and are about to see is unforeseen. The Affordable Care act problem is not a computer site. It would be common sense to me that a program that is designed in washington, d. C. By people who dont take care of patients thats supposed to affect people from maine to oregon, and to is sort of a top 10 fashion with patients being variables can have a lot of unintended consequences. Unfortunately, those are the patients that were going to talk about and also your constituents and our fellow americans. Im a private practice doctor but half of what i do is in the saudi position. What im going to talk about is not isolated to ms certain. Ms is a disease of the brain and spinal cord and it can be very disabling. Affects about half a million americans. Most of the patients are female and affects them at a young age, 20s and 40s but in 1990s we had no medications and now we have 10. The response is highly variable and they can have lifethreatening side effects. So that ms patients require twice the number of staff enforcement of time to give. These people can can present as young teachers, working mothers who all of a sudden cant walk. Typical presentation. Ms doctors must be would identify risk factors and start to very quickly to therapy. It takes a lot of experience to know how to do that which is why we have about 5000 patients that come from 20 states and 118 or 159 counties in georgia. And the like that us as their primary care providers because they see it so often. We are now set up with the Health Care Plan where we are looking at things like metrics that different physicians will be weighed against and i think my college will probably touch on this, too. Metrics are set up by people mostly in washington, d. C. Who dont take your patients. If you comply with these metrics there are bonuses. If you dont there are penalties. Section 302, 307 of Health Care Law states some of those penalties include removing physicians from government improved approved interest. Ill give you a couple of stores but never once was a report by cms or centers of medicare and Medicaid Services, february 2012 and they said i was an over utilizer of mris compared to my peers. Mris are what we used to look at brain injury, routine protocol for ms not to do so can lead to a severely so we dont want to not do the mri. I called cs and i said, first of all, who are my peers . Are they in best doctors . No. They also include Orthopedic Surgeons. I also said, are you aware that im an ms doctor and these are routine protocol . And i got a note to that is with the adobe on the report notes that this information will be on the medicare website in the future and people would look and they would see that im a that i did not meet their standards, again, that will be on their website. I heard earlier in the opening customers about unitedhealthcare. Many have dropped quite a few providers and according to the wall street journal article, it mentions that this was in part due to managing its Network Using medicares new heights a Rating System that ties bonus payments that meet certain measures on cost and quality. Youre looking at now a downgrade physician. Im not often off the Net Health Care but im downgraded because again, been compared to my peers which are fellow neurologists. They looked at cost and quality of the want you to know that my quality was literally off the chart. It was a bell shaped curve. We were over here thanks to the wonderful staff. However, because of cost i was also too high so that was what downgraded me. The two areas of cost were, guess what, mri and the other was drug costs. Ms drugs are expensive and i have no control over that. My peers send me the most complicated cases that require these therapies. So i reached out to sea mess a few years ago with a question and i want to ask Net Health Care but beside the deadline to appeal after three weeks of colic and we still now for weeks out have not gotten through the night health care to appeal after the deadline. What i want to note as a provider am i supposed cannot take care of ms patients . Or do i just take your them but i dont do whats required and limit my mris and i medications in order to meet metrics . This is just an example. I think physicians will be stuck with the way the law is written now that we will be penalized for taking care of these more public education. I will close by saying that i submitted testimony on the state exchanges. They are going to have as equal or difficult time as farce Access Communications and to providers or not to care for certain types of patients like i to myself. I will close and again i thank you for this opportunity. Thank you, doctor english. Dr. Mclaughlin. Good morning, mr. Chairman, and members of the committee. I want to thank you for the invitation to be here, and i welcome that opportunity. I have submitted testimony which i hope you all take the time to read. It is packed with details about the nuances of how these plans were designed in architecture with perhaps improper thoughts of the privates in the battlefield. And that being the patient and the doctor. You are all generals and we respect the hard work that youve done to get this law passed. And as mr. Cummings said, even in my own family i can personally attest the few that came when my father passed away him and my mother at the age of 61 with a terrible medical history, lost her insurance because it was Company Based with my fathers company. And for four years she was essentially uninsured. So i have walked that road and i understand where youre coming from, and the president come in wanting to do something for the citizens of this nation who have such fears as well. However, in taking care of that, unintentionally, they were horrific events that are only starting to come to light which is the part that concerns me so much. In my state society in ophthalmology, i served as a third party lays on and a look at all things that insurance is due as pattern behavior and i report on them and they we take appropriate action if necessary. And most times with good negotiations we can sometimes make great strides. So im an optimist at heart and i believe that everything can be fixed. My former training in college and my graduate work was an aerospace engineer. I had hoped to become an astronaut but because of my mothers health, my life took aa vast change. I must tell you, as a little diverge and comment, that pay for performance structure that we have now in medicare for bonus pay the most physician colleagues, i think we can honestly say should be scrapped. We are trained to give our best to our patients. We are paid supposedly to give our best to patients. We shouldnt be doing metrics that have no bearing on the field that we do. In my field of ophthalmology, some of the pay for Performance Measures could include something as ridiculous as doing a body mass index. What does that have to do with the health of the i or what the guy says about other conditions in the body . Nothing. So youre spending medicare money for ridiculous measures. Taking our time in clinical practice to document this for someone who is a statistician who wants to run numbers. This is not what the doctorpatient relationship is about, and that is the only thing that this is about. My comments have no bearing on politics or what brought us to this point. We are now at tminus 20 days, and counting. The doctors and the patients are going to be having extreme difficulties in accessing care and yes, mr. Cummings, i agree with you. Its nice to carry a plastic insurance card to say youre insured. Its quite another thing to access the care. Whoever allowed the Insurance Companies to devise the current plans and how they are structured on the transport, and i might say, affecting Small Businesses as well, outside or off the train for leaves a lot to be desired. And i am glad that i was put in the middle of this. Because for everything bad, something good comes of it and that is why i am here today. As the Small Business i ensured my family and my to employees, and i had wonderful insurance. I was pleased with it. It was a Small Business plan. And i might tell you a little fact now that you will find surprising. In 2008, just as you said, those premiums raised ridiculous amounts every year. One year it was 26 for this great Insurance Plan. I was in sticker shock. It got to the point in 2008, dollars, that each individual and my Small Business plan to have a fully comprehensive plan would have cost 859. These are 2008, dollars. I did the math and i said, i cant possibly afford this. I contacted the engines broker and i said what are my options . And he mentioned the Consumer Driven Health plans. Not very fo the money with it, a little bit lyric about the concept, i explored it. It took me two years to sign on, however. What that did in those 2008, dollars, without the Affordable Care act legislation, the Insurance Company took my premium of 859 dropped it down to 300 for the same plan. So why . It did that because we had to assume a 2000. 1 pay deductible expense. Thats where the risk got put. The Insurance Company lowered the premium by increasing the deductible. We didnt have a deductible before for in network coverage. We had a very modest deductible of 500 to go out of network. And i was blessed, yes, within out of network plan. I continue to this plan for all those years, and i was pleased. I was not pleased when i received a letter dated september 21 that my plan was going to be canceled. That it was not in compliance, it said, with the aca. Im no one to judge the. I have not read that 2000 page document. Im assuming the Insurance Company is telling me the truth. They said that that plan would be replaced by something comparable, and i trusted him for that. Ive been with this company for years. I was a participating provider with them for years, just like patients have trust in their doctors are patients have trust sometimes and her Insurance Company, too, and i was one of them. The new plan rolled out. It took away my out of network benefits, which i might say i might be able to live with because under the high deductible plan, the in network deductible was 2000 for an individual but the out of network was 3500. I was less likely i must say even in my position, and certainly my staff, to go to an out of Network Physician because those first dollar amounts would be ours to bear. And being a responsible individual, you should take care of your bills. The new plan does not give out of network benefits, not just to me but to all Small Businesses. The Affordable Care act insurance do not allow for individuals out of network benefit. What i also noted was my new plan that was developed was a very crafted letter that implied that even though i was going to have an in network plan, presumably of the same level as my current day plan, but only a network, it would now be called an ato. The epo plan was not going to have the same network of physicians that my current plan did, both epo and ppo have the same network. The hmo physician or a smaller, different network. So some doctors by the contract have the ability to be in one or the other network, but by some contracts they have to be in all products. So what happens now was there was this term about i needed to be careful as the administrator and i need to inform my employees that ended to check to be sure that all of their doctors that they currently sought in network. Now, mind you, the saint Insurance Company makes it a bit difficult because you would assume if your doctor was in network before, why wouldnt your doctor be a network afterwards . But that is what the catch was. The new network was given a fancy name. It was called pathway with variations. Pathway acts, pathway acts enhanced or simply pathway. I didnt understand that. I may purchase the position. I never pathway before. I just knew that i took care of the epo and ppo levels but i took care of the hmos and the point of services. But i didnt understand halfway. I went to the website and i looked this up. And what i saw was that i should these pathways were very restricted. So we have now an inability to refer patients as an ophthalmologist, i will need a neurologist. But if that neurologist is not in that network, how am i going to give the patient with opposite neuritis and sudden loss other side of the ability to see a fine physician that i have sitting on my right . We have to fix this and we have to fix this now. We have no time to play with this. Patients lives are at stake. Acutecare situations need a specific doctor to refer the patient to. It is not enough to send into an emergency room. And by the way, many hospitals are not in these networks either. I think it is a much for your , and i hope i can count on you to fix this. Thank you. Dr. Novack. Mr. Chairman, members of the committee, thank you for having me back again. When president obama made the case in 2009 that the u. S. Needed to lower costs and improve access to health or, i agree. On june 23, 2009, i told the house so good on health that quote the system within which youre about to provide care is as important to the delivery as the people providing it. So if we are not willing to put the same level of attention to detail into designing this system, it is doomed to fail. During that same hearing congressman dingell announce that hed quote would never presume to tell someone how to take out an appendix or to replace and me, but he does not look at about crafting law. Hes been doing it for 50 years. Since then the Health Care Law has failed to deliver on nearly every promise, including if you like your doctor you can keep her. And if you like your health care, you can keep it. The problems and failings certainly extend to medicaid. In february 2013 the Obama Administration made clear their position about access to care for medicaid patients in a court filing in the ninth circuit. Circuit. Quote, there is no general mandate under medicaid to reimburse providers for all or substantially all of their costs, unquote. As Childrens Defense Fund president , Marian Wright edelman said at the same hearing in june 2009, talking to a child with medicaid who died, quote, his mother couldnt get the dentist to take in because of low medicaid reimbursement rates. In addition, obamacare architect suggests between 5080 of all new medicaid enrollees will actually lose private insurance as it is crowded out by medicaid. And in arizona, according to a 2013 report, most hospitals receive 70 of medicare rates for medicaid, which is unsustainable. While some will benefit from the expansion, the losers will far outnumber the winners. To respond to congressman dingell, it may not be saying have the surgery gets done but he is impacting who will get it and win. The access problems do not end with medicaid. As i wrote in august 2010, the health care exchangers are just a variation of arizonas 100 Medicaid Managed Care system, which the last time it was expanded has actually caused over four times what was predicted by supporters. The policies available for the exchange, even with subsidies, our for more far more expensive than democrats and the president promised. And many have higher deductibles, copays and company insurance, and very narrow Provider Networks. Orthoarizona is a group of over 70 moscow providers i am income does not a Single Exchange contract by choice but one reason is the required 90 degrees prefer policies. This means we can provide two months of care thinking the patient has coverage, and then we are on the hook for payment and the insurers have no responsibility. Orthoarizona is not alone. At least one major phoenix and Hospital System is not yet have a Single Exchange contract, in large part because the rates being offered are at or near medicaid rates. Aires we spoke with a retired professor. She feels obamacare is morally right. But she knows none of her personal doctors take medicare let alone medicaid, unwilling to make a moral stand to not go to those doctors, the professor is blamed the doctors and seeks to have government forced them and hospitals except whatever payment the government decides. Even if they go out of business doing so. I strongly suspect we will be hearing some very patient very soon from the administration. Those who do not wish to defend the failures of the law say what is your solution. I know this hearing is not focus on alternatives by want to quickly mention three areas that should contribute to the many larger proposals that do exist. This year arizona passed a first in the nation Price Transparency law. I would add with significant bipartisan support the the law extends already own in the nation state Constitutional Rights to spend your own resources for legal Health Care Services, but it also ends direct they price this Commission Based on insurance status. This law goes into effect on january 1. Orthoarizona inception in 1994 has focused on quality, utilization and costs. We have shown repeatedly repair is that local, same accountability is a reproducible and effective way to Lower Health Care costs while maintaining high quality orthopedic care. Intelligent insights, a Software Company with whom i worked, is a company that provides a platform that takes automatically collected data and provides analytics on that data combined with other sources of information. Getting better, more accurate, unbiased information in the hands of everyone from transported in the hospital the doctors for Health Care System ceos, to you, the policymakers in the country, has never been more needed. Ultimately, we must move the policies that ensure patients and families maintain control of their Health Care Decisions and that includes access to quality physicians. Thank you. Thank all three of you. I recognize that self for a first round of questions. Doctor english, you said very well in five minutes a physician, i just want to make sure i ask the question that makes it clear to all of us. Under the Affordable Care act, what was often called rationed care is occurring center because you are being told that if you take an expensive practice you can be locked out. Well, a doctor who sends off, cast off the kinds of people you do with, in other words, a doctor, a neurologist who says anyone to get ms, im going to dump them onto doctor english, because doctor english costs more and going to keep my costs down by not having the patience, he or she wins, you lose under this grading system. Undesirable either to get full care which costs more or, quite frankly, to get to the doctor at all. Thats what youre dealing with unless we make these changes. Yes. Dr. Novack, transparency is a good thing. And, certainly, the person who walks in and writes a check or hands out cash for the service should not be disadvantaged. What happens, though, if and i support that. I really, from the bottom of my heart find it hard to believe that your cash customer pays more, as they do in almost every state and every hospital in america, and they dont even know theyre paying more because theres no transparency. But what would happen to the Hospital System if everybody walked in and paid the medicaid reimbursement, if thats the lowest rate . Mr. Chairman, in my conversations with a variety of Hospital System c suite folks over the last few months, for the most part they feel that they need to be able to be profitable at medicare rates which, again, major Hospital Systems meaning they need to actually cut their operating costs by 30 . So i can speak to arizona where the average hospital medicaid reimbursement is 70 of medicare, and so, for example, for a total Knee Replacement the average repayment is 24,000. Medicare pays 14, medicaid pays 8. Were that to be extended further, there is simply no way that any of the hospitals certainly in the phoenix area and id guess a bulk around the country would stay open. I would add that isnt that unique a statement because if you look at the actuary report that came out, there is an expectation that up to 25 of hospitals wont be able to survive this decade anyway. So one of the things we have to do is figure out how to stop cost shifting, in other words, anyone including the federal government mandating a rate less than it takes for an entity to stay in business unless were willing to work with that entity to make sure they can maintain at that rate. Thats right. As a very brief aside, remember that over 100 million americans get their insurance through a selffunded payer. And so in this same example of transparency, what we found out is, again, in arizona using Hospital Association data, the commercial payment was 24,000. In arizona if you pay cash, it was 19,000. So as one of the executives of a Large Company in the state said to me in exchange for doing everything right for our patients, our employees and their spouses, were paying 5,000 extra or 0 more for 20 more for that Knee Replacement. When we look at the Price Transparency law in arizona, its created a mechanism where not only can we protect the uninsured, but ultimately, were going to protect the folks who are insured by, hopefully, lowering the difference between what their going to what theyre going to pay. One quick question, and im going to respect the five minute clock very exactly today. The fact is that youre all seeing something else, i believe, and id just like a yes or no if youve observed it. Federal reimbursement for a particular event at a clinic or a Doctors Hospital is almost always less than in a hospital. Right . Correct. So one of the interesting things is if a Doctors Hospital is more efficient than a hospital, a Doctors Office is more efficient than a hospital, we dont say, well, were going to try and get people to the most efficient rate by paying a fair rate to the doctor. Instead, we simply pay less to the doctor, more to the hospital, and its causing hospitals to buy up doctors practices which means were paying more. Is that correct in all of your experience . Yes. Thank you. Gentleman from maryland, mr. Cummingsings. Thank you very much for your, all of you, for your testimony. I appreciate your passion, what you do. And i want you to be effective and efficient in what you do. And its so important. And dr. English, you talked about the work that you do with multiple sclerosis patients. Im very familiar with that whole area. Johns hopkins is smack dab in the middle of my district, so we spend a lot of time dealing with that issue. You also discussed the costs associated with it as being about 50,000 per year, is that right . And thats a hefty price tag. And, dr. English, ms is, of course, a terrible disease, and i sincerely appreciate the work you do to treat those patients afflicted with it. And i know you have concerns about the Affordable Care act. But i have serious concerns about what happens to the 20yearold woman or the 40yearold woman who is diagnosed with ms but does not have insurance. And so you agree with the Affordable Care acts prohibition on discriminating against people with preexisting conditions, do you agree with that . I cant hear you, im sorry. Yes. Again, as we opened up, everyone agrees, i think, with the majority of your Opening Statement about the need to fix the Health Care System and preexisting conditions, so, sure. Yeah. Do you agree that if an uninsured person with ms were seeking Health Care Coverage in the individual market prior to the aca, that person would have been very unlikely to have gotten insurance, would you agree . No. In my experience, at least in my state, the majority of my patients had very good access to care. Those who were uninsured, there were methods of getting them care. Again, as you as congressman issa mentioned, im cheap. The cost of seeing me is cheap. The medications are expensive, and those are usually subsidized. Got you. Prior to the aca, Insurance Companies were allowed to discriminate and exclude them from coverage, and thats a fact. But do you think that people with ms would have been able to get Health Insurance, or would it have been so cost prohibitive that they wouldnt have been able to afford it . Well, again, i would agree with your original statement that we need to handle preexisting conditions. What im seeing here is that patients are getting, again, a card that gives them access to nothing. I want to solve the problem that you exactly stated. Im onboard with you 100 , especially since at the time it was the university of maryland that was the ms center. Now hopkins has taken over, youre right. But at university of maryland you graduated from maryland . From maryland. Oh, wonderful. Two children born in your district and fantastic. Im a maryland graduate too. Go ahead. So, yes, we needed to solve this problem. In my opinion, my experience of what youve heard here, that didnt solve that problem, and were going to see those unintended consequences in the very near future. Thank you. Dr. Mclaughlin, i just couldnt help but think about the things you said about your mother not having insurance for a short period of time. A member of my immediate family had a, they found some precancerous cells with regard to the breast and could not get insurance, could not get it. For four or five years. And this was a young woman, couldnt get it. And how do we and as i listen to you, i can see that you all seem to understand the problem here. On the one hand, we want to make sure that treatment that is provided is the appropriate treatment and it does not because we hear all these complaints about and i know youve heard em, doctors giving too many tests and all this kind of thing. And at the same time, we want to get the results so that people can stay well or get well if theyre sick. Because if they have to keep coming pack, its only going to back with, its only going to cost the system even more. So how do you you said the last thing you said, and this is written in the dna of every cell in my brain with. You said i want you to fix it. Of thats what you said, didnt you . Yes, sir. And i want to fix it. What suggestions do you have based upon the things you talked about today that you would suggest about us fixing it . Well, im glad you asked, thank you so much. You see, the real problem with this, too, besides these networks being set up that are so restrictive, i also got a letter dismissing me as a participating provider from the insurance that would cover patients on the aca. No one here intended that to happen, im sure. But that is whats happening to us as physicians. Or were being put on these panels without knowledge that we are because of contracts we signed ten years ago that had all products clauses. And you might assume as someone who owns a business that if you were paid x number of dollars by the Insurance Company to be as a participating provider currently with them, wouldnt you be offered the same fee just simply because you were taking care of the new Government Law . Well, thats not the case. Theyre coming in with fees that are sometimes 50 of medicare. And as businesses, we cant survive. So back to your question, the other problem here is these deductibles, sir. Yes, theres subsidy, but thats for people who qualify for it. And maybe this is not universal across the nation, but in a large city like new york city a studio apartment is 2,000. A month. How is a person earning 50,000 which by most standards across this country is not a terribly small amount of money but someone earning 50,000 in new york city paying 2,000 rent for a hole in the wall cannot afford a 3,000 dedeductible for a plan that is being advertised as affordable because they take the bronze plan. The bronze plan in new york state for Something Like emblem has a 50 coinsurance after that patient reaches that 3,000 deductible. What we have found when we went back to that 2008 level is that just simply having these high deductible plans slowed down Health Care Utilization because patients were afraid that they would have to pay that first deductible amount. Other patients just saw the physicians, went to the hospitals and then are in collections. We cant have a whole nation of patients in collection. And we cant have a whole nation of physicians offices and hospitals fighting the system to get paid. And this isnt fair to the patient. So when we talk or theres rumor about a singlepayer system, i think in my heart the quickest answer to help us in the next 20 days is eliminate these networks, let everybody whos signed up stay in those plans, and those Insurance Companies must be made also to be transparent about what they will pay be which, by the way, up until this point they havent. I have colleagues that have no idea that a theyre even on these panels, and they have no idea whether theyre going to be aid. So let the Insurance Companies so not to hurt their operations because we all want them to stay in business too for the rest of us, let them pay that same dollar amount as the access reference point. And then allow a negotiated fee green between the fee between the patients and any doctor they want of any value for that service. Whos hurt by that . You will then establish a competition between physicians to keep prices controlled unless you want to have one of those often spoken about concierge rackses that charge enroll practices that charge enrollment fees of 24,000 for a certain 1 of this nation. But everyone else will keep their prices in check with this negotiated amount. The doctors will be able to remain in private practice, keeping them out of the facilities that are going to cost everyone more money, and the patients will have the ability to see someone for a modest fee if thats available, or they can negotiate some other fee. Thats the only fix right now. But get rid of, please, those networks and allow the doctors to stay in business at the same time. Thank you, mr. Chairman. Thank you. I now ask unanimous consent that the article today in the wall street journal or, actually, yesterday in the wall street journal entitled dunking the obamacare stats be placed in the record. Without objection, so ordered. I now recognize the gentleman from florida, mr. Mica. Thank you, mr. Chairman, perfect leadin, putting that into the record. The title of the hearing is obamacare impact on premiums and Provider Networks. Lets first talk generally about the impact on premiums and the people who have been affected so far that we know about. So far, and the chairman just put this in, the wall street journal said yesterday that between four million and five and a half Million People have had their plans liquidated. Isnt it your observation that most of these people are now going to face a higher premium . Dr. English . And, actually, the higher premium and lower deductibility. I mean, higher deductibility and higher premiums both. Would that with be your guesstimate . Well, i think theres so much variability i think as weve talked about. We want people to have but these people have had existing plans now have been notified that theyre not getting them. And with the new mandates in that, for example, ive been forced onto obamacare. My deductibles are doubled or triple, and my premiums are up. And i think thats, what, four and a half to five well, four to five and a half Million People have seen. What do you think, doctor . I mean, i would answer that im reading what youre reading. I just cant give you personal experience with my okay. So many of them dont know yet. They dont know what theyre having. Well, again, with more mandates the costs of premiums are more. So theyve shafted as many as five and a half Million People in their premiums. Dr. Novack, any comment here . No. Clearly, were seeing that it is highly likely that the number of net losers are going to substantially outweigh the yeah. And theyve signed up a whopping 364,682. And we dont know if those are since the countrys starting out with a 5. 5 million negative number, so we dont know who those people are, the 300,000 people or so just the people who previously had insurance but lost it. We dont know what those numbers are let alone whether or not they paid for it. Okay. Lets jump to the impact, again, the title of the hearing, impact on Provider Networks. Heres another article from the wall street journal about what the chairman talked about in his Opening Statement. My state, which has many, many Senior Citizens residing in southwest florida, their primary oncologist provider was moffett hospital. Thats been dropped. Thousands of seniors now do not have access to this critical care. Is that the kind of impact youre seeing . Again, this is on our seniors. This doesnt involve obamacare coverage. This is an existing Medicare Advantage of which 28 , i guess, of all people are on. This is an indirect result of obamacare and whats going on in the marketplace. Is that correct, dr. English . Yes. I think congressman issa, again, mentioned the drafter of the law who was on the talk shows talked about paying more to see doctors on those plans. The state exchanges are set up, theres different exchanges in the state, so your providers are in a different area. You cant even move out of that exchange to see those people yeah. But what were seeing is absolute turmoil in the marketplace. Seniors now, theyre the most vulnerable in our society and probably need the most medical coverage. And instead of getting coverage, theyre searching for a doctor to serve them as doctors have been thrown out in the cold. Dr. Mcoff lin . Well, absolutely, sir. And i can tell you in new york state, were such a large state. And really the behavior of the Insurance Companies has been quite different upstate new york as opposed to down state new york. In the down state area, 2100 physicians were dismissed from Oxford United so its not just florida. Were seeing it across the nation. Absolutely. And theres a reason to that, and it is a link to the aca. The cms budget to these managed Care Companies was decreased from 17 to i believe the figure is about 8 to manage the medicare beneficiaries. Now, with all due respect to the Business Operations of an Insurance Company when they have a cut like that this their payments from the government to manage these patients, as a business they have to do something to cut their costs. Morally and ethically, none of us in here are happy with that. But i can understand where that came about. Doctor, you had mentioned the panels that are being set up, and i hear from seniors these rumors that certain ages, certain ages, certain types of care going to be cut off. Do you envision that happening . Whats the i heard rumor 73 you dont get Cancer Treatment or theres a possibility of not getting transplants and things like that. What is, what do you see gentlemans time has expired. The gentlelady may answer. May i answer . Of course. Okay. A lot of that could be hearsay. We heard rumors about death panels and things like that, but, you know, clearly rationing care is something that has to be part of this to make it work. It is not the appropriate answer, however. So im not quite sure what the facts are about what age some procedures will be limited, but i would not dare say think that that may not come. Thank you. If i could ask unanimous consent just to follow up for 30 seconds on this, because when the word death panel is used, dr. Boustany and others who are serving in congress have a real problem with it. Dr. Mcrecall lin, you do agree, i believe all of you, that medicallysensible decisions about whether to use extreme Health Care Options or not, in other words, decisions that are not always to do the most expensive and thorough do change with age and that medical doctors need to make those decisions. So the term death panel, hopefully, does not mean that doctors dont make a decision that extraordinary measures sometimes are not appropriate for the elderly. And i want to ask that because i think both republicans and democrats found that word to divide us rather than unite us on your making decisions about whats best. So just a yes or no, if you can. The simple answer is most of us who are physicians will have a talk with the family and advise them what we feel is medically appropriate at the time. And well do Everything Possible to sustain life where there is life and to allow the family to make a just decision. We hope most people will do advanced bicep fishery beneficiary notices so that the individual has that choice and takes that burden away from the family. And if theres anything we can do as a society, we should be pushing individuals to make that decision. Thank you. I appreciate that. I didnt want that to divide this panel, because i think were united on the need to fix health care. The gentlelady from illinois, ms. Duckworth. Thank you, mr. Chairman. Thank you for that comment. As someone who was accused of being involved in death panels at the va where they is certainly use they certainly use outcomesbased analysis to deem what is appropriate for veterans, that is a very sensitive statement. So thank you very much for bringing that up, mr. Chairman. Dr. English, i just wanted to follow up with you a little bit. Of you know, the goal of giving americans access to affordable, quality, lifesaving health care is critical. Its not only the moral thing to do, to make sure that getting sick in america doesnt lead families to bankruptcies, but as far as im concerned, its common sense for our countrys economic competitiveness and our governments fiscal health. I personally think that the Affordable Care act made big steps in that right direction, but as youve mentioned, there have been some real problems with it that need to be fixed. And you spoke a little bit about, um, the issues with cms, for example, and how they rated your use of mris and incorrectly compared your use to others. I myself, um, you know, understand how different types of therapies will differ and associated diagnostic equipment that you need to do to treat that. Are you saying in your testimony that the cms decisions on how you are evaluated with your use of this is it specifically to the Affordable Care act, or are you saying this is just part of their trying to improve the Medicare Medicaid system . Um, i believe that outcomes measures are a major part of the Affordable Care act, and theyre using models like that. Some of those things were predated with the stimulus package. Some of that started ahead of the Affordable Care act, but thats a big push, and when we look at the medicare cuts for the future, you know, how will we evaluate outcomes and physicians and bonuses versus penalties, thats part of the Affordable Care act. So its a combination. Do you support outcomesbased Decision Making in medicine in terms of aggregate treatment in outcomes of various treatments for your patients, this particular procedure works better than others . I know you come from a very cutting edge institution that is, according to your web page, very progressive and aggressive in treatment which, if i had ms, thats what i would want. But do you support looking at outcomes . I do. I think when they come from as far away from where the actual patient care is occurring, the more mistakes are made, and i think the aca really pushes this coming from d. C. Which was the wrong, the wrong way. I really wish specialty societies were encouraged to come up with metrics, given a few years to say what is appropriate care in ms, what is appropriate care in, you know, knee surgery, etc. , and that would have been a better way, in my opinion. So what im hearing is not so much that looking at outcomes is a bad thing, but that the way cms is going about it, um, using accountants to look at it versus relying on the Health Care Practice decisioner practitioners to be the ones who inform that practice of developing what those guidelines are so that if theyre going to evaluate the outcomes, use outcomesbased evaluations of physicians who deal with ms, they should probably have some ms decisions who would inform that process of developing those guidelines so that your use of mri would be perfectly in keeping with other physicians who treat ms in an institution like in your setting, right . Yeah. I mean, as i stated, i think the Affordable Care act, again, is going to have all of these unintended consequences because its built from the top down, not from the ground up. So whether you like the law or not, i want you to understand these things, these unintended consequences are going to happen, and they are not unforeseen. Right. Well, i happen to agree with you that we need to fix those unintended consequences, and i would love to be able to continue to focus on that. I dont know that repealing the law or unfunding it or defunding it is the way to go, but i do agree with you that there are many problems that need to be fixed. But there are good things with it. You know, i have a preexisting condition. I would assume that someone with ms would be considered to have a preexisting condition if they were to enter the marketplace to try to find their Health Insurance now. Have you had experience with ms patients reaching lifetime gaps, lifetime caps, excuse me, from Insurance Companies for their treatment . Well, first of all, i will say everybody in this room has a preexisting condition, its just that some of us dont know it yet. [laughter] good point. If everybody owned their own insurance, then once they got sick, theres no such thing as preexisting conditions. So in my practice, the answer is, no. I have never to date, 13 years in atlanta at our center not been able to get our patients with care. Even with gaps, theres been ways to do that. Be let me fix that. Im talking about caps from Insurance Companies. I think your institution does a fantastic job of raising alternate funds as a charity to provide Charity Dollars in order to cover patients who have lost the coverage from their own Insurance Companies. Thats very different. Im glad that you can get the care to the patient, but the fact of the matter is youre using other techniques. And i would think it would be better if the patient had insurance that stayed with them and would cover so they did not have to rely on charity. And im out of time. Thank you. I thank you all. We now go to the gentleman from michigan for his questions. Thank you, mr. Chairman, and thanks to the panelists for being here. Thanks for the work you do as well. Dr. Novack, let me go back to some questioning beforehand and specifically, what are your views on the independent payment Advisory Board or ipab . Sure, thank you for that question. Actually, the ipab thats supposed to be in existence, they say its not going to be involved, and it doesnt have the power to determine what care can and not be given. Can and not be given, but as i believe not only are the people on the panel with me saying but i think in the comments of the members implies that what the ipab can do is determine effectively how much you get paid for it. And if the payment for something drops to a point where you cannot stay in business or keep your doors open if you continue to provide it, less of it is going to be available. So i think its a bit of semantics, and i think some of the words can cause division, but the ultimate reality and the ultimate goal of the independent payment Advisory Board if medicare expenditures go up faster than inflation or 1 above inflation is to reduce those costs. And they are going to go where the money is. Certainly if my world taking care of number of fractures and acute injuries i dont have luxury of longstanding experience with patients and families. You need to be able to get data so families can get the best decision. Do you have any evidence, doctor, that competition and choice is better way to increase value and reduce costs than government bureaucracies and their expertise . Sure. Obviously you have examples in certain parts of medicine where that does exist but i think even, we can look for example, in california, more recently with what wellpoint has done with reference pricing for joint replacements and by changing the structure, they have lowered the cost of joint replacements by 20 i think in less than two years. The idea of creating transparency and providing people, giving an opportunity to get new, creative ways to Bundle Services together you can provide high quality care at lower cost that ultimately results in better patient satisfaction. Okay. Thank you. Dr. English, just to make sure its clear, where you stand, will obamacare limit your patients treatments . Yes. In your testimony you mentioned 10 medications for ms patients. Washington post article from two days ago said one way Insurance Plans under obamacare are keeping costs low is by not covering widelyused ms drugs and requiring doctors to prescribe drugs in a certain order. Which would compel patients to take drugs more toxic to them potentially. Have you found that to be the case. This is our major concern. I cant impress upon you enough how variable patients are with drugs they need and without the ability to quickly move from one and switch to another. If i cant get that anymore that will fet me out of medicine. Not reimbursements. What does that to for your patients. My teacher is paralyzed and i know i can do something for her and i watch her stay paralyzed. That puts them at risk at the very least dont impact them postively and let alone produce the change that is necessary . Correct you. Stated obamacare punishes you because you care for the most vulnerable patients. How does it do that. Well lets look at that i think congressman issa had mentioned too, or might have been congressman cummings, if our Center Closed down and i was looking for a job at a hospital and 5,000 expensive patients were coming that was going to bankrupt my hospital, which ones do you think would sign up to take me on . I want to work, like you mentioned in maryland the trauma center, i learned there. That was incredible taking care of the sickest of sickest. I love doing that. I dont see how under these payment models that any Hospital System is incentivized by taking care of sickest patients. It will be disincentivized based on outcomes. What were looking at a twotier, those that cant afford it, specialized treatment have the money to do that and all of the rest of us . Correct. I thank the gentleman. We now go to the gentlelady from new york, miss maloney. Thank you, mr. Chairman and Ranking Member for calling this hearing and i thank all of the panelists and for all their testimony and participation, particularly dr. Mclaughlin who is from the great state of new york which i have the privilege representing a portion of it and i do believe youve raised some important concerns but i truly do believe that the Affordable Care act really is important legislation and it is by no means perfect but it really addresses some of the massive deficiencies in our nations Health Care System such as covering preexisting conditions, and providing coverage to over 30 million americans that did not previously have coverage. While i do want to get to your concerns and understand them, in a deeper way i would like to take a moment to highlight some of the successes of the marketplace in my home tate of state of new york. Earlier this week the new york state of health reported that over 314,000 new yorkers had completed their applications for insurance and over 100,000 new yorkers have enrolled for coverage starting on january 1st, 2014 and i understand that 70,000 selected a private Insurance Plan and one report stated that new york has the second highest raw enrollment numbers of any state. So there are some successes but i do want to acknowledge that there is always room for improvement in any massive, new change and something as complicated as health care is going to have to face many improvements and we need to be willing to Work Together on both sides of the aisle to correct deficiencies and challenges that we see during this implementation process. But, dr. Mclaughlin, i had like to understand the concerns that you raised today and i want to make sure that i understand completely your situation. You stated that you received notice last month from an Insurance Company stating that you would not be extended participating status on the new Insurance Plans in the pathway network. Is that correct . Yes, councilwoman, thats correct. And what about other insurers . Did you get similar letters from other insurers . Well the way this works is the Insurance Companies can only approach those physicians that happen to be already networked with them, under contract to them. So for instance, i am not in the emblem system so they can not approach me or do anything to me involuntary littlely. That is important to understand. But can you approach them, another insurance . Would you be willing to participate in any plan on the exchange . Can you, can you approach another plan . Im assuming that that door may be open, however, what is clearly evident by the plans that im already under contract to blue cross for the main one, they made the decision, for whatever reason, that they had enough participating physicians to form this pathway network. Which i might add by just looking at the opt poll gift search ophthalmologist serving manhattan in that list, came to less than 150 names, most of them were in solo practices with no affiliation to large Group Contracting forces. So these physicians happen to be under contract to that company, for the lowest fee reimbursement for the same service that another physician whose part of a Faculty Practice or a large Group Practice would get. And as insane as that sounds for doing the same work, physicians are paid differently in the Current System depend on how large of a group you belong to and what negotiating power comes with those numbers. Well, have you appealed the decision . I know that they are trying to save money and in fact the new york state testified or release ad report saying that the people that had enrolled, 100,000 were seeing premium rates are as much as 53 lower than the rates in effect in 2013 for comparable coverage. So that is great news for them but they are looking for service that is are more affordable but you can appeal these decisions as you know and as you know, particularly in new york state, it is being run by the state and state insurance is regulated by the state and you can appeal to the new york state insurance commissioner and i would be happy to work with you in setting up such meetings if you would be so interested. But have you appealed, the decision . There was not an opportunity mentioned in that letter for appeal. It was a unilateral decision. There was no notice in there that i even had a right to appeal. I must say also that i had an amended contract to my United Health care participating status and that also said that because i was not in an Oxford Liberty Current Network i would not be put on the Affordable Care act insurances. So that was in, an automatic opt out. So if, not an automatic opt out. I wouldnt be in it. And for those doctors who were in the Oxford Liberty current plan, once they see their fee schedule they could opt out. You can also get a navigate tore to help you or broker to determine what plan would be best to help you with your appeal but i would be delighted to help you with an appeal if youre so interested. I thank the gentlelady, we go to the gentleman from eke home the head of our energy subcommittee. Mr. Lankford. Thank you, mr. Chairman. Thank you for what you do, taking care of patients. Youre going through a lot of paperwork and process right now and i can imagine the incredible frustration a new regulation, new rumor, trying to take care of people and patients what you love to do. I want you to know from us we appreciate what youre doing and how youre trying to focus taking care of people. The problems are very, very real. Yall are experiencing on the ground. We hear about them in our offices all the tile. The numbers are out for the first two months of enrollment in the Affordable Care act in my state in oklahoma. Theyre now up to just over 1600 people have been able to sign up in my entire state. To give you a point of reference, 1400 Companies Got a letter two months ago that their insurance was canceled because they were in a Small Business group just in Oklahoma City. Just in one town in my district 1400 companies received a letter, all on the same day, they have all been canceled because their association is no longer legal and theyre out looking. Now weve had 1600 people total in the entire state have been able to sign up. One of those was a small car dealership in Oklahoma City with 14 employees. They now are having to select a different insurance policy, a different company. And as the owner of the car lot told me, we can either select a plan that is much more expensive than what we had last year but keep our doctors, or, pay the same as what we had last year but weve all got to switch doctors. But we cant do both. We cant both keep our plan and keep our doctors or keep the price and keep our doctors, we have to choose on it. It has been a very difficult process for them as a Small Business as facing a lot of Small Businesses across the area. Dr. Mclaughlin you mentioned that even with your own practice. That is one of the many big issues out there. Let me ask a question about process. By one count this law creates 159 new boards or agencies. We asked the Congressional Reserve Service to try to determine how many boards or agencies are created by this. They said it is not knowable at this point exactly how many. Dr. English, you mentioned multiple times, the difficulty of decisions being made in washington, d. C. And getting passed on to you. I have direct family members that have ms and im very familar with the process and drugs and what is going on. Im trying to process through 159 dirt agencies all setting these different rules and you get instructions about how to take care of your patients. What does that do for you daytoday . Well let me give you an example. I have for the first time in my career had patients who are healthy previously, not walking, et cetera, on a medication doing great who are crying in my office. People are really afraid as youre seeing as well. They dont know whether their medication will be covered. Im filling out forms, patients who are stable on medications but theyre not on the lists anymore of the restricted provider list. Talking about people who are currently under medication, doing better, stablized in the process instructions are coming down to them saying we may have to switch the regimen for treatment to a different drug or different treatment regiments when theyre currently stablized right now . Correct. That sounds like someone in washington telling you how to take care of a parity that is doing well with their treatments and saying were going to experiment with a different way to do this with your patient. And then in the Georgia State exchange we have no idea what medications will be available to those patients. Then again were less than a month away coming into us on those Insurance Plans. In the Current System as it has been set up, there is a discouragement to take the more complicated patients. So the more complex the cases, the more that is disgorged financial ally and every other way from the federal government and the civil, is that correct . The Current System, the aca, the Current System . Current system, aca coming at us. As i discussed in my testimony there will be many things discouraging me from taking care of the sickest patients yes. Dr. Novack you mentioned before all the patients on medicaid and reimburse rates and. Half of the people signed up for insurance nationwide are not signing up for private insurance. Theyre in state medicaid programs. While they have access to care on that, what are the issues theyre going to face in the days ahead . Well i think the first issue, again, i think the crowd out issue is something we really cant discount. Jonathan gruber, really the architect of romneycare and architect of the Affordable Care act, his own research that he did originally in the 90s and then repeated in 2007 showed half the people who ended up on the Government Program lost private care. Again the more recent study from i believe one of the boston area universities showed up to0 of the people who will get access, who will end up on expanded medicaid will lose private Health Insurance. When you look at smaller networks, when you look at lower payment rates that discourage people to accept it or create long waiting lists to get access to it, i think, there will be a few winners but ultimately the number of losers will be a lot greater. Well see in orthopedics in arizona access to certain kinds of durable medical equipment, access to getting physical therapy after an injury, in terms of limits, access to certain medication, all of these are severely restricted under medicaid relative to what was existing in the commercial market. There is tremendous difference between the hope what it would be and reality actually it is on the ground. With that i yield back. I thank the gentleman. We now go to the, gentleman from pennsylvania, mr. Cartwright. Thank you, mr. Chairman. Thank you for all the witnesses appearing today. I believe the Affordable Care act is a landmark law. It is obviously by no means perfect. It needs a lot of work but all of us need to roll up your sleeves and Work Together to make it better. I had planned to ask all of the witnesses questions about Provider Networks including dr. Thader but unfortunately the majority didnt inform us. They decided to change the Panel Structure today. They didnt inform dr. Fader either. He was here and ready to testify at 9 30 and i would say that the fact that she is here an waiting for the second panel while were not including her now is disappointing. But dr. Mclaughlin, i was interested in your testimony and your comments and i would like to follow up on some of the things that congresswoman maloney covered with you. Its my understanding that, well, a large part of your testimony has surrounded the fact thaw got dropped by empire blue cross and blue shield, right . As a participating provider in the new plan that is they are developing for Small Businesses off the Affordable Care act exchange, as well as those serving the aca. All right. And just to, not to put too fine a point on it, youre still waiting to hear about larger employers, whether you will be included in that coverage . No, im completely in that. You are in that. For now, yes. So, we want to look into, you know, why these things happened. You got less than a full explanation from empire blue cross and blue shield, am i correct in that. Yes. And everyone whos on my associated hospital staff had the same letter. This is not an isolated letter. This is clear across the board. Right. So, if im not mistaken, you got the empire blue crossblue shield letter on october 29th of this year, am i correct in that . Yes. So i want to, talk about what efforts youve made in couple of months since then to, to go over what the situation is and see what light you can help us shed on the situation. So, i think you said you saw about 150 names of opt that poll gifts who are included in the system, is that correct. Thats correct. Did you make an effort to compare different sets of facts, for example, compare your own credentials with those of the other opt that poll gift ophthalmologists who made the list . I assume youre board certified, for example. Were all equal. What it is base on the original fee net schedule for the networks were in. If youre a complete solo practice practitioner, not part after large group who negotiates fee schedule with the Insurance Companies, you get what is called the standard rack rate from the Insurance Company and those preferentially are those doctors on this network. They are the lowest paid of the physicians and that is clearly what the decision is. And i dont, i dont mean to belabor the point but are you saying you havent really engaged in a comparison of your own credentials of the 150 . There is nothing to compare. This is across the board. Everyone who is at my hospital was not offered the status. We are all equal rankings, do the same work, the same exams. That is not what this is about. So you think it is more about pricing . It is about money. It is clearly about money. So. He well lets take that then. Have you compared the pricing, have you compared how much it costs, people that to get treated by you and the other people who got dropped versus the people who got accept into the system . Well, first of all i would have no way to compare that. There are quite a bit of regulations on us also as far as fee schedules. We have antitrust regulations and we are not allowed to collectively negotiate. So in honesty i would have no idea to know pure facts as to what someone is being paid compared to myself. Well, obviously somebody engaged in that comparison. Thats why some people made the list and some people didnt. Thats right. That maybe for you to find out. Thank you. Youre welcome. But another thing you mentioned was this idea, and i had heard it before, if you want to protect yourself as a physician, you want to join groups and the bigger group youre in, the more protection you have as we enter the new age. You are a solo practitioner, am i correct in that. Thats correct. So, intertwined with that thinking you have the least protection of anybody entering the new age. And i i want to ask you, hadnt you heard this . Hadnt you heard what i had heard, you will protect yourself by joining medical groups . The gentlemans time is expired. The doctor may answer. Let me just say this with you, i had been for eight years fulltime faculty member at a Major Hospital in new york and enjoyed my time there but i also saw the benefit of being able to be a physician, to make choices for the patient care in a way that i see fit and the best care that i see fit for the patient that works for me and my patients. I dont want to give up that freedom by joining a larger group that has a nonphysician administrator telling me how fast i have to see a patient and what i can or can not do for them. That is a choice i have in this country thank god, and i want to keep it for my patients sake. I thank you. We go to somebody who knows about patient care, first on the list, dr. Gosar. Thank you, chairman. Dr. Novack, can you discuss for me the confusion your patients are peel feeling about obamacare, your services and also touch a little bit about urban and rural were from arizona. So there is definitely a dichotomy going on here. Sure. I think that theres one term that regardless of your Political Party preference that describes whether it is providers or patients or administrators or staff, its confusion because no one really knows and i have 100 patient as week coming through, the bulk whom will actually askhat question because they know im involved issues and my answer is,t dot know. Ns will be available. Ey dont know what services will be available. They dont know what medications are going to be covered. They dont know what hospitals they will be allowed to go to. So the issue here is, basically abject confusion. And no one knows what will happen january 1st. And, to say that that was an unforced error, because of political realities, the great tragedy are really the 10 of millions of americans and hardworking American Families that have been suffering emotionally because of uncertaiy the law created because of work that was not done, the lack of transparency,e regulations. I have patients who work for Insurance Companies and i was hearing from them throughout the summer that, large porons, th didnt even know the requirements that they were going to be forced to put into the software that they had to write. Were hearing they are being required to be responsible for the data on these servers but not allowed to get access to the servers to test the integrity of the data theyre being held responsible for. So at every single level, unfortunately, the claims that were made to pass the law are not the reality. And the losers, this is not about the three of us up here. It is not about the dentists. It is about the fact that we have, for every, we do need to do something about preexisting conditions but that was a small part of the population. The same amount of people basically that folks have recently been saying, oh, its a small numbers dont worry about them, getting their policies canceled, it was really only 10 to 15 Million People that had chronic conditions. We could have addressed that. Instead we totally uprooted essentially everybody. Real quickly about the Medicare Advantage issue. There is nothing tank against al to the change in the Medicare Advantage as regards the Affordable Care act. Remember the Affordable Care act cuts between 130 and 150 billion out of Medicare Advantage this decade. That is why youre seeing cuts to Medicare Advantage networks. So when you are talking about preexisting conditions, i will ask y and dr. English, we exchange ad the memberked about a prejudice to preexisting conditions we just traded one prejudice to another, would you agree with that. Correct. Dr. English, would you agree with that . [inaudible] correct. You havent, in my opinion increased care. You have shifted care. That is quite obvious. I will get to that. I really want to applaud you. I have family members and dear friends that have ms, so thank you very, very much. There is this prejudice now because were talking about acute care versus chronic conditio right, dr. Esh . So youre handicapped when were talking about chronic care, are we not . Correct. And so, were asking to you decrease time, reduce reimbursement. Reduce the possibility of drugs. Reduce your opportunity to standardize, or t individualize individual treatment modalities, t i got a question for you. Did you see any tort reform in this bill . No, sir. Hey, dr. Novack, did you see tort reform in this bill . No. Dr. Mclaughlin, how about you . Absolutely no. Have you ever heard of solving a problem without putting everything on the table . Dr. English. Say that again, please . Have you ever heard of solving a problem by not putting everything on the table . No. It is foreign to me. The law did actually approve the opportunity for some Demonstration Programs for medical Liability Reform but in the law, the plain language of the law says you may not do any Demonstration Program that includes any limits on noneconomic damages. So. The constraints were fairly significant. You know, dr. Mclaughlin, i want to go back to reducing time for physicians to see their patients. Were reducing reimbursement rates. Were reducing panels. All choreographing hurting the patient, would you agree. Absolutely. And you made the comment that you want to Practice Medicine your way. You want to individualize that, take your time, how you see fit. Individualize the treatments, right . Yes, sir. How do you feel most patients would like, would they appreciate your thoughtfulness . Absolutely. Because over and over again i will have patients returning to me, perhaps even out of network as they go to some larger Group Practices where physician extenders are employed to process patients literally through a quicker Assembly Line so that that facility can reap more benefits costwise out of the poorer reimbursements. But they may actually only have two to three minutes of facetoface physician time in that. And, most people are often told to bring a companion with them because when youre the one seeking care, youre only observing half the response from that physician and youre losing the other half which is why most of us actually face umpteen phone calls after the fact because there is something they forgot to ask or something they didnt understand. So you can only imagine how that problem is magnified with only two minutes of facetoface time with the doctor. Patients are generally nervous under those conditions. Thank the gentlelady. Dr. Novack, i want to make sure the record is clear, when you were talking about what wasnt in the act tort reform, prohibition on mcra like they have had in california since the0s, limitations things over and above full compensation for actual losings correct. Correct. There are a little money for demonstration projects in the states but in the law it says those demonstrations projects may not include any demonstration that is include limits on noneconomic damages. Thank you. Gentleman from mr. Nevada. Thank you, mr. Chairman. The title of this hearing is obamacares impact on premiums and Provider Networks but the majority of the opening testimony has largely focused on inadequate reimbursement from medicare and medicaid which private Insurance Companies use in large part to set their own rates. So werent the issues related to reimbursement rates under medicare and medicaid issues for the Provider Community before obamacare and the Affordable Care act were even law . Yes or no . There is no question but i think, and ill speak a little bit, if, the title is, about provider and Provider Networks we need to look at, this is not about us, right . It is about how do we get the maximum number of people the best Personalized Health care we possibly can and the practical reality is our large group employs 500 people. With all due respect, my question was, are medicare and medicaid reimbursement issues issues that the Provider Community were dealing with prior to the obamacare Affordable Care act ever becoming law, yes or no