Nice to see you. Melissa attias is making her first visit to newsmakers. Dr. Wall, we can we start our program about the expected consideration of what is called a doc fix. I know your organization does not prefer that term but i am sure many cspan viewers have heard that in washington parlance. Tell us what this issue is. Dr. Wah we are talking about Sustainable Growth rate which has been in place for a long time. It was originally passed in 1997. It was thought to be an effort to control the costs of the Medicare Program. It resulted in about 17 patches over the last 10 or 12 years. Each one of those paid for the one year period, not the committed interest, like a credit card, on past things. By kicking the can down the road each year, congress accumulated interest. Now april 15, if the senate does not act, there will be a 21 cut in physician payments, which is the acute related interest of all these years of kicking the can down the road. I want to talk about the term doc fix. As a physician, i am biased against that, primarily because it is not doctors that need to be fixed, it is medicare that needs to be fixed. We are searching for a fix in medicare that will stabilize the program for the future. The term doc fix has been picked up by journalists. Whenever i get a chance i try to correct it. It is really medicare that needs to be fixed. Host one of the implications of the Payment Program is not adjusted is that fewer doctors may take medicare patients . Dr. Wah yes. If doctors are faced with a 20 1 cut in their payments from the Medicare Program, it will be more challenging for them to continue to see medicare patients. If that happens, patients will have a hard time finding doctors that can take care of them. They may have to drive further or call more doctors offices and it will just ea more challenging environment for patients to find the care they need. Host gnome leavy. Noam i think it is fair to say that be put the presumption is that the summit the senate will act. I know you say it is by april 15. The smart money is a will be later than that. Can you talk further about what is in the package . What are some of the changes envisioned in the way medicare pays physicians . It is fair to say they are substantial. Dr. Wah right. Before i go i want to point out that this program we are talking about in eliminating the sgr not only impacts medicare patients but i have served 23 years little under in the u. S. Navy. The Tricare Program that covers the Service People and their family members is also impacted by the sgr. By law, the Tricare Program has to follow the same rules as the Health Care Medicare program. We are not only talking about medicare, we are also talking tricare and military. To your specific question, yes. Though the headline is about the sgr illumination in this bill, there is more than just the elimination in the sgr. It is in place a number of programs and policies that will offer us as physicians and the entire Medicare Program to take better care of the medicare and tricare patients who are our responsibility. It harmonizes some of the many programs in the centers for medicare and medicaid, such as such that we often have to report the same information multiple times slightly differently now. By harmonizing programs, you will d keep decreased the initiative burden on coming reports. Your port one and medicare can use information multiple times. It we authorize the chip program for children. Though we are talking medicare and tricare patients primarily this bill will provide additional years of coverage for children under the chip program. That is another major component of the legislation. It also does a number of things i think will alleviate the uncertainty and therefore provide stability in the Medicare Program. With the Current System of patches at the last minute every year there is a high degree of uncertainty in physician offices where they do not know what their revenue will look like from medicare. It looks like it will be 21 down now, or it may be the same or a small increase. That does not allow a Physicians Office to plan or innovate or make the kind of changes they would like to improve the care of their patients. You mentioned that there have been 17 shortterm patches for this. Last year, everyone was optimistic that there may be a permanent exit when the committees came together and agreed on the policy parameters to it again got kicked over. When did you realize this year that it could happen . Dr. Wah you bring up a good point. Last year, both houses of congress, the three committees of jurisdiction, both sides of the aisle came together in a very collegial way and hammered out a policy that would lead to the elimination of the sgr improvement to the stability of the Medicare Program. That is a major step in any legislative process. Getting the policy hammered out with a key step in progressing forward. Unfortunately, they did not pass it last year. We felt encouraged by the fact they made all that progress of coming together on the policy aspects. The window opened again this year for them to complete the journey, which is where they are now. We are pleased to see the house passed hr2 with more that 300 votes, which is suspect which is a spectacular achievement. 392 votes for this ale. It shows the overwhelming degree of support and providing stability in medicare for our patients eliminating sgr, and improving care in the future. When i was talking about payment reform in the white house president obama also stated he was in favor of the legislation. He is awaiting the bill to come to his desk. He will sign it. We are very encouraged about these signs. The passage in the house, the president announcing he is waiting or the legislation. For the legislation. Noam i know you and many of the leaders of the house had hoped the senate would actually act 10 days ago, before they left for their easter break. As you know, there was difficulty in getting a not senators to upgrade to upgrade to bring the bill quickly. One of the objections was that of this ease of legislation is not technically paid for. It adds to the deficit. A number of conservative republicans and groups had said at a time when washington ought to be focused on the debt, we should not be doing anything that adds to the deficit. I know there are efforts to overcome that in the senate next week. That remains a concern for quite a number of lawmakers. What do say to those who say that this is not there, to simply load up more debt to pay doctors differently . Dr. Wah i think there is a lot to the projections out there on how much this will impact the deficit or the debt. I see a lot of positive things that will save money over time. As we keep patients healthier and provide better care and they have Better Outcomes in their health and a more cost efficient and costeffective way, the overall system saves money. This legislation was crafted over hard work by the by diligent people, to say that they want to increase cost efficiency and the care of patients that we will see in the long term. The current process with these 17 patches, we have spent 170 billion to perpetuate a problem everyone agrees we need to eliminate. That is not money eight best spent either, to spend money on those 17 patches. If you want to do the fiscally correct thing, we have to stop perpetuating a problem that all of us agree we do not want. We have to do it in a way that is probably going to be a compromise on all sides. We have to hammer out a policy and piece of legislation that everyone can live with and support. Melissa there are expected to be democrats to push for amendments in the senate. For example, if they want another four years for the Childrens HealthInsurance Program versus the two years included in the bill now if any of these amendments are adopted and there is a possibly devote, how concerned are you that it could unravel . Dr. Wah we are big believers in momentum. Things moving forward is always a good thing. We recognize the senate has of the prerogative and will exercise that to look at the legislation and proposed amendment as necessary. Our main focus is we get this legislation are crossed the finish line before the april 15 deadline, when this huge cut will happen to Physician Practices and impact the care of our medicare patients out there. We recognize there are a lot of processes in washington that have to be gone through, but we do not want to lose sight of the big goal, to pass this legislation by april 15. Noam i would like to talk about a particular part of this legislation that deals with how patients are cared for and how doctors do their job and what it means for patients. You alluded to this earlier. There has long been a concern of what our Current System of paying physicians for every piece of work they do. A fee for service. A lot of people think it is inefficient and creates the wrong incentives for physicians to do more and not think about the outcomes, but to think about what sorts of things they are doing for patients. Can you talk a little about what is in this legislation to address those concerns and whether or not the things in there are adequate to take medicares system of paying doctors to the next level . To a place where the program is really catalyzing categorizing the changes that people think ought to be made in the Health Care System to better care for patients. Dr. Wah i think of things we are talking about here are things that have been demonstrated to potentially work in improving Health Outcomes of our patients and decreasing the expense of our patients. All this talk of payment form to me is unbalanced. I want to talk delivery reform. How do i deliver care to my patients that has the highest outcome of their health in the most cost efficient way. Talking about payment seems out of order by recognize the two are intertwined and have to be discussed together. Some of the things we have seen our patient centered homes. More care coordination. Will refocus more on the patient rather than the deceased part of the patient. See the patient as a whole. There has been a lot of the legislation talks about supporting things like Accountable Care organizations. Patient centered homes. More care coordination. These payment policies that will support those kind of innovations will lead to Better Outcomes at a lower caste lower cost to the overall system. Those are the things in there now that we think will be positive for our patients and the longevity and stability of the Medicare Program. Melissa i would like to give it to another Big Health Care issue that is one to be on the radar. The Supreme Court is expected to rule on a challenge, the subsidies under the Health Care Law that are given to people in states that did not set up their own insurance exchanges. How do you think congress should be preparing for this and what kind of concerns you have, representing the Position Community . Dr. Wah Congress Needs to focus on getting this pass on april 15, first and foremost. The ama was out front and vocal about the need or more insurance for our patients. We knew and as doctors we see it. Patients to do not have Insurance Coverage live sicker and die younger. We are in favor of more of our patients having Insurance Coverage. This summer with the Supreme Court decision, we want to make sure in whatever way possible, our patients have better coverage because with that they will have healthier lives and it will be less expensive to take care of them, because they will not come in at the last minute when they are very sick. They will be able to take care of themselves earlier and seek care earlier in the process. We have been upfront about that way before the discussion was as widespread as it was in washington. We have already been talking about the need for our patients to have insurance through a public relations, talking about the voice of the uninsured. We tried to give a voice to those people who did not have insurance. Noam the ama did back the aca, though i know it was a controversial decision among your number share. As the politics of the implementation of the law has progressed, we have seen a divergent experiences among the states. Some have expanded medicaid to provide the kind of coverage we were talking about. Some have not. What is your feeling about the role that organized medicine can play in those states where there has not been advocated expansion and where, potentially, you may have states electing not to do whatever is necessary to continue insurance subsidies provided by the aca, depending on what the Supreme Court does. What is your feeling about medical society in texas or louisiana or states that have strongly oppose the Affordable Care act, what is your feeling on organized medicine in those places . Dr. Wah we, as physicians, we want to take the best possible care of our patients. We will advocate for policies that we believe lead to the best care and health for our patients. That may vary in different regions and segments, but at the top line what we are all interested in doing is finding a way to take the best possible care of our patients. How we advocate it is centered on that principle. How to keep patients healthy and a cost efficient way. Noam what does that mean from a practical standpoint and some of the states i mentioned . Dr. Wah it means that are going to be geographic variations on how people approach, depending on the nature of that geography. We are 18 one of the strengths of the country is we have a big spectrum of plurality. We do not all do exactly the same thing in exactly the same way. It is a major strength we will always cherish. The way we approach the issue may be different but the goal is the same, to get the best possible care for our patients. But there will be different ways to approach which we have to recognize and support. I think any physician would say is to advocate on their behalf to make sure they are keeping them as healthy as possible and getting them as healthy as possible in the most cost efficient manner. I do not have a single answer for that. I do not think there is a single way for that to happen. There are many different options and avenues to take that process too. As long as we remember our collective goal, there is a lot of power in the unity of effort. Unity of effort can be powerful as my time in the military taught me. I think we will all be well served with unity of effort. Melissa beyond the medicaid expansion, there is a provision that expired at the end of last year that gave primary care doctors and medicaid additional money to get them up to the medicare rates. How doctors and i want to know how doctors and patients have been airing since that money owed since that money has gone away . Dr. Wah i think that was a thing that was successful. We continue to see benefits from that expansion in the medicaid system to come up to medicare levels. We are seeking to have that increase maintained and going forward. We did see more patients getting coverage and access to care they need. That was a benefit and we want to continue to see that happen. We recognize more legislation would have to come road to accomplish that. In terms of the impact of that not happening after the first year, it is too early to tell. But we did see a positive impact from that happening the last couple of years. Noam to followup, do you get any sense that there is any more openness to providing the funding that would be necessary to continue the augmented payments to physicians caring for medicaid patients . Dr. Wah it is not a completely closed matter, at this point. I do not know there is one thing i can point to buy think it is an ongoing discussion. We want to figure out a way that the system leads to the best possible health of our patients in a way that society can support it. Melissa another issue i believe you guys weighed in on is education for medical students after they graduated medical school. I know there was a call for feedback on how to shrink that program. How do you guys want that to go, and with the sgr built it is expected to be one of the only Health Care Bills moving through congress, if you expect any opportunities to move through on that front . Dr. Wah we are concerned about the fact we have rising graduate numbers out of medical schools but the place they go after they graduate is residency programs. Those slots have stayed stable over the last several years. We have more people graduating going into an area with the same number of slots that have not risen. We are worried that people will graduate and not have a place to train afterwards. We are exported as we are supportive of expanding gme we are supportive of expanding gme, to find a way to expand the number of gme spots. There is a societal benefit. 90 of aids patients get taken care of in a graduate medical care program. 8. 4 billion of Charitable Care gets delivered in gme programs. Society benefits from these and it is important to maintain the health of these and expand them because they are such a good benefit. Host four minutes left. Noam let me return to the sgr. I think cspan viewers may appreciate the politics of the sgr as a vehicle for advancing other health care priorities. There is some concern in washington that now that this is off the table, or may be off the table soon, i know it is good for you and your members, but it removes something that has allow congress under a fairly regular basis to revisit Health Care Issues that may need attention. As you report, past april 15 or whatever when the senate may actually act what you see coming up as real legislative priorities for the ama in dealing with all the other Health Care Challenges the country f