Good afternoon, and thank you, everyone, for joining us today. Im mary greeley, president of the Health Care Leadership council. The hlc is a coalition of leaders there all sectors of health care. We have hospitals, insurers, pharmaceutical companies, medical device manufacturers, Health Product distributers and many more sectors represented as well. But today i am also speaking on behalf of a campaign that we call protect my doctor and me. Over 670 organizations from throughout the country representing patients, health care providers, employers, americans with disabilities, veterans and others have formally urged congress to repeal the independent payment advisory board. Today were going to share some information and perspective on ipab and what it means for the Medicare Program, for beneficiaries and for those that provide health care to those Medicare Beneficiaries. Let me begin by introducing our panel. We have dr. Alex [inaudible] president elect of the American Association of neurological surgeons. Hes also chair of the department of neurosurgery at virginia commonwealth university. And he is a director of of the american board of neurological surgery. Bob lancato is the executive director of the National Association of nutrition and aging services programs. Hes also the Board Chairman of the American Society on aging. Bob has spent nearly 20 years in the executive and legislative branches of government including as senior staff of the House Select Committee on aging. And dr. Bill atkinson, he comes to us today from North Carolina where he is a widelyrespected as a champion of health care change and improvement. Hes been a hospital and health care ceo for over 30 years, and most recently of the wake med system in raleigh, North Carolina. Now, im going to turn to our expert speakers shortly, but first id like to welcome erin bill who is legislative director and counsel for congressman roe. Congressman roe has been a leader of the ipad repeal ipab repeal effort. And again this year he is a primary cosponsor of the house legislation that would eliminate the independent payment advisory board. So, erin, would you please share some of your thoughts with us. Thank you, mary. To start, ive got a big pile of business cards up here in case anybody has any questions and you want to reach out to me afterward. As mary mentioned, i work for dr. Phil roe, cochair of the gop doctors caucus, and hes also the sponsor of h. R. 849 in this congress which is aiming to repeal the ipab. Dr. Ruiz, from california, is our democrat lead, and were really excited to be working with their office on trying to make this actually happen this congress. I think we have a good, good shot of doing that. I do want to start out by giving a quick shoutout to the neurosurgeons because they asked that our boss put together a blog post that just went live this morning. So if you go to their twitter page, its neurosurgery, and you can see my boss wonderful blog post. The biggest thing that i have told people when theyve asked me about ipab is that this is not something that would affect just republican beneficiaries, its not something that would affect just democrat beneficiaries, it really is a bipartisan issue that we need to get support behind repealing the ipab. If it goes into effect, it would make drastic and arbitrary cuts to medicare that we would really have no control over any of it. Theres no judicial review. Congress has basically ceded the ability to make medicare cuts to an unelected group of people who arent working in medical practice, arent really doing anything by law. So if we can get this repealed and medicare cuts need to be made, then congress is the group that would be doing it rather than 15 unelected bureaucrats. Beyond that, were really just trying to get as much support as we can. I believe we have 21 cosponsors right now on 849, and we are up to three democrats, so im very excited about that. Think push that you guys any push that you guys can make with your bosses with advocating to other members of congress, wed really appreciate it. I finally have an updated colleague for this congress. It took me a little while, but im happy to the share it with anybody who may want it, so is please feel free to grab a card, reach out to me, and we look forward to, hopefully, having the ipab repealed this congress. Thats really about it. Well, thank you, aaron, for that update. Now, before i turn to our expert panelists today who are going to discuss the potential impact of ipab on patients, physicians and hospitals, im going to take just a moment or two to go over the basics of how ipab actually works and what it would do. So were going to do a little ipab 101 here. Now, im not going to delve into the weeds on this, im not going to go into excessive detall, but we have included the slides that ill be presenting in your Materials Today so you will have those. So even though it has never been activated, ipab has been with us for about seven years now. On paper it is to be a 15member board nominated by the president and then confirmed by the senate. And its supposed to be comprised of people who may not have any other position or employment while theyre serving on the board. There was an early criticism in the fact that this provision would make it extremely difficult to find people with expertise in health care and ask them to, essentially, give up their professions to serve on the independent payment advisory board. Now, the legislation creating ipab established arbitrary growth rates for medicare spending. In 2018 that rate is the gross domestic product, gdp, plus 1 . If the actuary for the centers for medicare and medicaid services, cms, determines that per capita medicare spending will grow faster than that established rate, then the ipab is triggered into action. Now, once that happens the board is charged with developing proposals that will find immediate and i emphasize immediate savings within the Medicare Program and reduce that projected spending growth rate. Now, as you know, president obama did not name any members to the ipab. There has been no sign as yet whether the new administration, president trump, has any inclination to do so either. The law attempted this possibility anticipated this possibility, that the president would not appoint be members to the board. The law states that if the board does not act for any reason, including not having any members, the ipab authority then shifts to the secretary of health and human services. So once ipab is triggered by the actuarial projections from cms, then sec tire price as of now holds all of the authority to act. So that brings us to the real crux of this issue. What would the secretary have the authority to do under the ipab statute. He would have the authority to identify adequate savings to reach this statutory budget target, that gdp plus 1 . There are some constraints in the law. Think proposal could only affect medicare, not think other program. Not any other program. Also no proposal could ration care, raise revenues, raise beneficiary premiums, increase beneficiary cost sharing, restrict benefits or Alter Program eligibility. So i think you can see that that creates a pretty narrow path for any proposal that would achieve those savings. And i should note here that just because the law explicitly forbids rationing of care to medicare men firlies beneficiarieses, it does not preclude actions that we believe could have the same impact as direct rationing. For example, if you with reduce payments to physicians and fewer doctors see medicare patients, then that has a definite impact on Health Care Access even though it doesnt carry that direct rationing label. Now, a couple of additional points about the legislation. Any administrative or judicial review of the boards or the secretarys proposals is strictly prohibited. So no administrative and no judiciary review. And also these proposed spending cuts must achieve savingsing within a single year savings within a single year, so theyre immediate. The organizations that oppose ipab have pointed out this really precludes any thoughtful, longterm initiatives that will strengthen the value of the Medicare Program. But rather, it really limits action to blunt, immediate cuts. In many ways, it reminds me of sequestration. Now, what i havent discussed yet is what is the role that Congress Plays in all of this. Ipab was constructed to largely take medicare Decision Making away from congress. But it left a very small window for the legislative branch to act. Congress may only revise the secretarys ipab recommendations by passing an alternative or an alternate piece of legislation that achieves the same level of savings, again, that gdp plus one growth target. Or the senate can amend the ipab recommendations with a twothirds supermajority vote. And this has to happen very quickly. The secretary submits the proposed cuts by january 25th, and the congressional committees with jurisdiction over this must act by april 1st. So a very short window of time. So here you see again that you have this also in your packets, an ipab timetable which triggers this 2017, and then you can see the implementation of those proposed cuts in january of 2019. So again, i cant emphasize enough that ipabs has now moved from theoretical issue to a very real teenager to medicare danger to Medicare Beneficiaries. Cms actuaries have projected that ipab will trigger for the first time this year and possibly as soon as next month. So at this point, secretary price is charged with finding savings of at least 1. 5 billion to take effect in 2019 once cms makes that projection. And the Medicare Trustees also project that ipab will trigger again in 2022 and 2024, and that would require billions more in cuts to the Medicare Program. So as you heard earlier, here are there are legislative remedies to keep ipab from doing serious harm to Medicare Beneficiaries and access to care. We have the bipartisan bill in the house that you just heard about, h. R. R. 849, that is cosponsored by congressmen roe and ruiz x it is rapidly gaining cosponsors so, thank you, aaron, for the work youre doing on that. We also have two repeal bills in the senate. One, s. 260 by senator cornyn, the republican whip. And also we have one sponsored by senator wyden, s. 250, and he is the Ranking Member of the finance committee. These two are gaining support in the senate. And in particular, were seeing more wisconsin partisan support in the Senate Bipartisan support in the senate than weve ever seen before. I think much of that has to do with the fact that members are now seeing that ipab is an imminent net and that they know that they need to protect their constituents who rely on the Medicare Program. So with that, im going to turn it over to our three experts who are also speaking on behalf of their medicare constituencies; physicians, patients and hospitals. Theyll each present their perspectives, and then well open the floor for your questions. So lets begin. Finish. Thank you, mary, and thank you all for taking time to attend this discussion of this very important issue. As harry said, its going to become a lot more mary said, its going to become a lot more important. Im a neurosurgeon, i treat medicare patients, and from that perspective, i can tell you ipab is one of the most insidious parts of the Affordable Care act, and it needs to go. Now, as you all know since medicares inception, its been congress whos been leading the way in shaping policies to insure our Seniors Health care needs will be taken care of. Ask we all saw this place play out in the last congress when we finally got rid of sgr and was replaced with macra which was signed by the president. Thats how medicares supposed to work, but as mary just summarized very, very nicely, if ipab comes into play, then your elected representatives no longer have any control over how medicare is supposed to work. Instead, well have 15 people with very little accountability, without any day jobs, and many of them have never even touched a patient who will be making decisions about how Health Care Spending new medicare is going to be run. And whats even worse, as she mentioned, if the boards not appointed, it all falls on one person, secretary of hhs. So you have one unelected member of the executive branch who would be performing the job that really historically has been part of the legislative branch. Now, i mentioned macra earlier, and as you all know, for the first time its forcing everyone into a quality, valuebased payment world. And if we do that right, not only will it drive down costs, more importantly, it can actually improve the quality of care that our Senior Citizens get. And the problem is instead of this kind of thoughtful, targeted type of approach, again, to what mary said, ipab would just be a very blunt instrument. Its kind of like instead of using a scalpel under macra, use a sledgehammer under ipab. And to put in this context, remember that medicare doesnt even pay for the cost of taking care of patients right now. The last statistics i saw says medicare picks up 60 cents on the dollar of what it costs me to pick up my patients. So when you already figure its essentially a money loser for my office to keep the practice running, then you layer in all the incredible bureaucracy, ongoing changes to coding and building practices, precertifications, quality reporting metrics that are often not related to what specialists do, you know, for example, my skill and value as a neurosurgeon may be based upon how well my patients cholesterol is managed. It really makes a lot of people wonder about the wisdom of participating in meld care. In medicare. Now, again, this may sound like an argument you all have heard in the pennsylvania. Some physicians just say theyre going to stop participating, and yet most statistics say 90 of all physicians till do. Well, its not black or white. You may be a participant on paper, but maybe you only see one or two patients per clinic session or limit the number you see per week or number you do surgery on. So in effect, that gets into the rationing without calling it rationing issue that mary raised. And mary also mentioned im the chairman of a clinical d. In a medical school. Department in a medical school. And be one issue that really hasnt gotten a whole lot of coverage is the effect that ipab would do to graduate and undergraduate medical education. So, tony, raise your hand. Tony is chief resident who not only is an excellent neurosurgeon, but he has an interest in health care policy. And to turn someone like tony from a fresh medical School Graduate into a highly competent brain surgeon takes about a Million Dollars or more according to our estimates. That moneys got to come from somewhere. Medicare hasnt increased the number of Residency Training spots since 1996, so the subsidies come from either clinical practice plans or from hospitals. And if we just arbitrarily start slashing here and there with ipablike cuts, that will mean we either have fewer physicians or more poorly trained physicians, and neither of those is an acceptable option. So at the end of the day, you know, bad policy is bad policy. Leaving medicare policy decisions in the hands of an unelected, unaccountable, governmental body with minimal congressional oversight will negatively affect access to timely care for our nations seniors and for those with disabilities. Remember that we promised our seniors a medicare system that offers the best care in the world, and bringing an end to ipab once and for all is a vital step towards fulfilling that promise. Thank you, mary, and good afternoon to everyone. Thank you, congressman roe, for your leadership, and senator wyden and senator cornyn. Im bob blancato with the nutrition and aging service program. Really long name, but what our 1100 members do is provide meals to older adults, homedelivered setting meals on wheels is a term you probably know better. Our members helped enroll low income seniors into the Medicare Part d program a number of years ago, and our members are very sensitive to issues that impact medicare because of its direct effect on our participants. And for the past four years, our association has passed resolutions supporting the repeal of ipab. Because ibe pab ipab repeal is the only same answer. Key policy decision on rates and spending that were the purview of Congress Since 1965. Its a dangerous power grab by 15 unelected individuals with no guarantee of consumer or patient representation on the board, and the power could even be more concentrated as the recommendations only need to be approved by a simple majority of a quorum should they with be convened. Ipabs reach is enormous, the entire medicaid program, to be exact. Congress goes from being the driver of medicare policy to a bystander, they can only get 60 votes in the senate to block ipab recommendations or come up with its own proposal achieving equal savings but must do so in an abbreviated period which doesnt always work up here. And lawmakers dont have the authority to pick up specific things they dont like because they must consider all the changes as a single package. The president appointed, but even the hhs secretary unless ipab isnt convened, has no authority to block recommendation ares. Many patient advocate groups expect a 15member panel to recommend fairly significant cuts which could force seniors to pay a larger share of their health care costs. This is particularly troubling when half of the people on medicare earn less than 23,500 a year which is just twice the poverty limit, according to census figures. Any direct cuts to medicare or limits on what the Program Covers could have a dire impact on many of those seniors who depend on medicare and other assistance programs just t