Health care leadership council. We have medical device manufacturers, Health Product distributors, and many more sectors pr sectors represented as well. But today im also speaking on behalf of a campaign that we call protect by doctor and me. Over 670 organizations from throughout the country representing patients, Health Care Providers, employers americanes with disabilities, veterans and others, have formerly urged congress to repeal the independent payment advisory board. Today, were going to share some information and perspective on iphav and what it means for Medicare Beneficiaries and those that compare medicare ben fish area res. We have alex valadka, president elect of American Association of neurological surgeons and director of the american board of neurological surgery. Bob blancato is executive director of National Association of nutrition and aging service proes grams. Also on the board of the society of aging. Bob spent nearly 20 years in the legislative and executive branches of government. Including senior staff of the House Select Committee on aging. Dr. Bill atkinson comes to us today from north carolina. Where he is a widely respected as champion of health care change and improvement. He has been a hospital and health care ceo for over 30 years and most recently of the wakemed system in raleigh, north carolina. I will turn to our speakers shortly. But first i would like to welcome aaron bill, legislator direnor own councilman for congressman phil roe. He is a leader of thesince this issue and again this year he is a primary could sponsor of the house legislation that would eliminate the independent advisory board. So aaron, would you please share some of your thoughts with us . Thank you, mary. Just to start, i have a big pile of business cards in case anyone has questions and you want it reach out to me afterward. I work for dr. Phil roe. He is cochair of the gop doctors caucus and sponsor of hr8 will 49 in this conference which is aiming to repeal the ipab. Dr. Ruiz from california is our democrat lead and we are really excited to be working with their office on trying to make this actually happen this congress. I think we have a good shot at doing that. I do want to start out by giving a quick shoutout to neuro surgeons because they asked that our boss put together a blog post that just went live this morning. If you go to their twitter page, neurosurgery and you can see my bosss 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. Not something that would affect just democratic beneficiaries. 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 seated the ability to make medicare cuts to an elected 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 we are just trying to get as much support as we can. We have 21 cosponsors right now on 849. And we are up to three democrats. So im very excited about that. Any push that you guys can make with your bosses with advocating to other members of congress, we really appreciate it. I finally have an updated colleague for this congress. Took me a little while but im happy to share it with anyone who may want it. Please feel free to grab a card, reach out to me, and we look forward to hopefully having the ipab repealed this congress. That really about it. 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 patient, 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 we will do a little ipa b101 here. Now im not going to delve into the weeds on this. B101 here. Noim not going delve into the weeds on this. 101 here. Now m not ing to delve into the weeds on this. 101 here. Now im not going delve into the weeds on this. Im not going into excessive detail. But we have presented the slides that your material today, so you will have those. 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 it is supposed to be compromis comprised of people who may not have any other position or employment while serving on the board. There was an early criticism in the fact that this provision would get 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 centers for medicare and medicaid services, cms, determined that per capita medicare spending will grow faster than that established rate, then the ipab is trigger need 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 aicipated this possibility. That the president would n appoint 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 actuarial provisions by cms then secretary 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 the statutory budget target, gdp plus 1 . There are some constraints in the law. Any proposal could only affect medicare, 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 Beneficiaries, it does not preclude actions that we believe could have the same impact as direct rationing. For example, if you 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 point 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 savings within a single year. So they are immediate. The organizations that oppose ipab haveoint o that this loally procludes any thoughtful, term initiatives that will strengthen the value of the Medicare Program. But rather it really limits action to blunt immediate cuts. In many ways it remind me of e sequestration. What i havent discussed yet is what is the role that Congress Plays in all of this in 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 al teternative or alternate piece of legislation that achieves the same level of savings. Again the gdp plus 1 growth target. Or the senate can amend ipab recommendation with two thirds super majority vote and this has to happen very quickly. The secretary submits the proposed cuts by january 25th and congressional committees over this must act by april 1st. A very short window of time. So here you see again that you have this also in your packets, an ipab timetable which triggers in 2017 and then you can see it to the implementation of those proposed cuts in january of 2019. So again, i cant emphasize enough that ipab moved from theoretical issue to a real danger to Medicare Beneficiaries. Cms actuaries 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. As you heard earlier, there are legislative remedies to keep ipab from doing serious harm to Medicare Beneficiaries and access to care. We have bipartisan bill in the house you just heard about, hr 49 that is cosponsored by congressman roe and ruiz and rapidly gaining cosponsors. So thank you, aaron, for the work you are doing on that. We also have two repeal bills in the senate. S260 by senator cornin, republican whip. And one sponsored by senator widen, s250 and he is Ranking Member of the finance committee. These two are gaining support in the senate. And in particular were seeing more bipartisan support in the senate than weve ever seen before. I think much of that has to do with the fact that members of now seeing that ipab is an imminent threat and though know they need to protect their constituent who rely on the Medicare Program. With that i will turn it over to ourhr expts who are also speaking on half of the medicare constituencies. Physicians, patients and hospitals. They will each present their perspectives and then we will open the floor for your questions. Lets begin with doctor valadka. Thank you, mary. Thank you for taking the time to attend this discussion as a very important issue. As mary said itll become very important in coming years. As very mentioned in the introduction, im a neuro surgeon. I treat medicare patients. I can tell that you ipab is one of the most insidious parts of the Affordable Care act and it needs to go. As you know since medicares insection it is congress leading the way and seeking policy in ensuring senior needs will be a taken care of. We saw this play out in the last congress when we got rid of sgr and replaced by macra which came from congress with bipartisan support and signed by the president. Thats how medicare is supposed to work. But as mary just summarized very, very nicely, if ipab comes into play then your elected represent tifs no longer have control over how medicare will work. Instead we have 15 people with very little accountability without any day jobs and many of them have never even touched a patient will make decisions about how the Health Care Spending through medicare will be run. And what is even worse, if the board isnt appointed it falls on one person, secretary of hhs. So you have one unelected member of the executive branch who would be perform the job that historically has been part of the legislative branch. I mentioned macra and macra is forcing everyone in a quality based payment world. If we do that, itll drive down medicare costs but more importantly improve quality of care that our seniors citizens get. And with this target approach, to what mary said, ipab would be very blunt instrument. Instead of a scalpel under macr use a sledge hammer under ipab. To put this into context, remember that medicare doesnt pay for the cost of taking care of patients right now. The last statistic i saw is that medicare picks up 80 cents on the dollar of what it cost me to take care of my patients. When you figure that it is essentially a money loser for my office and to keep the practice running then you layener the incredible bureaucracy, whether it is ongoing changes it coding and building practice, precertifications, quality reporting metrics that are often not related to a specialist do. For example my skill and value as a neuro surgeon may be based upon how well my patients cholesterol is managed. It makes a lot of people wonder about wisdom of participating in medicare. Now, again, this may sound like an argument you have all heard in the past, as some say we will stop participating in medicare and yet most statistics show that 90 plus percent of all physicians still do, well, it isnt black or white. You can be a Medicare Participant on paper but maybely only see one or two medicare patient per clinic session or limit the number you do surgery on. So it is rationing without the rationing issue that mary raised. And mary also mentioned im the chairman of a department of a medical school. One issue that hasnt gotten a whole lot of coverage is the effect that ipab or further rationing down medicare would do to graduate and undergraduate medication. So tony, raise your hand. Tony, one of our residents, chief resident, who is not only an excellent neuro surgeon but he has an interest in health care policy. To turn to someone like tony fresh medical School Graduate into highly competent brain surgeon, it takes about a Million Dollars or more, according to our estimates. The money has to come from somewhere. Medicare has an increased number of training slots since 1996 so the subsidies for that come from clinical practice plan or hospitals. And if we just arbitrary start slashing here and there with ipablike cuts that will mean we 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 c congressional oversight will negatively affect access to timely care for nations seniors and those with disabilities. Remember we promised seniors a medicare system that offers 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. Good afternoon, everyone. Thank you congressman roe, for your leadership and senator wyden and senator cornyn. I have a really long name but what our 1100 members do is provide meals to adults, meals on wheels are terms you probably know better. Our members helped enroll, low income seniors into Medicare Part d Program Years ago. And our members are very sensitive to issues that impact medicare because of the direct effect on participants. And for the past four years our association has passed resolutions supporting the repeal of the ipab. Because ipab repeal is the only safe answer. Ipab makes an unprecedented care taking key policy on payment rates and spending that were the purview of Congress Since 1965. It is a dangerous power grab by 15 unelected individuals with no guarantee of either consumer or patient prep zen tags on the board, andhe power could even be more concentrated ads recommendations only need to be approved bay simple quorum should they be convened. Congress goes from being the driver of medicare policy to a buy bystander. Congress can only turn away ipab by getting 60 vote in the senate to block ipab recommendations or come up with the own proposal, and must do so in a very abbreviated period which doesnt always work up here. Lawmakers dont have the ability to pick out certain things they dont like because they must consider all changes as a ing is el package. President apoints but even hhs secretary unless ipab isnt convened has no authority to block ipab recommendations. Many patient advocate groups except the pan toll recommend fairly significant cuts to the program which could force seniors to pay large share, larger share of the health care cost. This is particularly troubling when half of the people on medicare earn less than 23,500 a year, just twice the poverty rate. And there are limits on what the Program Covers could have a dire impact on many of the seniors who depend on medicare and other assistance programs just to survive. For our members and the seniors we serve, medicare provisions such as Preventative Services and reduced cost vaccines have been vital the past year. So our demonstration programs that provide Community Care transitions and Referral Services and Important Services and innovations like these could be in danger under costcutting measures. This is a volatile time for medicare. Votes will occur throught the ahca and more could follow. It is Still Congress doing the work with advocates here and at home about changes that occur. No such luxury on ipab. No one could have a town hall meeting on ipab. There are smarter ways to achieve savings. More electric Health Records and Delivery Systems and greater focus on outcomes. Time for early a vet as possible on bipartisan bills which should have been done seven years ago. We should kill ipab before it goes anywhere. Thank you. Good afternoon and thank you for being here. Im Bill Atkinson from north carolina. And although ipab does not immediate immediate immediately affect hospitals immediately, let me assure you, everything that affects patient, communities, doctorsis, affects hospitals. Theres no way around that. Thats the reality of how it works. When we first came in the room earlier this meeting you heard a siren. It wasnt an ambulance. If youve been around it enough, you have been around police, fire or ambulance and it was an ambulance. Whether ems is goi