Good afternoon, and thank you everyone for joining us today. Im mary grealy, president of Health Care Leadership council. We have hospitals, insurers, medical device manufacturers, Health Product distributors, and many more sectors represented as well. But today im 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 formerly 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 Medicare Program, for beneficiaries and for those who poifd health ca provide health care to those Medicare Beneficiaries. Let me introduce the panel. We have alex valadka, president elect of American Association of neurological surgeons and chair of the department of neurosurgery at Virginia Commonwealth University and also director of the american board of neurological surgery. Bob blancato is executive director of National Association of nutrition and aging service programs. He is also the Board Chairman of the American Society on aging. Bob spent nearly 20 years in the executive and legislative 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 a 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 expert speakers shortly. But first i would like to welcome aaron bill, legislator director and councilman for congressman phil roe. He is a leader of the effort since this initially became an issue and again this year he is a primary cosponsor 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 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 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 the neurosurgeons 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 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 democratic beneficiaries. Its really 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 ceded 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. I believe 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 would 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. Thats 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 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 we will do a little ipab 101 here. Now im not going to delve into the weeds on this. Im not going into excessive detail. But we have included the slides that i will be presenting in your Materials 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 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 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 centers for medicare and medicaid services, cms, determined 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 anticipated this possibility. That the president would not 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 projections from 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 of 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 have pointed out that 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. 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 alternate piece of legislation that achieves the same level of savings. Again, the gdp plus 1 growth target. Or the senate can amend ipab recommendations with a twothirds supermajority vote, and this has to happen very quickly. The secretary submits the proposed cuts by january 25th and congressional committees with jurisdiction 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 has now 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 we have the bipartisan bill in the house you just heard about, h. R. 49 that is cosponsored by congressman roe and ruiz and it is rapidly gaining cosponsors. So thank you, aaron, for the work you are 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 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 threat and they know 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 speak on behalf of their 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 of this very important issue. As mary said, its going to become a lot more important in the coming years. So as she mentioned in the introduction, im a neurosurgeon. I treat medicare patients. And from that perspective 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 all know, since medicares inception it is congress leading the way and seeking policy in ensuring seniors medical needs will be taken care of. We saw this play out in the last congress when they finally got rid of sgr and it was replaced by macra which came from congress with bipartisan support and it was 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 representatives 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 your Health Care Spending through medicare is going to be run. And whats 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 performing the job that really historically has been part of the legislative branch. I mentioned macra and macra is forcing everyone in a quality valuebased payment world. If we do that, not only will it drive down medicare costs but 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, what mary said, ipab would be a very blunt instrument. Its kind of like instead of using a scalpel under macra use a sledgehammer 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. So when you already figure that its essentially a money loser for my office to keep the practice running, then you layer in all the incredible bureaucracy, whether its all these ongoing changes to coding and building practices, 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 may be a Medicare Participant on paper but maybe you only see one or two medicare 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. You can be a medicare tony, raise your hand. So tony mido is one of our residents. Hes a chief resident who not only is a neurosurgeon but has an interest in policy. To turn him from a fresh medical graduate to a highly competent sbrarnlgon takes a Million Dollars or more according to our estimates. That moneys got 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 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 nations seniors and those with disabilities. Remember we promised 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. Good afternoon, everyone. Thank you, congressman roe, for your leadership and senator wyden and senator cornyn. 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 its direct effect on participants. And for the past four years our association has passed resolutions supporting the repeal of 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 representation on the board, and the power could even be more concentrated as recommendations only need to be approved by a simple majority of a quorum should they need to be convened. Ipabs reach is enormous. The entire Medicare Program to be exact. Congress goes from being the driver of medicare policy to a bystander. Congress can only turn away ipab recommendations as was mentioned by getting 60 votes in the senate to block ipab recommendations or come up with its own proposal, achieving equal savings but must do so in a very abbreviated period, which doesnt always work up here. Lawmakers dont have the authority to pick out certain things they dont like because they must consider all the changes as a single package. The president appoints but even the hhs secretary unless ipab isnt convened has no authority to block ipab recommendations. Many patient advocate groups expect a 15member panel to recommend fairly significant cuts to the program, which could force seniors to pay a large share 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, just twice the poverty limit according to census figures. Any direct cuts to medicare or limits on what the Program Covers could have a dire impact on many of those seniors who depend on medicare and other assistance programs just to survive. For our members and the seniors we serve, medicare provisions such as Preventative Services and reduced cost vaccines have been vital these past few years. So are demonstration programs that provide Services LikeCommunity Care transitions and referral services. Important services and innovations like these could be in danger under costcutting measures. This is a volatile time for medicare. Votes will occur throughout the ahca that could impact medicare and more could follow. But it is Still Congress doing t