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 Like Community 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 the work with advocates reacting both here and at home about changes that occur. You have 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 more innovative treatments and Delivery Systems and greater focus on outcomes. So time for as early a vote as possible on the 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 immediately affect hospitals theoretically, let me assure you, everything that affects patients, everything that affects communities, everything that affects doctors impacts hospitals. Theres no way around that. Thats the reality of how it works. I would suggest to you when we first came in the room early in this meeting, you heard a siren go by. And it was an ambulance. You because let me assure you, if youve been around it long enough you can tell a difference between a fire truck and a police car and an ambulance. It was an ambulance. And whether they were going, whether ems was going to a call or they were coming back from one, someone, likely by no choice of their own, is receiving aid through emergency medical services. And for the most part, unless thats a patient or someone who didnt need to be treated at the scene and couldnt be released, that person is on the way to the hospital. It could be any one of us in the room. And the question is, are those hospitals available 24 hours a day, 7 days a week, 365 days a year including in the snowstorm tomorrow that is supposedly going to be here. Are the doctors available to be in that hospital or to come to that hospital . And you dont know what an individual patient is going to have. And if youve ive had the great pleasure of being president of institutions with level 1 Trauma Centers for a long time. And let me assure you when a level 1 trauma patient, the most severe trauma patient comes in, and unfortunately in our world today with the violence thats occurring even in domestic settings, when 20 patients come in or 25 patients come in to a major center, it is not a matter of the people that are standing there can do that alone. Youre dependent on a large army of nurses and doctors and specialists in many, many fields, and primary care doctors. You name it, you need it. All of the surgical technicians and all of the people that run that, it is a very expensive to create a safety net and to actually keep that net in place 24 hours a day, seven days a week, 365 days a year. And what happens in many Rural Communities and ive run a 50bed hospital, in a Rural Community in South Carolina at one point in my early career. When you had a patient in trouble regardless of what happened after 5 00 they were going to a hospital in another county. Because there were only five doctors in that community at the time. And you were going to transfer a patient. And if that patient was serious enough to go, even if it wasnt a lifethreatening event and it is after 5 00 and you send them to another community, if that community doesnt have doctors available to come in and see those patients, even if they had a long day, that patient is simply moved from waiting chair to waiting chair to waiting chair, and thats no way to run a ship, as they say. This is a country that one of the freedoms and responsibilities we have is to take care of our neighbor. It is just the right way to do it. Now im going to suggest to you that we are all responsible for finding ways to reduce the cost of health care. I buy insurance just like you do. You know, my children, weve still got kids in school. Were in college. We are responsible for the same thing parents are anywhere. We are responsible for each other. My wife and myself are taking care of each other, and it is very expensive to do so in the Health Care World we have today. We as consumers agree we have to reduce the care cost in this country. And the cost of being well, because thats not easy either. Because you have to have good meals and you have to have nutrition and you have to have things that can keep you out of the hospital if its done right. But to do that, you have to use innovation to find ways to improve health care, not cut your way there. You have to do it with smart shifts in where we spend money. And the right use of money and right place can avoid many, many, many repeated visits to a hospital or to a doctor all of which go kaching every time somebody moves. I want to tell you, ive always been interested in my career. And ill end on this spot. In emergency medical services. I happened to be when i was very young in the very first paramedic class in the state of North Carolina. A long time ago now. I still keep those certifications. Just want to. Ive always been interested in emergency medical services. Theres an interesting move in ems around the nation today called community pair amedicine. And some big cities and small cities alike including North Carolina are working with it. And theyre taking paramedics, some of whom are firefighter paramedics, and theyre training them to do Community Health in addition to their ems emergency response. An interesting thing i heard in dallas, texas from one of the chief officers not long ago there was who were they trying to set that program up to start. Because you have to start somewhere. And the interesting thing he told me was they were starting with patients who had called 911 50 times in the last year. 50 times. And thats not the big users. What theyre doing is having these firefighter paramedics who have additional training and see what is the issue. Is it about nutrition, social services, is it about drivers license, is it about being lonely. Is it truly a Health Problem thats just being recycled . And the answer to many of those questions, its all of the above. Hospitals deal with that all the time. Communities deal with it. There is a much smarter way to do this instead of cut through Something Like ipab blindly. It is an opportunity to do smart things, to do innovation. To do innovation. On that day in america when dr. Don burwick who many of you know from the institute of Health Improvement stood in florida and said people were being injured and killed in hospitals by accidents and just deeds, things that could be improved, i was standing on the stage with him. Trust me, it doesnt make you a hero in the industry when you talk about hurting people in hospitals, but the reality is we know there are issues that need to be improved. We know there are actions that need to be taken across the entire nation to strengthen health care. Blindly cutting how we spend money as opposed to where we direct that money is a mistake. Ipab is a mistake. Thank you for sharing those different perspectives. Well open it up for your questions now. I also have a few that i can ask. Anyone in the audience . Yes. [ inaudible ]. So elaborate a bit on why ipab is not a good way to address health care costs. Alex . So you can think of it as bottom up versus top down. Top down you see the total aggregate spending goes up above a certain line and you push the button and try to bring it down. Bottom up is somebody who is there on the Assembly Line who sees how the work is getting done. You can be at a hospital or clinic and you look for ways to decrease waste, boots on the ground type of approach. This is an artificial too high, got to cut this much and you may decide if youre running a business it has to come out of personnel or supplies or insurance or contractors or things as opposed to people doing the work. We can improve quality if we focused on these things i deal with every day. Does that answer your question . I think its the unknown thats concerning about what they decide to do to fulfill their mission and where they would choose to take their cuts. As someone said earlier, something done over here has an implication over here if youre a medicare beneficiary. Youre not doing anything about limiting access to sxar also driving up costs. Theres many unknowns associated with ipab that would make us very concerned. The assumption of ipad is that Everything Else thats being done or could be done has failed, has failed to control cost. And i suppose that could happen. But the reality is there are so many approaches, very much like i mentioned about community paramedicine. Its a small example. There are so many things that are relatively inexpensive and in fact in the end save millions of dollars. And take a burden off health care and get people in the right place as opposed to absorbing large numbers of resources that are inappropriate for their needs and inappropriate use of public and private money. There are so many programs like that that should in fact be funded versus talk about you know, and that may take money from one program and move it to another. If you can take the burden off Emergency Departments, the most expensive place in america to receive care, if you can take the burden off communities by helping the least amongst us, and many of them are people with money who just dont know how. Older patients who just dont know how to access the system. And if you come in the wrong door, if you would, if you come in through the Emergency Department or other places, its immeasurably complicated what your care cycle will look like and what the cost is. I think the smart way to do this is to introduce innovation and change at the starting line of the system, not in retrospekt in a dark room somewhere simply cutting costs. Yes. You mentioned how [ inaudible ] so the question here is the statute says explicitly that it cannot ration these cuts cannot ration health care for Medicare Beneficiaries. And also you cannot pass a tax to increase revenues to the program to offset that growth in spending. You cannot increase cost sharing by Medicare Beneficiaries as part of this. So i think the real question here is, and all of this has to be done within a period of one year. What would you expect to see in terms of reductions . How it would affect and then what is the real effect on Medicare Beneficiaries . So if you run a coffee shop or a fast food place and theres a couple items on the menu you that lose money on every time, your company cant survive you continuing to sell a lot of those. So you may sell a certain ub. 95 cups of that coffee or a certain number of those things but you cant try to make that a big part of your business. Now, medicare, you know, every physician of course were very devoted to our patients. We take an oath. We want to take care of them. But we also have to pay the bills. As i tell people all the time, even mother theresa had to pay her bills and balance her checkbook. So you have these sort of competing interests between wanting to take care of people, especially the elderly, many of whom in your communities are your neighbors, versus the realities of trying to keep things running. Its kind of like slowwalk the process. As i said, im a Medicare Participant. If i look at the books in my payer mix and im getting paid, i just cant afford to see more than x number of medicare patients per clinic, per week, or do more than a certain number of surgeries or procedures on them. In effect, that is going to be rationing. It may be a queue forming for people with that type of reimbursement but not for other types of reimbursement. I think that word needs to be looked at, ration, as well. In other words, many new innovations as bill pointed out that have occurred in medicare in recent years. You know, some of them may get stopped cold in their tracks. They may not expand preventative benefits as the Affordable Care act was able to do, giving you a welcome to medicare physical or osteoporosis screening or things of that nature. So some of the things that are more innovative and newer could just be stopped. Thats rationing care to some degree too. If youre not letting new people in or youre referring back to things. Thats a word that youve got to be very careful about because again, a decision made here may not look like anything beyond that decision but it has Ripple Effect throughout medicare down the road. There are many innovations that are occurring as we refer to a person 65 and above or any range. Any person that needs help. But a good example is how many patients are transported from nursing facilities, Nursing Homes or other facilities that have a slight fall. And the protocol in many locations is you need to go to the Emergency Department if its a fall. And its different in every nursing environment. But again, in some cases, in Wake County Emergency Medical Service in raleigh, North Carolina has a protocol now. Its been under play for a couple years. But when theres a fall an ems goes. They can clear that patient with a standard that says either they need to be transported or not. A vast majority of the patients that have a simple fall in a nursing home today do not go to the hospital and spend 100 review of each of those patients, and theyve had no fallout from that. The patients that need to go really go, and ones that dont are cleared. And the issue historically was the Nursing Homes were in a position where they thought it would be a legal issue if the patient didnt go to get checked out. Well, the answer is they are getting checked out because its a physician on the evened of the line and the medics themselves arent going to make a mistake intentionally. Theyre not going to do that. And so theyve been able to save money. Thats a classic example of using innovation and having 100 review of those cases to make sure there wasnt something missed. And thus far thats been a great, great system. But there are a million examples of that where common sense can be applied to make sure that people get the care they need, not just the care thats traditional, which is not going and sitting in the Emergency Department when you dont have a true emergency. Trust me, its not an experience anybody wants, including somebody of the medicare age. Or medicare or medicaid age either. Yes. So given the critical implications of what might come to pass, with respect to ipab, could you speak to the fact that this body which is has such powerful mandate is unelected, not regulated by federal law and half of the constituents, less than half, are Health Care Providers making these critical decisions which ultimately is going to impact access unquestionably and however one describes that with respect to rationing, in terms of access or provision of care, i think the ultimate end result is going to have a profound impact over time. So i would have concern about underrepresentation from the Health Care Arena that its an unelected body with no federal oversight. So i think the point here is its clearly stated in the statute that the majority of members of this board cannot be those with what i would call real world experience in providing health care. And also they cannot hold any other job while they are in this position. So your reaction to that and what effect you might see from that . I think we talked about in marys comments and i can tell by the tone of your question where you come down on the side of this and i think youre exactly right. You have somebody who presumably has a successful career as a provider or Health Care Administrator whos supposed to give that up and go work for the government and do nothing else you cant keep doing your own previous job on the weekends. Again, not all of these members are going to have the reallife experience. Thats going to be a big problem. Its been said that in the military the best generals and admirals are the ones who start at the bottom and work their way up through the ranks so they see how the Organization Works at every level. If you just parachute people in at the top without a lot of that experience. Or that experience may have been very old. The health cares changed so much in the last couple years that its not the same system your father had. I agree with you thats going to be a big problem. So what it feels like is being dorothy on the yellow brick road. Id like to know who is behind the curtain, to be honest. I think anytime you have to deal with a wizard you who dont see and dont know and you dont know what levers are being pulled or what tasks are being assigned that doesnt feel very good. Now, most of us that have been in health care for a long time are used to coming into this city or to our capitals and other places to talk about health care. And many, many times what we ask for or say is important doesnt happen but thats okay. At least theres a voice and opportunity to Say Something about it and maybe somebody has a better idea that we didnt think of. As ive noted to you today, the opportunity to know what theyre doing in dallas or boston or california or florida impacts all of us and that ability to share information is extremely important. The concept of ipab, as i said, its the wizard. It doesnt work. Yes. Ipab, does it have any value as a catalyst to spur action . Congress if left on its own usually is not especially eager to cut spending to pretty much anything, especially Something Like medicare. Is there a value in keeping it around if only to spur cuts . Like will cuts happen realistically if theres not an agency like that thats forcing congress to either accept what theyre proposing or at least according to the slides come up with a better place to do the cuts . So the question is whether having an entity like ipab will get cuts done or spur congress to take action and what happens if we dont have that pressure. So ill let the panelists comment and then ill chime in. All right. Well, i think if we were talking about reductions that might take place over a period of years and we would have some time to come up with thoughtful innovations on how we could actually change the delivery of health care and providing services, i think the real challenge with an entity that we see in this statute is they have to make recommendations for cuts that will reduce spending within one year. And that just in my mind completely negates the ability to do thoughtful longterm change as were trying to turn this huge ship called health care delivery. Again, thats a great answer. I agree with that, but thats not looking at the cost side of the equation. What macra, our Current Program has, also focuses a lot on quality. You could argue thats even more important than cutting costs. At least if its your grandmother or grandfather there in the hospital. So cutting costs is great, but thats an incomplete solution. It would be interesting to its a great question. There are going to be tough decisions made on medicare over the course of time and there will be more coming in the months frankly. I expect the future decisions that will be made about medicare we hope have bipartisan support. Theres no guarantee of ipab having a bipartisan approach to anything. And i think thats one of the concerns i would have. In addition to the fact the people make those decisions are not qualified. Even if we dont know who they are yet. Again, just a pragmatic response. If you want to know how to make Health Care Better the physicians have to be in the middle of it, but the people dealing with the pragmatic side of how the patient can get in or out and not be seen are generally the nurses and they would have an idea of how it fits and all of us have to have an ability to sit down and talk to the people who really handle the 24 7 movement of patients, which is at that level and you cannot do it without the physicians and pas and the people that do it. Theyre what make the clock work. But the reality is youve also got to take care of people that run the train, if you would. And thats the focus on the line either in a Doctors Office or in the call center or in hospitals. And nursing, many times is silent on this issue or at least is left in a silent position. I would invite them to the table in a big way. And i assure you theyre not going to go for the wizard of oz model of a blind board sitting behind a sheet. Its not going to happen. That was a very pragmatic answer which i agree with. But also lets go back up to 30,000 feet and a philosophical approach. The legislative approach may have trouble balancing its budget but that doesnt mean it should cede this much power to the executive branch. Thats not how our system was created. And i cant resist as a former house staffer. I cant imagine what the mail would be like. And the answer youd have to give would be a little tricky. Keep that in mind too. And i think thats a very good point that this approach really is the antithesis of representative government. In other words, patients, constituents, voters won have a voice in this process because again this is an unelected board, one that isnt dominated by those who are familiar and close to health care. And again the fact that all of this would have to happen in such a short period of time. Which leads me to question, all right, if you had to come up with several billion dollars in reductions what would you expect to see . What is the likely cut that one would expect that i think would probably be a lot different than the transition youre going through under macra, the physician payment reform proposal . So what are the types of cuts that this board could make . Im not sure what youre asking. What the ipab board might make . What you would expect to see. Ipab has a target weve got to make these cuts within one year. What would hospitals, physicians and others expect to see . I believe dont quote me on this. It was originally formulated. Most of the cuts are supposed to fall on providers and sort of exempt other parts of the Health Care System like hospitals and in the short term. Yeah. I think that was several years ago. Were past that. But i imagine these broad strokes, okay, the physician provider part cut this much. So many hospitals cut this much. Other parts get cut here and there without any more thoughtful and targeted approach to that. I think part of the answer rests with who sits on ipab, who ends up being put on ipab. And if its imbalanced a certain way you probably could find an imbalance in the way they would recommend cuts. Thats why the composition of it becomes very important and who was on the panel. I think the one would hope that the first place that they would look as we Hope Congress will continue to look at it is fraud, waste and abuse in the system. You can extract a lot of money and have year after year by being more aggressive on that front. Im sure they would go deeper than that. Well, again, if you look around and talk to people who had experience in Health Settings and not just hospitals because thats a small percentage of people that would be involved in the daytoday access to health care but if you talk to people about their time. Whats their time worth . Whats their transportation cost . Whats it mean to have to go to an Emergency Department as opposed to being seen by your doctor maybe in the milled of the night . So our Urgent Care Centers but not so much the type weve seen which were sort of driveby centers but a true presence in a Community Health network that might be open around the clock. Around patients needs, not necessarylit systems. There are many innovations we could do, and one of the things we heard earlier was about the importance of training programs, training sxejs programs, future nurses, future physicians, future p. A. S going down the list. Laboratory personnel. Very important thing to do. We have a tremendous shortage in some areas, especially around nursing in some communities, not all, but some. And the absence of the people who can continue to prove the process along, patients get caught in a time warp. They cant move as far through the system or as quickly as they need to be. Its not a call to more technology. In many cases its just a call for the right workforce including physicians. Rural communities who do not have specialty physicians as i said many times transfer by ambulance their patients on weekends and nights when those doctors are not available because they have to get a break too once in a while. They have to live a life. They cant be on call 24 7 in a Small Community or a suburban community. And thats why the urban areas many times handle that case load at a very expensive cost. Any other questions from the audience . Why are there could somebody explain the difference between the two . Well, the short answer is you have senator wyden whos the ranking democrat on the Senate Finance committee and then you have john cornyn, who is the republican whip. And each from their individual parties have decided to take on this issue, and we are just looking to get this problem solved. And the real effect of both of these pieces of legislation is repeal of the ipab. So they have the same goal. They have the same effect. They each decided to sponsor their own piece of legislation. Its easier for us in the house. We have a bipartisan bill so theyve started down that path already, but at the end of the day were trying to get Critical Mass to make sure it gets done and i may point out the clock is really tick here. Last year there was an expectation that ipab might be triggered. This year it is pretty darn certain that cms actuary is going to come out with that projection, that medicare per capita spending will exceed gdp plus 1 . As we all know, gdp growth has been rather constrained and low. So its a pretty low target. It looks like its going to be exceeded. And then were going to begin this process. Of having these ipab cuts. Whether we have a board or not, the secretary will now have that responsibility and must make by statute those recommendations to achieve those reduction targets. We are really looking to all of you in the audience here and whoever may be watching today to please ask your member of congress to sign on to this legislation and to get this legislation passed because it is now an imminent threat. Its been out there for a while, but it is now becoming real. And as you heard from our panel today, there are real effects that will affect not just the providers, not just physicians and hospitals and those that provide goods and services to Medicare Beneficiaries but its pretty clear that it will directly affect Medicare Beneficiaries and the type of services that theyre able to access under this. Any last comments from our panel . All right. Thank you all for joining us today. Appreciate it. [ applause ] cspans washington journal live with news and policy issues that impact you. Coming up thursday morning, Virginia Republican congressman tom garrett discusses the house Gop Health Care bill. Then Wisconsin Democratic congressman mark pocam, first vice chair of the progressive caucus, looks at the House Democratic agenda, the gop aca repeal and replace bill, and the trump budget. And reuters Howard Schneider talks about the decision by the Federal Reserve to raise the shortterm Interest Rate and how consumers could be affected by the decision. Markup, 2 00 p. M. Eastern, also on cspan 2. This week is sunshine week. An annual campaign for Greater Public access to government. Its also cspans anniversary week. 38 years ago on march 19th, 1979, the house of representatives opened its debates to tv cameras for the first time. And the Cable Television industry launched cspan to bring the congress into americas homes. The gentleman from tennessee. Good afternoon. [ inaudible ] mr. Speaker, on this historic day the house of representatives opens its proceedings for the first time to televised coverage. I wish to congratulate you for your courage in making this possible. And the committee who has worked so hard under the leadership of charles rose to make this a reality. Television will change this institute, mr. Speaker, just as it has changed the executive branch. But the good will far outweigh the bad. From this day forward every member of this body must ask himself or herself, how Many Americans are listening to the debates which are made . When the house becomes comfortable with the changes brought by television coverage, the news media will be allowed to bring their own cameras into this chamber. In the meantime, there is no censorship. Every word is available for broadcast coverage. And journalists will be able to use and edit as they see fit. The solution for the lack of confidence in government, mr. Speaker, is more open government at all levels. I hope, for example, that the leadership of the United States senate will see this as a friendly challenge to begin to open their under the rules the gentlemans time has expired. The marriage of this medium and our open debate has the potential, mr. Speaker, to revitalize representative democracy. And in 1986 the cable industry launched cspan 2
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