The state up north, from ohio, mr. Levin. Youre still bitter about some of the back and forth between our two states. I dont think ron kind was here when we introduced judy chu. And earl was here part of the time. So dr. Miller, welcome. As i read your report, your testimony, and also the executive summary, i was just struck by the thoroughness of the work you do. A lot of the issues are controversial. I remember when we first talked about controlling payments to physicians and the heck that we received and how much controversy there was. And you thought the sky was falling and it would never work out. And i mention that because i really think your report, and it has areas where there are difference of opinion, your report shows how successful this has been, this program, that is, in some respects a public but not only public, but public and private partnership. And with a lot of back and forth from the private sector as reflected in your report. And i just want to comment for each of us on this committee and this subcommittee, when we go home, we have lots of meetings with the various providers, the various groups, and they have differences of opinion. And they have some urgent pleadings. But i really think your report shows why medicare is such a necessary and Popular Program for the people of this country. And not only for those who are covered by it, but by their families who benefit because those who are older than others in the family have the security of care. So without saying i agreed with everything you said, i wanted to congratulate you on your work. And i hope, mr. Chairman, that well be able to have some further discussions in depth about each of these important components, because i think theres a danger that each of us kind of picks and chooses one particular area where we think there is a special problem or grievance, instead of looking at the program more comprehensively. So let me start off, i think others are going to followup on this, because Prescription Drugs has become so urgent an issue, begin to discuss with us how med pack has begun to look at this issue and my time will have run out and others will carry on. Thank you. I can just say one thing. Id like to thank you for saying that. Remember, i have a tremendous task and gao has done a great job of appointing solid commissioners, so thats why you have the work that you have in front of you. Thank you, mr. Levin, with respect to the issue that you just brought up, i think thats a really good suggestion, in terms of looking at these things together. And i hope that we can do that in a bipartisan way. I would like to. Start talking about Prescription Drugs, you have 48 seconds. And others will carry on. Okay, weve done two areas of work in Prescription Drugs. Most relevant our current conversation is in part d. What weve seen is generally you look at part d, beneficiaries are more beneficiaries are being covered. People have high degrees of satisfaction and the premiums have been relatively level in part d. But if you look a little bit closer at the program, theres a portion of payment that is covered by the federal government exclusively, the catastrophic portion of the benefit, and thats been growing at a rate of about 20 . So the commission has been concerned about that growth rate. Theres a couple things that mr. Chairman, you want to gavel me down. Dr. Miller, others will carry on. Keep within the time. Did you want me to gavel you down . Its unusual. I think everybody wants their five minutes impa. Speaking of five minutes, the gentleman from illinois is recognized for five minutes. Thank you. Dr. Miller, thank you. And ill pick up a little bit on the wholistic theme of mr. Levin, that is, theres a general recognition that medicare is a program that everyone celebrates. To his point, let me bring up a particular concern thats been brought to my attention based on feedback from an inpatient rehabilitation facility in my district. And really one of the leading ones in the midwest. The concern is that the march report recommends an aggregate reduction in payments by 5 for that group. And im talking specifically about those that are in the nonprofit sector. Their margin is only 3. 6 . And so this is a this is a crown jewel rehabilitation facility in my constituency. Their margins right now, under medicare, are minus 20 . So the notion of putting more pressure on them is difficult to fathom. Can you give me a perspective on that . Is this a final word . Is this dispositive . Are you looking for feedback . Whats the state of play . I guess the first question is, do you agree with my characterization, and if so, then what can we do about it . If not, why not . I think youve asked and made a completely fair comment. Weve talked to a ton of inpatient rehab facilities and people in the industry. We do understand the phenomenon, and our data makes your point very clearly. In the post acute care sector in general and in the inpatient Rehab Facility sector in particular, what you see are very high aggregate margins, and then you see differences in financial performance. And as you said, it often is between for profit and not for profit, but its often tied to what kinds of patients that the difficult facilities tend to focus on. Theres a whole section of the report, i wont go through it in a lot of detail. I know were under pressure here in terms of time, but weve seen coding practices that raise questions, patient selection types of practices that have raised questions. So what weve tried to do is, in all of these instances is say, okay, total payments can be lower, but they have to be redistributed across the different kinds of providers. We generally try and do that by tying the patient the payment to particular types of patients. So if youre taking medically, the more medically complex, we would tend to shift the payments in that direction, which would have the effect of creating better or more support for the kind of facility that youre talking about. In the patient heres the last thing ill say and you can get back in. Im sorry. In the inpatient rehab sector, the other thing we said in addition to bringing it down, it to increase the size of the outlier pool so that more payments would come out of the general payment and go to those kinds of facilities that have the financial circumstance that youre talking about. There was a recognition and an attempt to get at that, and then we also think theres some coding practices that the secretary or the i. G. Or people like that should be looking very hard at on the very profitable side of the industry. Okay, thank you. Thats helpful for me. And maybe we can engage further. This is the white knight sort of mace that you want to be successful. Theyre doing, from my point of view, all the right things. So this is exactly the type more than happy to talk to you about that. Thank you. Thank you, mr. Chairman. Mr. Thompson, youre recognized for five minutes. Thank you. Thank you for having this opportunity to talk with mr. Miller. Thank you for being here, i appreciate the work that you and your staff do a great deal. As you probably know, in march this Committee Approved legislation, the republicans did, the democrats voted against it unanimously, that was a trillion dollar tax cut that included 75 billion reduction in the revenues in the Medicare Trust fund. Its my understanding this is going to shorten the life of the trust fund. Do you know, were there any provisions in that legislation, or do you know of other legislation that would codify any of the recommendations by med pack to save enough money in the Medicare Program to cover that 75 billion loss . Im not aware of legislation that would offset that loss, if thats what youre asking me. What . Im not aware of legislation, that includes med pack recommendations that would. So 75 billion taken out of the Medicare Program will affect the access to care for the millions of americans who rely on that . I cant comment on the effect of that particular provision, but your other question, im not aware of an offset. Does med pack have recommendations to find 75 billion worth of efficiencies in the program . Can i interrupt you real quick . A reminder, this is about med packs recent report as well as thats what im asking. As well as the extenders. About the report . Im asking if there are recommendations in the march report . In any report. This is about the march report. Are there recommendations by med pack that would cover the 75 billion loss that was brought about because of the legislation that was passed by the republicans in this committee in march. So, without comment on the pending legislation, there are an array of recommendations in the med pack report that result in savings. So for example, the post acute care things that we just talked to, we dont estimates, but we think were talking in the neighborhood of 30 billion. I mentioned the m. A. Coding issues. Theres potentially a savings there, for example. We also think, you know, the changes in the part d recommendations could yield savings. And also theres a couple of other places we havent talked about, where we restrain the updates that would produce savings. So those savings, the 30 billion worth of savings, how would they come to fruition . Would it require legislation . Almost everything i have referred to would require legislation. I have to think about that for a second, but generally, legislation, yes. So of the 75 billions that will be stripped from medicare because of this American Health care act, you can identify possibly 30 billion that could make up some of that difference, but that legislation, but to get there, weve have to pass separate legislation . Yeah. To get to the 30 billion, have to pass separate legislation and theres more i dont know that i can ballpark the number for you. Theres more savings in that report than the 30 billion. And that additional savings, would that require legislative action . In general, it would require legislation. Do you happen to know if any of that has been introduced . I dont happen to know that. So we have a 75 billion hole in medicare with no legislative attempt to address that loss . Im not aware of introduced legislation. I wouldnt necessarily be the person who would be aware of introduced legislation. Are you the person, or could you, in your position, give us some idea of what sort of problems a 75 billion loss to medicare would bring about . You know, again, on that particular provision, i dont feel real versed in talking about what the implications of it would be. Thank you very much. The time has expired. Mr. Smith, youre recognized for five minutes. Thank you, mr. Chairman and thank you, dr. Miller for your presence here today. Your responsibilities are large and you have a big job to do so we appreciate your effort. Its no secret that Rural America has some challenges, especially with the agriculture economy and many of the challenges with access to care. Critical access hospitals are very important to serving the rural population of america. I know they face challenges with funding and so forth. But one concern that ive been working on and my colleague, miss jenkins has as well, is enforcement of the provisions for critical access hospital. It requires physicians presence over all procedures administered in hospitals, and this has been burdensome for the rural areas. The 21st century cures act requires med pack report to congress on the economic and staffing impacts of this regulation on rural hospitals by the end of this year. And i was just wondering, were about six months in, i was wondering if you might have an update on what has been found so far, if anything. I really dont, at this point in time. And i dont mean to be unhelpful, but i dont have anything to say about it at the moment. Well, i would hope that we can have as much information as is practical and possible in a timely fashion. To look at another issue, shifting gears here a little bit. I know that in the past the commission has recommended allowing the ambulance addon payment expire. Despite this recommendation, i know i hear from my district that they need these payments. Is there any cost Data Available that indicates these payments are needed in rural areas . My understanding is there is not cost report Data Available, and i think there has been discussions in the environment. We had some discussion in our particular in our particular in our particular ambulance report about how cost reports could potentially work. One big issue in trying to go after it is, theres very large, you know, or even reasonable sized operators where submitting a cost report makes a lot of sense. But you also have a segment of the industry where youre talking about volunteer Fire Departments and that type of thing where a fullscale cost report is probably something of an issue. Theres probably a way to square that circle, relatively slim cost report that ambulance providers and excluding certain small ones from the reporting requirements, which might be a path way. Its not commission recommended, but theres discussion to that effect in our report. Well, i appreciate that. I know that one size fits all approach is not always helpful. In fact, it rarely is. And as rural providers face these challenges, i hope youll keep in mind the flexibility and i do want to, unless were done, i do want to say in our recommendation, this principle that i tried to stay in the introduction of, if youre going to provide support for rural providers, which the commission fully support, its really about targeting, not duplicating, not supporting two providers who are right next door to each other and may be, in effect, not able to fully cover their fixed cost, and then youre trying to subsidize both of them. And so in the ambulance situation, we took one of the addons that was targeted to rurals and redistribute it and target it to counties with very low population. We end up covering about 75 of the same areas. You can provide a much larger subsidy. And basically youre moving the subsidy away from places that are near metropolitan areas and giving it more trul toe the isolated areas. And in our opinion, and people disagree, making that dollar go further. Thank you. I yield back. Thank you. Mr. Higgins, you are recognized for five minutes. Thank you, mr. Chairman. Mr. Miller, the New York Times on monday reported that United Health care, one of the largest Privacy HealthInsurance Companies in america, is being sued for defrauding the American People in the Medicare Program under the Medicare Advantage program. Estimated to be between well, billions of dollars each year out of the past decade. The article also went on to name four other private Insurance Companies that participate in the Medicare Advantage for defrauding the federal government and the Medicare Program as well. Potentially tens of billions of dollars each year. Yesterday the department of justice joined that lawsuit and is rigorously investigating those allegations. If these allegations are true, that would represent one of the most egregious defrauding of a federal program in a long time. What is your knowledge of this . And my understanding is, several audits have been done or the last several years, that identified a problem and why hasnt more Decisive Action from an administrative point occurred which presumably the consequence of this is this legal action. So, let me try and answer what i think might be three questions in there. Yes, were aware of the lawsuit. In fact, weve gone through it in some detail ourselves, just as a way of educating ourselves, and i agree with you, there are some relatively egregious things in there. I dont know how much of it you got into with the email traffic back and forth among the company and people in the company, is certainly an issue. Number two, on the auditing and then ill get you to something. Number two, on the auditing, obviously were a small operation, we advise the congress. We dont do any of that oversight. That falls to cms, but what we have been doing, weve made estimates of looking at over time, the coding plans relative to what is assumed and built into the risk. We think that there is excess coding occurring and we have recommended that it be taken out. Weve also recommended that it be taken out differentially based on how much activity is occurring within the plan. And the only other thing i want to say and i want to say this carefully because you may have a different view, not all of it is fraudulent. Plans are collecting these codes in order to understand what their mix of patients are. Let me just reclaim my time. This is not one company. Its the largest provider under the Medicare Program, 17 Million People in this country get their health care under the Medicare Program, through Medicare Advantage. Its four others as well. So that says to me, that this is a systemic problem within the system. It needs to be fixed because theyre defrauding the American People and the medicare problem, number one. Number two, ceo of United Health care in 2014 was compensated 66 million, one person, one salary, one year. The Republican Health care bill that was passed by this house included, on page 67, a 15. 5 million tax cut to United Health cares ceo and their top executives. 15. 5 million. In total. The other companies that are questioned for overbilling, defrauding the Medicare Program, that bill provided their top executives with a 78 million tax cut. At the same time, that company and four others are under investigation for defrauding the Medicare Program. You can parse it any way you want. To me, its a blatant violation of the trust that every member of this Congress Took an oath to uphold and to protect. Ill yield back. The gentlemans time is expired. Mr. Miller, thank