Want to recognize the members here now. Peter roskam from illinois. Erik paulsen from minnesota. Did i say that right . Minnesota . And tom reed from new york. With that, i will yield five minutes to the gentleman from the state up north from ohio, mr. Levin. Youre still bitter about some of the back and forth between our two states. Judy chu and ron kind. 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 for physicians. And i mention that because i really think your report, and it has areas where there are differences 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, on the 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. 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 health care. Without saying i agreed with everything you said, i wanted to congratulate you on your work. And i hope, mr. Chairman, that we will be able to have some further discussions in depth about each of these important components, because i think there is 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 follow up on this because Prescription Drugs has become so urgent an issue. Begin to discuss with us how medpac has begun to look at this issue. And my time will run out and others will carry on. Thank you. I can just say one thing. I would like to thank you for saying that. Remember, i have a tremendous staff, and also g. A. O. Has done a great job of appointing solid commissioners. 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 that 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. So 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 to our current conversation is in part d. What we have seen is, you know, 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. If you look a little bit closer at the program, there is 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. There is a couple things that are mr. Chairman, you want to gavel me down. Dr. Miller, others will carry on. Okay. So i keep within the time limit. Thank you. Did you want me to gavel you down . No, but i think everybody wants their five minutes. So speaking of five minutes, the gentleman from illinois is recognized for five minutes. Thank you. Dr. Miller, thank you. I will pick up on the a little bit on the wholistic theme of mr. Levin. That there is a general recognition that medicare is a program that everyone celebrates. 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. I am talking specifically about those that are in the nonprofit sector. Their margin is only 3. 6 . So this is a parochially, this is a crown jewel rehabilitation facility in my constituency. Their margins under medicare right now are minus 20 . 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 mean, 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 . So i think you have asked and made a completely fair comment. We have talked to a ton of inpatient rehab facilities and people in the industry, and we do understand the phenomenon. And our data makes your point very clearly. So in the post acute care sector in general and in the inpatient Rehab Facility sector in particular, what you see are very high ag gra gat margins and you see differences in financial performance. As you said its often between for profit and not for profit. Its often tied to what kinds of patients the different facilities tend to focus on. There is a whole section of the report i wont go through it in detail because i know were under pressure in terms of time. But weve seen coding practices that raise questions. Patient selection types of practices that have raised questions. So what we have tried to do is, in all these instances is say, okay, total payments can be lower, but they have to be redistributed across the different kinds of providers. And we general try and do that by tying the payment to particular types of patients. So, if you are taking medically you know, 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 you are talking about. Here is the last thing ill say and then you can back in. Im sorry. In the inpatient rehab sector, the other thing we said in addition to bringing it down is to increase the size of the outlier pool so that more payments would come out of the general payments and go to those kinds of facilities that have the financial circumstance that you are talking about. So where there was a recognition and an attempt to get at that. We also think there are some coding practices that the secretary or the i. G. Or people like that should look very hard at on the very profitable side of the industry. Thank you. Thats helpful for me. Maybe we can engage further. This is the white knight sort of place that you want to be successful. Theyre doing, from my point of view, all the right things. More than happy to talk to you about that. Yield back. Thank you, mr. Chairman. Mr. Thompson, you are recognized for five minutes. Thank you, mr. Chairman. Thank you for having this opportunity to talk with mr. Miller. 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 obviously 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 the that would codify any of the recommendations by medpac to save enough money on the in the Medicare Program to cover that 75 billion loss . I am not aware of legislation that would offset that loss, if thats what you are asking me. The which . I am not aware of legislation that includes medpac recommendations that would yeah. 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 i am not aware of an offset. Does medpac have recommendations to find 75 billion worth of efficiencies in the program . Im going to interrupt you. This is about med caps medpacs recent report as well as the extenders. Thats what i am asking, mr. Chairman. About the report, the march report . Im asking if there are recommendations in the march report . In any report. Are there recommendations by medpac 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, you know, comment on the pending legislation, there are an array of recommendations in the medpac report that result in savings. And so, for example, the post acute care things that we just talked through, you know, we we dont do estimates. Thats cbo and the rest of it. We think were talking about the neighborhood of 30 billion. I mentioned the m. A. Coding issues. I mean, there is potentially a savings there, for example. We also think, you know, the changes in the part d recommendations could yield savings. And then, also, there are a couple 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 yeah. Generally, legislation, yes. So, of the 75 billion 75 billion 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, we would have to pass separate legislation . Yeah. To get to 30 billion, have to pass separate legislation, and there is more you know, i dont know that i could ballpark the number for you. There is more savings in that report than the 30 billion. And that additional savings, would that require legislative action . I think as a blanket response to your question in general, it would require legislation. Do you happen to know if any of that legislation has been introduced . I dont happen to know that. So we have 75 billion hole in medicare with no legislative attempt to address that loss. I am 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. Gentlemans time has expired. Mr. Smith, you are recognized for five minutes. Thank you, mr. Chairman, and thank you, dr. Miller, for your presence here today and certainly your responsibilities are large and youve got a big job to do, so we appreciate your efforts. 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, and i know that they face challenges with funding and so forth. But one concern that i have been working on and my colleague, miss jenkins, has as well, is the enforcement of the physicians supervision requirements for criticalaccess hospitals. As you know, these rules require a physicians presence and supervision over nearly all routine procedures administered in hospitals. And this arbitrary regulation has been especially burdensome for hospitals and doctors in the very rural areas. It seems unnecessary. The 21st century cures act requires medpac to report to congress on the economic and staffing impacts of this regulation on rural hospitals by the end of this year. I was just wondering, we are about six months in already. I was wondering if you might have an update on whats been found so far if anything. I really dont at this point in time. I dont mean to be unhelpful but i dont have anything to say about it at the moment. Okay. 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 a little bit. I know that in the past the commission has recommended allowing the ambulance addon payments expire, despite the this recommendation, i know i hear from suppliers in my district that they need these payments. Is there any cost report Data Available to cms 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 there is very large, you know or even reasonable size operators were submitting a cost report probably makes a lot of sense. You also probably have a segment of the industry where youre talking about volunteer Fire Departments and that type of thing where, you know, a fullscale cost report is probably something of an issue. There is probably a way to square that circle relatively slim cost report that, you know, and ambulance providers and then excluding certain small ones from the reporting requirements, which might be a pathway. Its nothing the commission recommended, but there is sort of a discussion to that effect in our report. Okay. Well, i appreciate that. I know that onesizefitsall approach is not always helpful. In fact, it rarely is. As rural providers do face these challenges, i hope youll certainly keep in mind the flexibility that oftentimes needs to occur. I appreciate your efforts. I do want to unless were done. I do want to say, in our recommendation, you know, this principle that i tried to say in the introduction of, you know, if youre going to provide support for rural providers, which the commission fully supports, its really about targeting, not duplicating, not supporting, you know, two providers who are right nextdoor to each other and may be, in effect, you know, not you know, not able to fully cover their fixed costs, and then youre trying to subsidize both of them. So, in the ambulance situation, we took one of the addons that was targeted to rurals and redistributed it and targeted it to counties with very low population density. We end up covering about 70 75 of the same areas, but you can provide a much larger subsidy. And basically you are moving the subsidy away from places that are near metropolitan areas and giving it more truly to the isolated areas. And in our opinion and people disagree making that dollar go further. Okay. 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, among the largest private Health Insurance companies in america, is being sued for defrauding the American People and 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 among 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 over the last several years that identified a problem, and why hasnt more Decisive Action from an administrative point occurred, which presumably the consequence of which is this legal action . So, let me try and answer what i think might be three questions in there. Yes, we are aware of the lawsuit. In fact, we have gone through it in some detail ourselves as a way of educating ourselves. I agree with you. There are some relatively egregious things in there. I dont know how much of it you got into, but the email traffic back and forth among people in the company is certainly an issue. Number two, on the auditing, and then i will get you to something. On number two on the auditing. Obviously we are a small operation. We advise the congress. We dont do any of that oversight. That falls to cms. But what we have been doing is we have made estimates of looking at, you know, over time the coding in managed care plans relative to what is assumed and built into the risk models. We think that there is excess coding occurring, and we have recommended that it be taken out. We have also recommended that it would be taken out differentially based on how much activity is occurring within the plans. 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 that needs to be fixed because theyre defrauding the American People and the Medicare Program. Number one. Number two, the ceo of United Health care in 2014 was compensated 66 million. One person. One salary. One year.