Health care leadership council. We have medical device manufacturers, Health Product distributors, and many more sectors pr sectors represented as well. But today im also speaking on behalf of a campaign that we call protect by doctor and me. Over 670 organizations from throughout the country representing patients, Health Care Providers, employers americanes with disabilities, veterans and others, have formerly urged congress to repeal the independent payment advisory board. Today, were going to share some information and perspective on iphav and what it means for Medicare Beneficiaries and those that compare medicare ben fish area res. We have alex valadka, president elect of American Association of neurological surgeons and director of the american board of neurological surgery. Bob blancato is executive director of National Association of nutrition and aging service proes grams. Also on the board of the society of aging. Bob spent nearly 20 years in the legislative and executive branches of government. Including senior staff of the House Select Committee on aging. Dr. Bill atkinson comes to us today from north carolina. Where he is a widely respected as champion of health care change and improvement. He has been a hospital and health care ceo for over 30 years and most recently of the wakemed system in raleigh, north carolina. I will turn to our speakers shortly. But first i would like to welcome aaron bill, legislator direnor own councilman for congressman phil roe. He is a leader of thesince this issue and again this year he is a primary could sponsor of the house legislation that would eliminate the independent advisory board. So aaron, would you please share some of your thoughts with us . Thank you, mary. Just to start, i have a big pile of business cards in case anyone has questions and you want it reach out to me afterward. I work for dr. Phil roe. He is cochair of the gop doctors caucus and sponsor of hr8 will 49 in this conference which is aiming to repeal the ipab. Dr. Ruiz from california is our democrat lead and we are really excited to be working with their office on trying to make this actually happen this congress. I think we have a good shot at doing that. I do want to start out by giving a quick shoutout to neuro surgeons because they asked that our boss put together a blog post that just went live this morning. If you go to their twitter page, neurosurgery and you can see my bosss wonderful blog post. The biggest thing that i have told people when theyve asked me about ipab is that this is not something that would affect just republican beneficiaries. Not something that would affect just democratic beneficiaries. We need to get support behind repealing the ipab. If it goes into effect, it would make drastic and arbitrary cuts to medicare that we would really have no control over any of it. Theres no judicial review. Congress has basically seated the ability to make medicare cuts to an elected group of people who arent working in medical practice, arent really doing anything by law. So if we can get this repealed and medicare cuts need to be made, then congress is the group that would be doing it rather than 15 unelected bureaucrats. Beyond that we are just trying to get as much support as we can. We have 21 cosponsors right now on 849. And we are up to three democrats. So im very excited about that. Any push that you guys can make with your bosses with advocating to other members of congress, we really appreciate it. I finally have an updated colleague for this congress. Took me a little while but im happy to share it with anyone who may want it. Please feel free to grab a card, reach out to me, and we look forward to hopefully having the ipab repealed this congress. That really about it. Thank you, aaron, for that update. Now before i turn to our expert panelists today, who are going to discuss the potential impact of ipab on patient, physicians and hospitals, im going to take just a moment or two to go over the basics of how ipab actually works and what it would do. So we will do a little ipa b101 here. Now im not going to delve into the weeds on this. B101 here. Noim not going delve into the weeds on this. 101 here. Now m not ing to delve into the weeds on this. 101 here. Now im not going delve into the weeds on this. Im not going into excessive detail. But we have presented the slides that your material today, so you will have those. Even though it has never been activated, ipab has been with us for about seven years now. On paper, it is to be a 15member board, nominated by the president , and then confirmed by the senate. And it is supposed to be compromis comprised of people who may not have any other position or employment while serving on the board. There was an early criticism in the fact that this provision would get extremely difficult to find people with expertise in health care and ask them to essentially give up their professions to serve on the independent payment advisory board. Now the legislation creating ipab established arbitrary growth rates for medicare spending. In 2018, that rate is the gross domestic product, gdp, plus 1 . If the actuary for centers for medicare and medicaid services, cms, determined that per capita medicare spending will grow faster than that established rate, then the ipab is trigger need action. Now once that happens, the board is charged with developing proposals that will find immediate, and i emphasize immediate savings within the Medicare Program and reduce that projected spending growth rate. Now as you know, president obama did not name any members to the ipab. There has been no sign as yet whether the new administration, president trump, has any inclination to do so either. The law aicipated this possibility. That the president would n appoint members to the board. The law states that if the board does not act for any reason, including not having any members, the ipab authority then shifts to the secretary of health and human services. So once ipab is triggered by actuarial provisions by cms then secretary price as of now holds all of the authority to act. So that brings us to the real crux of this issue. What would the secretary have the authority to do under the ipab statute . He would have the authority to identify adequate savings to reach the statutory budget target, gdp plus 1 . There are some constraints in the law. Any proposal could only affect medicare, not any other program. Also, no proposal could ration care, raise revenues, raise beneficiary premiums, increase beneficiary cost sharing, restrict benefits, or Alter Program eligibility. So i think you can see that that creates a pretty narrow path for any proposal that would achieve those savings. And i should note here that just because the law explicitly forbids rationing of care to Medicare Beneficiaries, it does not preclude actions that we believe could have the same impact as direct rationing. For example, if you reduce payments to physicians and fewer doctors see medicare patients, then that has a definite impact on health care access. Even though it doesnt carry that direct rationing label. Now a couple of additional point about the legislation. Any administrative or judicial review of the boards or the secretarys proposals is strictly prohibited. So no administrative and no judiciary review. And also, these proposed spending cuts must achieve savings within a single year. So they are immediate. The organizations that oppose ipab haveoint o that this loally procludes any thoughtful, term initiatives that will strengthen the value of the Medicare Program. But rather it really limits action to blunt immediate cuts. In many ways it remind me of e sequestration. What i havent discussed yet is what is the role that Congress Plays in all of this in ipab was constructed to largely take medicare Decision Making away from congress. But it left a very small window for the legislative branch to act. Congress may only revise the secretarys ipab recommendations by passing an al teternative or alternate piece of legislation that achieves the same level of savings. Again the gdp plus 1 growth target. Or the senate can amend ipab recommendation with two thirds super majority vote and this has to happen very quickly. The secretary submits the proposed cuts by january 25th and congressional committees over this must act by april 1st. A very short window of time. So here you see again that you have this also in your packets, an ipab timetable which triggers in 2017 and then you can see it to the implementation of those proposed cuts in january of 2019. So again, i cant emphasize enough that ipab moved from theoretical issue to a real danger to Medicare Beneficiaries. Cms actuaries projected that ipab will trigger for the first time this year. And possibly as soon as next month. So at this point, secretary price is charged with finding savings of at least 1. 5 billion to take effect in 2019 once cms makes that projection. And the Medicare Trustees also project that ipab will trigger again in 2022 and 2024. And that would require billions more in cuts to the Medicare Program. As you heard earlier, there are legislative remedies to keep ipab from doing serious harm to Medicare Beneficiaries and access to care. We have bipartisan bill in the house you just heard about, hr 49 that is cosponsored by congressman roe and ruiz and rapidly gaining cosponsors. So thank you, aaron, for the work you are doing on that. We also have two repeal bills in the senate. S260 by senator cornin, republican whip. And one sponsored by senator widen, s250 and he is Ranking Member of the finance committee. These two are gaining support in the senate. And in particular were seeing more bipartisan support in the senate than weve ever seen before. I think much of that has to do with the fact that members of now seeing that ipab is an imminent threat and though know they need to protect their constituent who rely on the Medicare Program. With that i will turn it over to ourhr expts who are also speaking on half of the medicare constituencies. Physicians, patients and hospitals. They will each present their perspectives and then we will open the floor for your questions. Lets begin with doctor valadka. Thank you, mary. Thank you for taking the time to attend this discussion as a very important issue. As mary said itll become very important in coming years. As very mentioned in the introduction, im a neuro surgeon. I treat medicare patients. I can tell that you ipab is one of the most insidious parts of the Affordable Care act and it needs to go. As you know since medicares insection it is congress leading the way and seeking policy in ensuring senior needs will be a taken care of. We saw this play out in the last congress when we got rid of sgr and replaced by macra which came from congress with bipartisan support and signed by the president. Thats how medicare is supposed to work. But as mary just summarized very, very nicely, if ipab comes into play then your elected represent tifs no longer have control over how medicare will work. Instead we have 15 people with very little accountability without any day jobs and many of them have never even touched a patient will make decisions about how the Health Care Spending through medicare will be run. And what is even worse, if the board isnt appointed it falls on one person, secretary of hhs. So you have one unelected member of the executive branch who would be perform the job that historically has been part of the legislative branch. I mentioned macra and macra is forcing everyone in a quality based payment world. If we do that, itll drive down medicare costs but more importantly improve quality of care that our seniors citizens get. And with this target approach, to what mary said, ipab would be very blunt instrument. Instead of a scalpel under macr use a sledge hammer under ipab. To put this into context, remember that medicare doesnt pay for the cost of taking care of patients right now. The last statistic i saw is that medicare picks up 80 cents on the dollar of what it cost me to take care of my patients. When you figure that it is essentially a money loser for my office and to keep the practice running then you layener the incredible bureaucracy, whether it is ongoing changes it coding and building practice, precertifications, quality reporting metrics that are often not related to a specialist do. For example my skill and value as a neuro surgeon may be based upon how well my patients cholesterol is managed. It makes a lot of people wonder about wisdom of participating in medicare. Now, again, this may sound like an argument you have all heard in the past, as some say we will stop participating in medicare and yet most statistics show that 90 plus percent of all physicians still do, well, it isnt black or white. You can be a Medicare Participant on paper but maybely only see one or two medicare patient per clinic session or limit the number you do surgery on. So it is rationing without the rationing issue that mary raised. And mary also mentioned im the chairman of a department of a medical school. One issue that hasnt gotten a whole lot of coverage is the effect that ipab or further rationing down medicare would do to graduate and undergraduate medication. So tony, raise your hand. Tony, one of our residents, chief resident, who is not only an excellent neuro surgeon but he has an interest in health care policy. To turn to someone like tony fresh medical School Graduate into highly competent brain surgeon, it takes about a Million Dollars or more, according to our estimates. The money has to come from somewhere. Medicare has an increased number of training slots since 1996 so the subsidies for that come from clinical practice plan or hospitals. And if we just arbitrary start slashing here and there with ipablike cuts that will mean we have fewer physicians or more poorly trained physicians. And neither of those is an acceptable option. So at the end of the day, you know, bad policy is bad policy. Leaving medicare policy decisions in the hands of an unelected, unaccountable governmental body with minimal c congressional oversight will negatively affect access to timely care for nations seniors and those with disabilities. Remember we promised seniors a medicare system that offers best care in the world and bringing an end to ipab once and for all is a vital step towards fulfilling that promise. Thank you, mary. Good afternoon, everyone. Thank you congressman roe, for your leadership and senator wyden and senator cornyn. I have a really long name but what our 1100 members do is provide meals to adults, meals on wheels are terms you probably know better. Our members helped enroll, low income seniors into Medicare Part d Program Years ago. And our members are very sensitive to issues that impact medicare because of the direct effect on participants. And for the past four years our association has passed resolutions supporting the repeal of the ipab. Because ipab repeal is the only safe answer. Ipab makes an unprecedented care taking key policy on payment rates and spending that were the purview of Congress Since 1965. It is a dangerous power grab by 15 unelected individuals with no guarantee of either consumer or patient prep zen tags on the board, andhe power could even be more concentrated ads recommendations only need to be approved bay simple quorum should they be convened. Congress goes from being the driver of medicare policy to a buy bystander. Congress can only turn away ipab by getting 60 vote in the senate to block ipab recommendations or come up with the own proposal, and must do so in a very abbreviated period which doesnt always work up here. Lawmakers dont have the ability to pick out certain things they dont like because they must consider all changes as a ing is el package. President apoints but even hhs secretary unless ipab isnt convened has no authority to block ipab recommendations. Many patient advocate groups except the pan toll recommend fairly significant cuts to the program which could force seniors to pay large share, larger share of the health care cost. This is particularly troubling when half of the people on medicare earn less than 23,500 a year, just twice the poverty rate. And there are limits on what the Program Covers could have a dire impact on many of the seniors who depend on medicare and other assistance programs just to survive. For our members and the seniors we serve, medicare provisions such as Preventative Services and reduced cost vaccines have been vital the past year. So our demonstration programs that provide Community Care transitions and Referral Services and Important Services and innovations like these could be in danger under costcutting measures. This is a volatile time for medicare. Votes will occur throught the ahca and more could follow. It is Still Congress doing the work with advocates here and at home about changes that occur. No such luxury on ipab. No one could have a town hall meeting on ipab. There are smarter ways to achieve savings. More electric Health Records and Delivery Systems and greater focus on outcomes. Time for early a vet as possible on bipartisan bills which should have been done seven years ago. We should kill ipab before it goes anywhere. Thank you. Good afternoon and thank you for being here. Im Bill Atkinson from north carolina. And although ipab does not immediate immediate immediately affect hospitals immediately, let me assure you, everything that affects patient, communities, doctorsis, affects hospitals. Theres no way around that. Thats the reality of how it works. When we first came in the room earlier this meeting you heard a siren. It wasnt an ambulance. If youve been around it enough, you have been around police, fire or ambulance and it was an ambulance. Whether ems is going to a call or coming back and someone likely by no choice of their own is receiving aid through medical services. If it was someone 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 dayes a year including in the snowstorm tomorrow that is supposedly going to be here. Are 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 level 1 trauma patient, most severe trauma patient cups in, and unfortunately in our world today with the violence thats curring 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 a specialists in many, many field, primary doctors. You name it, you need it. All of the surgical technicians and 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, 7 days a week, 365 days a year. And what happened 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 add patiehad a patient trouble regardless of what happened after 5 00 they were going to a hospital in another county. But 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 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 the patients, even if they add loha long day, that patient is moved from waiting chair to waiting chair to waiting chair, that is 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, we 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. And the Health Care World we have today. We ads consumers agree we have o 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 nutrition and things that can keep you out of the hospital if its done right. But to do that, you have to use innovation it 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 ka ching every time somebody moves. Ive always been interested in my career. Now i will end on this spot, in emergency medical services. I happened to be when i was very young in the very first paramedic clas in north state carolina and i still keep those certificati certifications. An interesting move in ems around the nation today called paramedicine. Some big and small cities alike are working with it and they are taking paramedics and training them to do Community Health in addition to their ems emergency response. An interesting thing i heard in dallas, texas who were they trying to set that program up to start. The interesting thing he told me was they were starting with patients who had called 911 50 times in the last year. 50 times. 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, lonely, is it a Health Problem that is being recycled. The answer is 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 blindly. It is an opportunity to do smart things, to do innovation. To do innovation. On that day in america when dr. Don burwick stood in florida and said people will are being injured and killed in hospitals by accidents and by just 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. Ipad is a mistake. Thank you for sharing those different perspectives. Well open it up for your questions now and i have a few i can ask. Anyone in the audience . Yes. [ inaudible ] so elaborate a bit on why this 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 clinicened 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 take cuts. Something done over here as an implication over here if youre a medicare bien fish area. Everything else that is being done or could be done has failed to control costs and i suppose that could happen, but the reality is there are so many approaches, there are so many things that are relatively inexpensive and save millions of dollars and take a burden off of 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 be funded versus talk about 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 most 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. 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 the cycle looks like and what the cost is. The smart way to do this is to introduce innovation and change at the starting line at the system and not simply cutting costs. Yes. [ inaudible ] so the question here is the statute says that it 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 as part of this. I think the real question here is all of this has to be done within a period of one year, what would you expect to see in terms of reductions . What is the real effect on Medicare Beneficiaries. If you run a coffee shop or fast food place and theres a couple of items on the menu that you lose money on every time, your company cant survive you continuing to sell a lot of those. So you may sell a certain number of those things, but you cant try to make that a big part of your business. Medicare, every physician of course were very devoted to our patients. We take an oath and we want to take care of them, but we also have to pay the bills. I tell people all the time mother theresa has to pay her bills and plans her checkbook. You have these competing interests between wanting to take care of people, especially the elderly, versus the realities of trying to keep things running. Its like slow walk the process. Im a Medicare Participant, but if i look tat the books i cant afford to see more than x number of patients or do more than a certain number of surgeries or procedures on them. In effect, that is going to be rationing. I think that word needs to be looked at. There are many innovations as bill has pointed out. Some may get stopped cold in their tracks. They may not expand benefits. So some of the things that are more innovative or newer could be stopped. Thats rationing care too if youre not letting people in. Thats a word thats you have to be careful about because a decision made here may not look like anything beyond that decision, but it has a Ripple Effect on medicare down the road. There are many innovations that are occurring and as we refer to persons 65 or above or any person that needs help, but how many patients are transporting from 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, i wak carolina has a protocol now that has been in play when theres a fall and 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 theres been a 100 review of those patients and theyve had no fallout from that. The patients that need to go and the 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 get checked out. The answer is they are getting checked out because theres a physician on the other end of the line and the medics themselves arent going to make a mistake intentionally. Theyre not going to do that. Theyve been a believe 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 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 an emergency. Its not an experience anybody wants, especially somebody of the medicare age either. So given the implications of what might come to pass, could you speak to the fact that this body, which is has such a powerful mande is unelected, not regulated by federal law and half of the constituents, less than half, are Health Care Providers and 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 youre 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 are you come down on the side of this and i think youre right. You have someone who has a successful career either as a provider or a Health Care Administrator who is supposed to give that up and go work for the federal government and again not all of these members are going to have the real life experience. Thats going to be a big oblem. Its been said that in the mitary the best generals and admirals are thenes 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 bring people in at the top without that experience or that experience may be old the health care has changed so much in the last several years its not the same system your father had, i agree with you, its going to be a big problem. What it feels like is being dorothy on the yellow brick road. Id like to know who is behind the curtain. Any time you have to deal with a wizard who you dont see and you dont know and you dont know what tasks are being assigned, that doesnt feel very good. Most of us that have been in health care for a long time, are used to coming to 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. This is the wizard. It doesnt work. Does it have any value as a catalyst for action . Congress if left on its own is usually not eager to cut spending to anything, especially Something Like medicare. Is there a value in keeping it around if only to spur cuts . 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 tity like this will get cuts done or spur congress to take action a what happens if we dont have that pressure. So ill let the panelists comment and then ill chime in. 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 in 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 in my mind 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 thater t 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 gener 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. They make the clock work, but the reality is youve also got to take care of the people that run the train, if you would, and thats the folks on the line either in a Doctors Office or the call center or in hospitals and nursing. Theyre not going to go for the wizard of oz model of a blind board sitting off behind a cheachea sheet. Its not going to happen. That was a very pragmatic answer, which i agree wit but alsoo back up to 30,000 feet. The legislativeranch may have trouble balancing its budget, but that doesnt mean it should cede this much power to the executive branch. I cant resist, i cant imagine what the mail would be like. The answers you would have to give would be a little tricky. I think thats a very good point that this approach really is the antithesis of representative government. In other words, patients, voters, constituents, voters would not have a vote in this process because this is an unelected board, one that is not dominated by those familiar and close to lehealth care. The fact that all of this would have to happen in such a short period of time, if you had to come up with several billions 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 the physician payment reform proposal. What are the types of cuts that this board could make . Im not cut sure what youre asking. You mean what the board might take . Yes. Theres a target to make these cuts within one year. What would hospitals, physicians and others expect to see . I believe dont quote me on this. Most of the cuts were supposed to fall on providers and exempt other parts of the Health Care System like hospitals. In the shortterm. I think that was several years ago and now were passed that, but i imagine these broad strokes, the physician provider part gets cut this much and hospitals get cut this much, other parts get cut here and there without any more thoughtful and more targeted approach. I think part of the answer is who sits there. If its being balanced a certain way, you could find an imbalance in the way they recommend cuts. Thats why the composition becomes important and who is on the panel. I think one would hope that the first place they would look is fraud, waste and abuse within the system. You can extract a lot of money by being more aggressive on that front, but im sure they would go deeper than that. If you talk to people in the health care settings, not just hospitals because thats a small percentage of people, 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 middle of the night, in urgent care centers, but not so much the type weve seen but driveby centers, but a Community Health network that might be open around the clock, there are many innovations we can do and one of th. Doctors cant be on call 24 7 in a small community. Any other questions from the audience . Could somebody explain the difference between the two . Well, the short answer is you have the ranking democrat senator on the finance committee and you have the republican whip. 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 program. They have the same goal and the same effect. They each decided to sponsor their own piece of legislation. Its easier for us in that path already, but at the end of the day were trying to get critical math to make sure it gets done and the clock is ticking here. Last year there was an expectation that it might be triggered. This year it is pretty certain that cms is going to come out with that projection that medicare per capita spending p exceed gdp per 1 . Gdp growth has been low. Its a low target. It looks like its going to be exceeded and then were going to begin this process of having these cuts. Whether we have a board or not, the secretary will now have that responsibility and those recommendations will achieve those reduction targets. We are really looking to all of you in the audience here and whoever may be watching today to please is your member of congress to sign on to this legislation and get this legislation passed because it is now an imminent threat. Its been out there for a while, but its becoming real. As you heard from the panel today there are real effects that will affect not just the provides, not just physicians and hospitals and those that provide goods and services to Medicare Beneficiaries, but its pretty clear it will directly effect Medicare Beneficiaries and the types of services theyre able to access under this. Any last comments from our panel . All right. Thank you all for joining us today. Appreciate it. Anyone working at any hedge fund involved in shortterm trading, every day theyre coming and trading in and out of stocks, all of those people want edge. Thats a common term in the industry, they want edge. Theres this white edge thats kind of useless for their purposes and the gray zone and then theres black edge, which is clearly inside information. Sunday night on q a, new yorker staff writer talks about the Insider Trading case against Hedge Fund Manager steven cohen in her book black edge. The two are kind of central characters at the heart of the story, theyre very central characters in my book, are these two former portfolio managers. One gentleman is serving a lengthy prison sentence, although his case is on appeal and then the others conviction was overturned after an Appeals Court made it harder to convict somebody for Insider Trading. Sunday night on cspans q a. With the confirmation hearing for neil gorsuch starting next week, on thursday at 8 00 p. M. Eastern well look at confirmation hearings of all eight justices. President trump on the road today in detroit earlier and in nashville this afternoon visiting jacksons home and speaking in favor of the republican plan to repeal and replace the Affordable Care act at a rally in nashville thiss g evening. As the House Budget Committee gets set to take up the republican plan, some gop members of the Budget Committee are indicated theyre not in favor of advancing the plan. Well have that session for you, the Budget Committee meeting at 10 00 eastern and live coverage
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