Erik paulsen from minnesota. Id i say that right . And tom reid from new york. Ith that i will yield five minutes to the gentleman from the state up north from ohio, mr. Levin. Mr. Levin youre still bitter about some of the back and forth between our two states. I dont think ron kind was here hen we introduced. And judy chu. And earl was here part of the time. Dr. Miller, welcome. Read your property your testimony and also your 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 that we s and the heck received and how much ontroversy it 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 thist shows how successful has been, this program, that is in some respects a public, not only public but public and private partnership. And with a lot of back and forth rom the private sector as rehe flected in your report. I just reflected in your report. I just want to comment for each of us on this committee, 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 urging pleadings, but i really think your report shows why medicare is such a necessary and popular frame for the program for the people of this contry. And not only for those who are covered by t. By by their families who by it, but by their families who benefit because those who are older than others in the family have the security of health 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. 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 dwun to begun to look at this issue on my time and others will carry on, thank you. Mr. Miller i could just say one thing. Id 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. Chairman tiberi thank you, mr. Levin. With respect to the issue you just brought up i think its a good suggestion in terms of looking at these things together. I hope we can do that in a bipartisan way. Mr. Levin i would like to. Start talking about Prescription Drugs, you have 48 seconds. And others will carry on. Mr. Miller ok. We have done two areas of work in Prescription Drugs. Most relevant are current conversation is in part d what we have seen is generally look at part d beneficiaries are more 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 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 mr. Levin mr. Chairman, i want to gavel me down. Others will carry on. I keep within the time limit, thank you. Chairman tiberi did you want me to gavel you down . Mr. Levin i think everybody wants their five minutes. Chairman tiberi speaking of five minutes. The gentleman from illinois is recognized for five minutes. Mr. Roskam thank you. Dr. Miller, thank you. Ill pick up a little bit on the holistic theme of mr. Levin. There is 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. One of the leading ones in the midwest. The concern is that the march reports recommends an aggregate reduction in payments by 5 for that group. Im talking specifically about those that are in the nonprofit sector. Their margin is only 3. 6 . This isis a parochially a crown jewel prohibition 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 . Mr. Miller 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. 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. Then you see differences in financial performance. As you said, it often is between forprofit and notforprofit. Its offer 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 we have seen coding practices that raise questions. Patient selection types of practice that is have raised questions. What we have tried do is in all of these instances is say, ok, total payments can be lower, but they have to be redistributed across the different kinds of providers. And we generally try and do that by tying the patient payment to particular types of patients. So if youre taking medically more medically complex, we would tend to shift the payments in that direction which would have the effect of creating better more support for the kind of facility that youre talking about. In the patient heres the last thing ill say. You can get back in. In the inpatient rehab sector, the other thing we said in addition to bringing it down is to increase the size of the outliar pool so more payments would come out of the general payments and go to those kinds of facilities that have the financial circumstance that youre talking about. Where there was a recognition and an attempt to get at that. We also think there is 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. Mr. Roskam thats helpful for mee. Maybe we can engage further. This is the white knight sort of place you want to be successful. They are doing from my point of view all the right things. This is exactly the type mr. Miller more than happy to talk to you about that. Chairman tiberi mr. Thompson, are you recognized for five minutes. Mr. Thompson thank you, mr. Chairman. Thank you for having this opportunity to talk to mr. Miller. Miller, thank you for being here. I appreciate the work 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 1 trillion tax cut that included ad 75 billion reduction in 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 medpac to save enough money on the in the Medicare Program o cover that 75 billion loss . Mr. Miller im not aware of legislation that would offset that loss, if thats what youre asking me. Im not aware of legislation that includes medpac recommendations that would mr. Thompson so 75 billion taken out of the Medicare Program will affect the access to care for the millions of americans who rely on them . Mr. Miller i cant comment on the effect of that particular provision, but your other question im not aware of an offsefment mr. Thompson does medpac have recommendations to find 75 billion worth of efficiencies chairman tiberi just remind. His is about med caps medpacs recent report as well as the extenders. Mr. Thompson thats what im asking, mr. Chairman. Chairman tiberi about the report . Mr. Thompson im asking if there are recommendations chairman tiberi in the march report . Mr. Thompson any report. Recommendations by medpac that would cover the 75 billion loss that was brought about because of the legislation that was passed the republicans in this committee in march . Mr. Miller without comment on the pending legislation, there are an array of recommendations in the medpac report that result in savings. So, nor example, for example, the post acute care things we talked through, we dont do estimates. Thats c. B. O. And all the rest of t 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 the changes in the part d recommendations could yield savings. And then also there is a couple of other places we havent even talked about where we restrain the updates that would produce savings. Mr. Thompson those savings, 30 billion worth of savings, how would they come to fruition . Would it require legislation . Mr. Miller almost everything i have referred to would require legislation. I have to think about that for a second, but, yeah, generally legislation. Yes. Mr. Thompson of the 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 to get there we have to pass separate legislation . Mr. Miller to get to 30 billion you have to pass separate legislation. And there is more i dont know that i could ballpark the number for you. There is more savings in that report than the 30 billion. Mr. Thompson that additional savings, would that require legislative action . Mr. Miller i think as a blanket response to your question, in general, it would require legislation. Mr. Thompson do you happen to know if any of that legislation has been introduced . Mr. Miller i dont happen to know that. Mr. Thompson we have 75 billion hole in medicare with no legislative attempt to address that loss . Mr. Miller im nooth wear of introduced legislation. I wouldnt necessarily be the person who would be aware of introduced legislation. Mr. Thompson 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 . Mr. Thompson again, on that particular provision, i dont feel real versed in talking about what the implications of it would be. Mr. Thompson thank you very much. Chairman tiberi the gentlemans time has expired. Mr. Smith, you are recognized for five minutes. Mr. Smith thank you, mr. Chairman. Thank you, dr. Miller, for your presence here today and certainly your responsibilities are large and got a big job to do. We appreciate your effort. Its no secret that Rural America has some challenges. Especially with the agriculture economy and many of the challenges have access to care. Could critical access hospitals are very important to serving the rural population of america. 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 ms. Jenkins, has as well is the enforcement of the physician supervision requirements for critical access hospitals. S you know these rules require a physicians press and supervision over owl routine procedures in hospitals. And this has been especially burdensome for hospitals and doctors in the very rural areas. It seems unnecessary, but 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 were about six months in already, i was wondering if you might have an update on what has been found so far, if anything . Mr. Miller i dont at this point. I dont mean to be unhelpful but i dont have anything to say about it at the moment. Mr. Smith 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, i know that in the pant the past the commission has thought about allowing the addon ambulance payments have expired. Despite this recommendation, i hear from suppliers in my district they need these payments s there any cost report Data Available at c. M. S. That indicates these payments are needed in ruralaire . Mipe understanding there is not cost report Data Available. And i think there has been discussions in the environment. We had some discussion in our articular 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 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 you are talking about volunteer Fire Departments and that type of thing. Where fullscale cost report is probably something of an issue. Theres probably a way to scare that circle relatively slim cost report that ambulance providers and excluding certain small ones from the reporting requirements. Which might be a pathway. Its nothing the Commission Recommended but there is a discussion to that effect in our report. Mr. Smith i appreciate that. I know that one size fits all approach is not always helpful t rarely is. As rural providers do face these challenges, i hope youll certainly keep in mind the flexibility that needs to occur. I appreciate your efforts. Mr. Miller unless were done. I do want to say in our recommendation this it principle i tried to say in the introduction, if youre going to provide support for rural provide e. Which the commission fully supports, its about targeting not duplicating, not supporting to providers who are two providers right next door to each other and maybe in effect 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 rurels and redistributed it and target it to counties that had very low population density. We end up covering about 70 75 of the same areas, but you can provide a much larger subsidy. Basically you are moving the subsidy away from places near metropolitan areas and giving it more truly to the isolated areas. And in our opinion, people disagree, making that dollar go further. Mr. Smith thank you. I yield back. Chairman tiberi thank you. Mr. Higgins, are you recognized for five minutes. Mr. Higgins 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 the americanauding people and the Medicare Program under 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 ustice joined that lawsuit and is rigorously investigating those allegations. If these allegations are true, they would represent, among the a egregious defrauding of 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. Mr. Miller let me try and answer what i think might be three questions in there. Yes, were aware of the lawsuit. In fact, we have gone through it in some detail ourselves just 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 the company, people in the company, is certainly an issue. Number two on the auditing and ill get you to something. On number two on the auditing, obviously were a small operation. We advise the congress. We dont do any of that oversight. That falls to c. M. S. But what we have been doing is we have made estimates of looking at over time the coding and 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. And we have also recommended that it be taken out differentially based on how much activity is occurring within the plans. The only other thing i want to say, i want to say this carefully because you may have different view. Not all of it is fraudulent. Plans are collecting these codes in order to understand what their mix of patients r mr. Higgins let me reclaim my ty. 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 for others as well. So that says to me that this is a systemic problem within the system that needs to be fixed because they are defrauding the American People and the Medicare Program. Number one. Of united c. E. O. Was h care in 2014 compensated 66 million. One person. Onalry. One year. One salary. One year. The Republican Health care bill onsed by this house included age 67 a 15. 5 million tax cut to United Health cares c. E.