And excluding certain small ones from the recording requirements which might be a pathway. That is nothing the Commission Recommended but there is a discussion to that effect in our report. I appreciate that. 1sizefitsall approach is not always helpful. It rarely is. We face these challenges and i hope you will keep in mind the flexibility that often needs to occur and i appreciate your efforts. Unless we are done i want to say in our recommendations, the principle i tried to save in the introduction, if youre going to provide rural providers, it is about targeting, not duplicating, not supporting two providers next door to each other may be in effect, not covering fixed costs, subsidize both of them. In the ambulance situation we took one of the add ons targeted to redistribute and targeted to counties that had low population density. You end up covering 70 , 75 of the same areas but they can provide a larger subsidy. And removing subsidy away from places that are near metropolitan areas giving it more truly to the isolated areas and in our opinion, people disagree, making the dollar go further. I yield back. Mister higgins, recognized for five minutes. The New York Times on monday reported the United Healthcare among the Largest HealthInsurance Companies in america is being sued for defrauding the American People and Medicare Program under the Medicare Advantage program estimated to be between billions of dollars each year out of the past decade, the article went on to name four other private Insurance Companies that participate in the Medicare Advantage for defrauding federal government and Medicare Programs as well, potentially tens of billions of dollars each year. Yesterday the department of justice joined that lawsuit, and is rigorously investigating those allegations. Of these allegations are true, the most egregious, defrauding of a federal program in a long time. And several audits have been done, and why is it more divisive action from the administrative point occurred. Which presumably the consequence of which is this legal action. Let me try to answer what might be three questions in there, we are aware of the losses, we have gone through it ourselves as a way of educating ourselves and agree with you that there are some relatively egregious things, not sure how much of it you got into but the email traffic back and forth, people in the company, is certainly an issue. I am auditing and i will get you to something, never 2 on the auditing, and what we have been doing, we are looking over time, what is assumed and built into risk mode. And it is taken out, and what is occurring within the plan. And you may have a different view. Not all of it is fragile and fraudulent. We are collecting these codes to understand their mix of patients. Let me reclaim my time. This is not one company, it is the largest provider under the Medicare Program, 17 Million People in this country, healthcare under their Medicare Program for Medicare Advantage, and it is in the system, and it was complicated 66 million, one person, one salary, one year. And on page 67, 15 a halfmillion dollar tax cut to the United Healthcare ceo and their top executives, the other companies in question for overbilling, defrauding, Medicare Program, that bill provided their top executives with 78 million tax cut, at the same time that company and four others are under investigation for defrauding the Medicare Programs, you can parse it anyway you want. The blatant violation of the trust that every member of congress to uphold and protect. I yield back. The scope of this hearing, to give an opportunity, i remind you of mister millers valuable time in the scope of this hearing. I dont want to get in a titfortat, allegations the gentleman brought up are very serious. Individuals or companies are innocent until proven guilty, but i want to remind my colleagues, dont want to waste mister millers time in a titfortat about the American Healthcare act or the Affordable Care act, we could spend all day debating with each other about the Affordable Care act or the American Healthcare act. Mister miller and his staff have graciously given their time today to talk about the report, how we can Work Together in a bipartisan way to improve medicare. I hope my colleagues will spend the rest of the time respecting mister millers time on how to Work Together to implement those recommendations. I recognize the gentlelady from the great state of kansas for five minutes. Thank you for being here. Medicare was created as a promise to seniors, so we talk about how to keep that promise and reform the system, and the affordability of the trust fund. And services that have not moved in that direction. In your march of 2017 report, Skilled Nursing facilities are able to control the money medicare will pay them based on their payment model. I want your sense of the impact of move to evaluate these payment model and Skilled Nursing facilities, the American Healthcare association has a valuebased payment idea, and the march report discusses, reducing payments, increasing payments to nonprofit facilities. Can you talk about medpacs believe that this will strengthen the Skilled Nursing facilities . There are a few things we are seeing that we are responding to. It is not dissimilar inside the Skilled Nursing facility, overall spending is too high but we also think the way the system is structured but we get into the technical, the way the system is currently structured, not paying properly for different kinds of patients. And avoiding complex medical patients. Patient need and barring a greater balance, improve value for the beneficiary, the greater balance in how the payment works, we mentioned the notforprofit or for profit, it isnt about making the Payment System peculiar to for profit or notforprofit, it happens because the way the payments shift based on what those different types of providers take. The other two quick comments on value, we do talk about the notion of time, patience, payments to different outcomes, returning to the hospital, avoiding going to the emergency room. And other conversations about reorganizing the entire Payment System, having unified Payment System but also ultimately moving towards more episodes of care in which inside, clinicians would have the flexibility to engage in practices and delivery practices that they would hopefully bring lower cost and higher quality. A few threads in this particular area. To follow up, the reform Payment System proposed by the American Healthcare association is based on the creation of clinical groupings that would include an array of different patient types and cms has studied this type of payment and i would like to know if you believe that a move to Patient Characteristics instead of length of stay is feasible for cms and providers if it results in better cost savings. Our work, the starting point in this process reconstructed in a different way to do the Payment System based on Patient Characteristics, what you are referring to, the industrys notion is taking that and aggregating it into patient category. As long as the underlying patient payment to patient need is not lost in the process of doing that, it is consistent with the direction we have been talking about going. We appreciate your being here. Medpac over the years has helped deconstruct the hopelessly complex System Congress routinely makes more complex and helping us dive into the details that otherwise we wouldnt have. We can explore some of this but otherwise we wouldnt. Im hopeful that once we can move past the current controversies we can do a better job diving into what some of these elements are to understand them better, look for areas of being able to rebalance the complexities, coach more value and incense more appropriate behaviors. And obamacare, we still pay twice as much as anybody else in the world and too Many Americans get mediocre to poor care. People in canada and france and Great Britain and japan live longer than we do, we get well faster, dont get sick as often and they pay far less. You are helping us understand some of the elements that are part of that, how we can use some of these large Healthcare Programs we finance to get better performance. I want to turn to one specific item you had in your report talking about hospice. This is an area that works over the years. Spend a lot of time dealing with end of life care hospice treatment and in your report you reference that people can get this medicare hospice if they are terminally ill with Life Expectancy of six months or less, but they agreed to forgo Medicare Coverage for conventional treatment of terminal illness and related conditions. I would like you may not have hard data on this. There is a Pilot Project underway looking at what the implications are for continuing punitive care while allowing people to access the Palliative Care in terms of hospice treatment. I think there is some evidence that this is a Decision Point for people approaching hospice that is a difficult decision to be in that mindset letting go, forgoing carrot of as a note of finality to it. If there arent some incentives for some people who would dramatically benefit from hospice care, they and their families and scale down some of the curative activity if they didnt have to be in either or. Would you comment on whether there might be some savings over all, hospice care that might be appropriate to them and not force them to jump off of that cliff. I am aware of the issue. The issue has come up a couple times in the commission conversation. There is no inherent hostility to the notion. A couple thoughts, there is a demonstration out there. And the answer to these questions, hard to get your arms around it because counterfactual is difficult. And hospice should be included in the maa benefit, we are in a full episode, the notion of the tradeoffs being made by clinicians on the ground makes a lot more sense. A typical problem, we take it out and see for service where a lot of things and a lot of people can get involved. They are making the trade off. Again, it is not hostility to it but the concern whether it plays out the way they hope it plays out. We are looking at that demonstration too. Thank you, mister chairman was i wholeheartedly concur with the motion of Medicare Advantage, makes a lot of sense, watching the Pilot Project as a way to federate, the best of both and appreciate having a chance to talk about it. Thank you for your leadership in the hospice area. Thanks for being here today. It is critical for members to have a Firm Understanding of how the program operates as we look for ways to continue to strengthen medicare for the future and as has been discussed, Medicare Advantage program plays a Critical Role in the medicare system. Almost a third of beneficiaries around the country are enrolled in a Medicare Advantage plan. Those numbers will only continue to grow. I know in minnesota our seniors are interested in enrolling. 55 of minnesota seniors were enrolled in the maa plan which was the highest in the country and that is why i remain focused on ensuring highquality. The report you released in march highlights the growing trend of seniors in feeforservice plans choosing to enroll in Medicare Part a only. Given Medicare Advantage enrollees must enroll in both parts a and b can you discuss the impact of more beneficiaries, in the program. Ticking up on something we said, we talked about in the report, getting more of this phenomenon of beneficiaries, a only or be only but the be only is a small phenomenon. What happens in that circumstance if you are in a only beneficiary your expenditures are below average. If you think of the way the Payment System works which you are first in. You accumulate for feeforservice beneficiaries and set a benchmark and there is some administrative to that benchmark, plans bid against. What we started to become concerned about is to the extent that you get more a only and this is geographic in its impact across the country and concerned that it would grow over time youre saying i will set a benchmark and include large body of people or growing body of people the plans cant enroll and it compresses the benchmark. It may be a different we may need a different way to set the benchmark. The aab beneficiary, and this would add costs because it would potentially raise benchmark that the plans are betting against and we have pointed out at the same time there is a coding phenomenon that needs to be taken into account and those dollars need to be taken back. Let me follow up, looking at you mentioning the possibility of adding costs but can you mention what would the benefits be to the beneficiaries themselves if we move to the system of calculating medicare benchmark only using data for feeforservice beneficiaries. Thought about the question that way, a good question but what happens now is to the extent you bid below the benchmark, a portion of that dollar has to be converted to a benefit that goes back to the beneficiary. Mostly they do it through lower cost sharing is arguably the plans are basically bidding below the benchmarks now and offering the additional benefits. Of the benchmark went up in theory they would be able to offer in theory, a lot of behavioral response out there, would be able to bid below the benchmark. They should be able to offer more benefits. I am hopeful over the next few months we continue to examine and explore and address the medicare extender policies, the therapy exceptions process, ambulance and payments, it is critical we ensure there is not a disruption, those Critical Services provided to seniors around the country that rely on strengthening the Overall Program in the future so thank you, yield back. Doctor miller, thank you for your testimony today and the good work you and your staff doing the report we submit, i will follow up with my friend and colleague from minnesota, appreciate his interest in and appreciate the report as far as the benchmark caps and what you are recommending. From my colleagues edification, hr 40 to 75 along with mike kelly, mike doyle, get that this issue so we are glad to see you focusing additional tension on the benchmark issue and interested in following up what we have. To benefit us from the legislature moving forward. Also along those lines, you are aware we introduced a reform bill that would begin the conversation and start getting feedback, appreciative of the effort medpac and all of you, the work you are doing in this field, looking forward to following up with policy recommendations, there is more integration that could be had, more efficiency, Better Outcomes at a better price, the next generation of healthcare reform where we can get Better Outcomes at a better price, cost savings, we tried to follow up with that and i too share the concern of a number of my colleagues about the impact 75 billion worth of cuts in the Medicaid Program and the Republican Health care bill proposal, the impact that will have on health care providers, that will be on top of over 800 billion in cuts to Medicaid Managed Care as we know it in wisconsin and the disproportionate impact that will have on providers and i look forward to following up with medpac as you do a deeper analysis. You are not in a position to comment, detail as far as the impact to follow up in the future so we know what to prepare for, the adverse consequences of future cuts that are being proposed in legislation and the impact it will have in rural america, rural providers struggling already with thin margins as it is and this could be adding on to their roles. Getting back to mister higginss line of questioning, New York Times article in front of me today. That article submitted for the record stated be 152017 authored by mary williams, a whistleblower tells of Health Insurers bilking medicare. Billions of dollars being affected by the up coding issue. Doj has an interest in it. We need more guidance and information as far as how real this problem is and what poli