00:00And what one of the reasons I often go to the end is it's just us. I want to
00:08first off thank all of you. I know it's been a long day. We're already, you know,
00:13far beyond. I promise not to keep you here more than a couple hours. Also to
00:19say thank you to staff. So let me start with a couple things I want to run.
00:27Much of the, let's call them the lobbying, the expert community, you've been
00:32remarkably helpful to us in understanding the complications of a managed
00:37care model, you know, capitated, those things. There are some bad actors. If any
00:42of you are the lobbyists for whoever is buying the MAGA influencers to basically
00:49attack anyone who's trying to understand the economics within MA, please
00:56understand we've asked the lawyers to start investigating is this little
01:00unregistered lobbying and we're going to find out who's paying for it. So just if
01:05anyone's watching, please understand you started it we're going to end it. All right.
01:10Can I walk through a handful of things? First let's just get it out of the way. I
01:14have a series of articles that I'm going to put into the record and because I get
01:20to not object to myself, you've all probably followed the five, is it seven
01:27part Wall Street Journal series that walk through even people in Arizona that
01:32were diagnosed with diseases, except they were never treated for them. And the plan
01:39always said well that was be we hired a contractor to send people's homes. We paid
01:46billions of dollars in diagnosis. This is the up coding problem. Our risk
01:53adjustments problems. The going at those who ask a question. And it just and some
02:01of it just continues and continues and continues. And we even had a couple members talk about the
02:06Wall Street Journal article about those who are actually getting their health
02:10care from VA but somehow still sitting in Medicare Advantage. We've also have
02:17articles and we're actually looking into those when it's a push-off to force
02:23someone who starts getting your end of life and it's part of a MA plan and to
02:29force them into fee-for-service for hospice care and trying to now chase down some
02:33of the odd numbers there. You've also seen the articles that on some of the
02:39brokers and the investigations going into there and the false claims that
02:44appears to be coming. But why are we doing this? Why are we having parts of this
02:49conversation? Here's some of our math that in seven years Medicare is supposed to be,
02:58this is full Medicare, this is the whole plethora, two trillion dollars. We go from
03:05functionally one trillion this year in seven years to two trillion. Some of
03:10that's demographics, actually it's mostly demographics, health care costs, the peak
03:15of the baby boom moving into much higher utilization years. I get some math
03:22problems trying to make this all work and so we're trying to figure out I think the
03:32concept of a managed care model that helps our brothers and sisters who have
03:37moved into their benefit years live healthier. When I'm seeing data that 31% of
03:42Medicare is diabetes and then when we broke down the subsets of that, the number of
03:50our brothers and sisters who are 65 and up that had obesity issues. How do I
03:57incentivize a model, particularly if 50, our math is 55, not 54, 55% of our brothers
04:04and sisters on Medicare Advantage across the country, some places higher
04:08penetration, that there's an incentive for a plan saying we benefit by making our
04:16members healthier. So this is from my opening statement the alignment of
04:22incentives. One of the reasons I have great fondness for Dr. Miller is he's been
04:28very kind enough to testify in front of our Joint Economic Committee and in that we
04:32were fixated on the use of technology to also lower the cost. So first question
04:39before I go off on some of the things. Dr. Miller, first let's just go where we
04:44were going to go before. If I came to you and be a little utopian, said okay we have
04:52the technology today that follows you around, that the AI transcribes your
04:58notes, here's here's my doctor's notes, here's my healthcare contract, whether it be
05:03private or Advantage plan, the AI can say they match and it's basically automated or
05:10pre-authorization. Am I being too utopian? I think it's operationally possible. I think
05:18that the issue is does the industry have the willpower to do this and then will
05:23the hospital industry come to the table? Because one of the other issues is is
05:28that if you're an incumbent large health system you don't have an incentive to
05:33improve operations. When if you're a hospital executive and you can lobby to increase Medicare
05:41fee-for-service rates, you can merge with a larger health system, you can do all these
05:47other things before coming to the table to improve clinical and technical operations.
05:53I think that's an incentive issue. So I think we need pressure on the health systems in conjunction
05:59with the managed care industry to work together to solve these technical problems because they
06:03are very solvable.
06:06Doctor, so you think the brain trust like us, we need to be more prescriptive in our expectation?
06:14I don't think prescriptive. I think it's sort of like when you have two squabbling
06:18children, the answer is stop fighting over the matchbox cars and learn how to share. So I
06:24think you have the hospitals and you have the health plans arguing and you have the plan
06:29saying I have big monopoly hospitals and then you have the big monopoly hospitals saying I
06:33have these big mean monopoly health plans and sometimes they're monopolies and sometimes they're
06:38not, but they need to figure out how to work together for a better system and solve that
06:43technical operational friction and you've you all are functionally their parents.
06:47Dr. Miller, one thing I want you to touch on how you would adjust Stark to accomplish one of your
06:54goals.
06:55So I think that's really important. If you're a physician and you know I mentor and train
07:00a lot of young physicians, you don't really have any employment choices. You face a labor
07:04monopsony where you can work and I remember I saw this dermatologist who was depressed and
07:09I asked him why he's depressed and he said well you know he had two large health systems
07:13that he could work for and he couldn't do anything else and he was stuck on an assembly line.
07:17So Stark Law was created with to address valid concerns about induced demand that if physicians own
07:24and operated integrated care delivery that they would self-refer and drive a lot of unnecessary
07:30services, whether it's imaging, whether it's labs, whether it's home health. And so we have
07:35an opportunity now with Medicare Advantage being half the marketplace to waive Stark because
07:43you have health plans who are doing utilization review and prior authorization to make sure that
07:48the right thing is done because it doesn't make sense for us now to say that if you're
07:53an orthopedist and you work for a large health system, the health system can require you to
07:57self-refer for physical therapy and MRI. But if you're in private practice, that orthopedist,
08:03you cannot self-refer for MRI or physical therapy for integrated care delivery. So we need to put
08:10private practice physicians on an equal platform to large multi-billion dollar health systems and
08:16manage care as our vehicle for us to do so.
08:19Dr. Jane, your written testimony actually, this is going to sound odd, provided me some joy because
08:30in many ways in there you have much of the model that we've been trying to move back, not reform
08:40to in some ways we're just trying to go back to what the original vision was, that the incentive
08:45is an organization benefits by our brothers and sisters becoming healthier and trying to find
08:54those steps where because an enrollee, a patient, a member can stay with you longer, you invest in
09:04their future health. In your vision for your organization, because you have lots of data
09:11points, do you see a place where you could also use things like, you know, grandma gets a whoop or an
09:18oral ring or the wrap that sits as a wristband that actually helps you monitor hypertension and
09:26your temperature and those things. Is there a place where the continuity of care, particularly
09:35for your rural, you know, we had a whole conversation about transportation and those things, but that
09:42telehealth, digital health in many ways is the future on helping the maintaining of latitudinal health data.
09:53Is that woven into or do you see that? I think it's absolutely possible. I think one of the reasons
09:59that value-based care has largely been a failed experiment in this country is that it can't be
10:05practiced in one-year increments. If I don't know that you're going to be my patient a year from now,
10:09three years from now, ten years from now, I'm not necessarily going to make the rational investments
10:15in year one to improve your health in year three or year ten. And so I think one of the opportunities
10:21that the committee has and that Congress has more broadly is to start to entertain this notion
10:26of multi-year enrollment and Medicare Advantage. Multi-year enrollment would enable us to have
10:32stability of the population, which would allow us to integrate these digital health solutions
10:39in year one that ultimately have really failed to improve population health, even though we have
10:45very sophisticated technology right now because people are under-investing in these technologies
10:51because they don't necessarily have the confidence that investing in year one will result in savings in
10:57year two, three, four, five, and six. If plans had a longer period, plans or even CMS in the traditional
11:05Medicare program had a longer-term view of cost and had a way of internalizing the savings, I think there would be
11:11incredible momentum towards the kind of health care system that you're imagining, Mr. Schweikert.
11:16Dr., you may be about to become one of my best friends, which is a little creepy. You never want a politician
11:21as one of your best friends. We're expensive. But look, we've been trying to model the concept of
11:27what happens if I have someone who has multi-chronic conditions or BMI issues? How do I help them
11:34stay there? And then, but make it so it's rational to invest in it and then help them stay there. And that's, look,
11:41that's not partisan. That's just investing in long-term health care. But one of the issues that's been brought to us by,
11:49actually, a handful of the plans that have been remarkably good at working with us and providing us
11:55actually some very private data, we've made some promises not to say some of the things
12:00out loud, is the way the advertising broker, when open enrollment is, of how you're often
12:08trying to steal each other's members. We saw a number, and we're still working to vet it,
12:15that the total advertising broker marketing could be as much as 20% of the book.
12:22Does that number seem rational to you?
12:2520% seems high, but what I will say is that, you know, the number one line item, you know,
12:30the G&A line item for most plans is distribution. So if there were ways to actually cut our overall
12:38distribution costs or recast the distribution costs to be more focused on health promotion behaviors.
12:46Investing in actual health care instead of late-night cable television.
12:51We have a proposal that we've put forward, which is the notion that brokers should be recast as
12:58community health workers. These tail commissions that we pay folks several hundred dollars a year
13:03should be reoriented around making sure that older adults get primary care appointments,
13:10they get their colonoscopies, they have someone in their life.
13:13But that would be within the plan once you're enrolled. But Dr. Miller had actually sort of the other side saying,
13:20look, if I have the data set that says I could do fee-for-service, I could do a combination here,
13:26I could do, and see it all right in front of you. The technology is your educator.
13:34You know, Dr. Miller is 100% right. The front door to the Medicare experience is one that needs to be totally rebuilt.
13:41Turning 65 in this country is very complicated. And it's one of the reasons that I think people are very confused
13:49and don't know what to do is because there isn't a lot of transparency. It's because you have to sign up for Medicare,
13:55you've got to sign up for Part B. It's an alphabet soup for the average older adult who feels paralyzed in the face of the decision-making.
14:02And I think, you know, I'm not a Republican or a Democrat. I tell people I'm an effectivist. I believe that we need...
14:10Oh, so you're starting another party with Musk?
14:12No, no, no, not at all. Not at all. But what I would say is I really want our programs to work the way that they were intended to work.
14:19And I think that that's where our focus should be right now.
14:21Look, at some point we have to deal with the reality and this is more for staff to hear.
14:27Our current model says in seven years the Part A trust fund is empty.
14:32And there's a structural 11% cut coming, let alone a 24% cut coming to people on Social Security and we double senior poverty.
14:43We have the scale of these things is stunning amounts of money.
14:48It's demographics. You know, we have a shortage of young people, we got much older.
14:53So, Dr. Bassel, you actually, one of your specialists, you have everything from urban to rural.
15:03If I came to you and said we're going to incentivize the ability to use much more digital healthcare in rural America,
15:16is there a way that actually both raises your quality, lowers your cost?
15:22Because I can't tell you how many of my doc friends tell me someone came in from rural Arizona and they didn't need to, you know, drive for two hours down from Flagstaff to get to Maricopa County if we had had the scan had been, you know, sent properly.
15:40Or we duplicate the scan, like I have a fixation of all MRIs, x-rays, ultrasounds need to be attached to this so they travel with the individual.
15:49We think there could be 25 plus billion a year just in duplicative scans.
15:54But the ability for you to have continuity, more investment in technology, does that solve or at least help your rural issue?
16:03No, absolutely.
16:04So, we've actually changed EMRs lately to get access to a broader network of electronic records.
16:11That interoperability piece is certainly part of that equation.
16:15And you talked about digital health as well.
16:17So, my wife is a pulmonary and critical care doctor.
16:20And, you know, in a very rural network, probably 15, 20 percent of her patients already are via telemedicine.
16:26So, if she's in clinic on a given day, her 9 o'clock patient will be in person.
16:31Her 9.30 is very likely going to be somebody from three hours away that she's seeing via telemedicine.
16:37You know, to save that family having to drive that three hours.
16:41I want you to think much more revolutionary.
16:43Maybe this is more in Dr. Miller's utopian of technology.
16:47And staff is telling me they're late for their cocktail hour.
16:53We actually, look, I've been doing telemedicine since I got here.
17:00It was never ever going to get a hearing until COVID hit.
17:04And then suddenly it's the law and the world didn't come to an end.
17:08And the amount of inbound crap I took in advertising those things beating me up because I was.
17:15But the fact of the matter is the data that I can wear, come off my body, you know, the breath biopsy, all the other things you can have in your home medicine cabinet.
17:25That telemedicine may not be talking to a human.
17:28Yeah.
17:29It could be getting my readout, telling me if I need to go to, you know, my, my doctor.
17:39We're already having steps like that.
17:40My watch just told me it's, I need to be getting up and move around.
17:43Yeah.
17:44Yeah.
17:45So look, I cannot thank you enough.
17:51We're going to have the continuing sort of debate and we're digging into it.
17:55As you know, the oversight committee is doing a deep dive.
17:58We're trying to do the data.
18:02We're trying to understand is MedPAC, you know, is this thing correct that I have 120% over the cost of fee for service.
18:11If that's gap, you know, that gap would be a stunning amount of money over 10 years.
18:19We want the continuation of a managed care where the incentives are properly aligned.
18:25Help us, help us with any articles, help us with data.
18:30And for any of you, thank those plans, those insurers, those researchers who've been positive in helping us.
18:39And fuss at the ones that are trying to burn us down for even looking under the hood.
18:44And with that, we're going to call the hearing to an end.
18:48But please be advised that over the next couple of weeks, you may get written inquiries that we will ask you to respond to,
18:56that we will attach to the permanent record.
18:58And with that, we're going to call this hearing adjourned.
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