or employer mandates or employee mandates that may be in this bill per call by can say is i acknowledge the process and i hope to cooperate, but i don't see how you can set up are richard deadlines next week to even cover a decent part of the coverage aspect. that is what has me upset. . this. >> that's our intention. i appreciate the comments. senator casey? >> let me just add a couple of comments here. this is a difficult process and those who have been here longer than i have know how difficult probably more than i have a full appreciation for. today and yesterday we're still on inequality, is that correct? >> that's correct. >> we're doing quality today.

we're nowhere near getting to coverage. we're a ways from that. i understand the concern about having -- having information. we're not on coverage yet. we're still on quality and still a lot of work to do on this, but i know one thing, the american people want us to move. they don't want us to delay. they don't want us to slow down. they want us to move and get something done here. so, i realize it is difficult and i realize people want more information but if we are still on quality today we can make progress on quality but the last thing they want us to do is sit back and slowdown. they want us to get this done as fast as we can and i think we are making progress on quality. we ought to make progress on coverage when we get there but we are still a quality and should get something done today. its quality and i feel we could even make progress this morning. >> let me say to my colleague for pennsylvania all i am going

to work with the chair and the majority but i think the american people want us to get it right. i don't think they want us to get anything, they want us to get it right and as i said to the chairman in the opening statements, we all have to remember what we do, we get one shot and i want to work with the chair and with everybody on this committee to make sure at the end of the day we can be proud of the product if we accomplish that by friday, great, if we don't we will know that we have a healthy debate good for the process at the end of the day nobody knows what the products will be. >> let's get to work on quality, that is what we are here to do. >> let me turn if i can't senator mikulski. why don't we take care of those and reach some agreement. >> by the way we have got a quorum of 12th so let us go into

the executive session if i can for a few moments with my colleagues to return to the affordable health choices act in a moment. kathy martinez is the assistant secretary for the disability, kathy is the nominee for the administration for aging department of health and human services. i want to thank chairman kennedy and remember mike enzi for their work on the nominations. >> i have comments i will put in the record it's been clear on our side. >> all of those in favor say aye, the ayes appear to have it and the nominees are confirmed by the committee. they will be reported. let me go back if i can to senator mikulski about amendments that have been cleared. >> thank you, mr. chairman. i want to say to the committee we had a good day yesterday.

we accepted 17 amendments, and very few from our side, but as the other side of the aisle offered suggestions and we could either accept them because they did improve the bill, senator enzi amendment men's particularly comparative effectiveness were constructive and we voted on two of them. i believe we could finish quality today or certainly finish quality on monday. let me get to what we could accept overnight. i have four amendments we could accept. number one, we can accept murkowski number nine which adds physician's assistants were to providers who may be part of a community of team. we could accept hatch mine which makes patient navigators have a minimum set of knowledge and skills, an excellent amendment and also we are accepting hatch

21 as modified and we agreed upon to add a study with hospitable readmissions and i think that would add value to what our bill is. the other is we have enzi for which goes to administrative simplification which we can also accept. therefore i ask unanimous consent that murkowski nine, action line, hatched 21 as modified and enzi blood be accepted by unanimous consent. >> mr. chairman, not an objection but there was enzi number six was the easy one, enzi number four was the easy one. >> why don't we then talked about enzi number four. i withdraw my unanimous consent and resubmit to murkowski number

nine, a couch, number nine and had 21 as modified. i ask unanimous consent that it be adopted. they are saying that is murkowski six. i'm sorry, i can't quite read this note. i apologize. i withdraw my unanimous consent request. murkowski number six is the physician's assistants, hatch number nine, had 21 as modified. i ask unanimous consent of the three amendments be adopted. >> is their objection? without objection i thank senator enzi for the agreement. those amendments will be agreed to. >> i need to go to enzi number four and number six on administrative simplification. i am going to say to my good friend from wyoming that in

consultation with the white house, because what enzi number six does is one to strike the word operations procedures in the administrative simplification. there is concern that if we implement well, first of all, senator enzi, you might explain what number four and number six or and then rather than me explaining what it is and what the flashing yellow lights or about it. >> thank you. yes, we certainly agree that we need to simplify the administration of health care and that will make a huge difference so i actually filed three amendments on this section. number five strikes the section because i didn't think of what work the way the authors intended but i use number six to modify that so that i didn't

need to do number five and that allows it and minimum to do no harm and the final amendment was amendment number four which replaces the underlining language with language like equal simplify the administration of health care. so, this number six is to make sure we do no harm and if there is still a word or something that's different i guess we need to talk about that, but i think that six is important to keep the underlying provisions from backfiring and actually adding red tape, and with the modifications, the underlining professions might slow the process with the department of health and human services and if the language is enacted without my amendments, business operations would be interrupted and conversion costs could be astronomical. so i think cms is confirmed that this language that i am trying

to modify would throw a wrench in the works so i'm trying to come up with language that would insure that we did no harm and then in amendment number 4i have what i think is additional simplification and i am pleased that was recognized. because there is some burdensome timing and time consuming process for updating of the standards relying on related claims and if we facilitate quicker updates and implementations to the transaction standards we can make a huge difference. and i do applaud senator mikulski's intent regarding this administration simplification. i just didn't think it went quite as far as we could go to simplify and make the changes to get >> well, let me respond to the senator and usually on management and administration i

tend to be often in synch because one of the considerable background in business and accounting and so on, however on this one we have respectful disagreement. the amendment number six strips the inclusion of operating rules on administrative simplification. i am concerned that the enzi amendment would undermine efforts to reduce the administrative burden when health care providers both public and private by deleting the inclusion of operating rules. operating rules are important because they build on existing standards to make electronic transactions more predictable, consistent regardless of the technology. operating rules reduce costs and administrative hassles baiji taking out and leaving in words like standards and procedures but taking out operating, the operating folsom goes to the heart of it. the current affordable health

choice act of administrative simplification standards that allow doctors, patients, hospitals and payers to more efficiently carry out administrative transactions and would reduce the it ministry if hassle in this area. the administration of health care claims alone cost ten to 14% of doctors, practice, revenues. we estimate section 22 could save anywhere from 25 to $30 billion. now, so that's what his amendment does. to be sure though i did consult with omb because i want to work with you and we have had a good time working to get there. but they were concerned that by striking the requirement data elements within the standards

unambiguous could likely lead to more variations which information is required, how we would be collected etc. and to the extent the greater variation undermines the very savings so we want to decrease variations and we are concerned that the very intent instead would go against the whole concept of administrative simplification. so i don't object -- this is not a vote -- >> we are very close on it and move where my request came is from cms so we ought to check with them, too -- >> i tell you what we're out rather than voting you down why don't we put you aside and let's make sure that everybody in terms of the white house team both cms and omb have conferred and give the best advice where

we could have the best practices to achieve the greatest savings because the white of administrative simplification is not an end on to itself. it's not a quality, quality is an end onto itself. administrative simplification is administrative procedures and if we can iron out i would be happy to do so. >> i agree and we are both talking about the same thing. cms seem to think they have the rules cover a different way and it turned out to be duplication, so if that is the case we will probably have it solved so yes i will wait on that. >> hopefully we will be able to sit through on monday. let's go to something that will be hard to zip through which is roberts number-one. in terms of roberts one, after

-- if we go to page 323 section section 219 the current language says the center, meaning health outcomes reports and recommendations shall not be construed as mandates for payment, coverage for treatment senator roberts and his amendment would strong concurrence from senator coburn suggested an alternative that says what they would do is strike which shall not be construed and insert the words are prohibited from being used. is that accurately reflect the amendment, senator robert? >> yes, ma'am. >> now, again, in consultation

with those in the washington policy department, they objected to that language but they did not object to finding a middle ground. stick with me in a net. >> what washington policy department? cms? >> no. we are dealing with the white house policy. who in turn deal with their agencies. could i go on to find a sensible center here which would just talk with your staff but i don't think -- okay. the potential counteroffer which would say this, so the senator reports and recommendations are prohibited from being used as

mandates for payment coverage or treatment. so what they are saying is your sense prohibited from being used for payment, coverage or treatment. all we want to do is after prohibited from being used in search of the word as mandates. >> i thought that was sort of the plan. >> and actually i thought -- even more finely tune to what you wanted because we instructed as we were going to have this conversation pay attention to what the others were saying. there have been bonafide arguments raised. of course the need for outcomes research is widely accepted in most circles. so i could go on and tell you what the rationale was. the mandate explicitly means

government regulatory policy. since congress and the administration set policy the originals to the replacement language would make policy makers, policy makers subject to the provision when making center reports or recommendations st requirements for payment coverage for treatment decisions. he or amendment would instead place the prohibition on all public and private health plans not just policy makers. so we think the suggestion i am offering is actually more to the heart of what you were saying which it really keeps everybody out of the treatment room, and it also deals with the payment issue. this information couldn't be used in practice as well as policy which is a significant limitation on its use since it applies to doctors as well as health plans.

doctors would not be allowed to use senter reports and recommendations treatment decisions even if they were good ideas. and we are worried about that. so we want doctors to go to your question about who is in charge in the treatment which is also the heart of senator colburn's argument. our language would be make it clear is the doctor who is in charge, but you were language could prohibit doctors from actually using solid information that could come out of the southcom. >> i put in front of each of you hear the bill language as it is. the roberts, colburn amendment. >> mr. chairman? senator mikulski, have you

finished ma'am? >> senator roberts? >> thank you, senator mikulski for your willingness to work with us and staff to get to some kind of understanding about this where we could agree. i think that you have counter language, i think we have counter language. but we will see where we go. i am not concerned and i can't speak for dr. colburn but i think that he would agree about the center being prohibited from mandating. my concern is prohibiting cms from using information to mandate doctors' decisions and treatments and if i might, a mandate is not the same thing as a prohibition. a mandate means to force or

blind, prohibit means prevent and the language on page 323 that the distinguished senator points to says that the reports and recommendations of the center for health outcomes research and evaluation which will be conducting the needed i might add and i'm very supportive of that comparative effectiveness research there's no reason why they can't inform doctors and disseminate the information, but that language says shall not be construed as mandates for payment coverage for treatment. now you have to the other language. >> it is on the bottom very last line. >> -- from being used as a treatment decision as i indicated mandates is not the same thing as prohibit. this language with all due respect i do not think will

prohibit cms from using this language for payments, coverage or treatment. i don't think any of office support allowing cms to use this information in this way. i know that i do not and i know that the distinguished doctor does not. cms -- and i went into it, probably way too long remarks of the long track record of missing data to deny access to new treatments. and i gave the example of the former head of the cms and bachelet coming to my office since i have a hold on him, and he actually talked to great providers and cleaned up the ladder that we sent and i felt that we had gotten along fine and then within months cms was doing precisely the opposite of what he indicated.

and then later when we had the chance to visit on an airplane i let him know about that and he expressed shock and amazement. so, i think we have to take that extra step using the word prohibit. i just think we should have a flat prohibition cms shouldn't be allowed to use this information to set payments or coverage for treatment. that doesn't mean they can't in four or disseminate. to better educate and better help doctors across the country. and let me just repeat in terms of controlling cost in cer, peter orszag who is very influential on this administration has said they would use cer to control cost.

larry summers said they would use cer to control cost. raymond kingston said -- he is the director out at nih and i know the distinguished senator from maryland knows him personally, kathleen sebelius said this, the new secretary of health and human services and a personal friend of mine. i even have heard the president's dog boe said, well he barked, but in case you didn't follow cms there would be a biting consequence. now, i don't want to quarrel and get down into the weeds to the degree that we talk up our efforts for the whole morning especially since it is a friday and i do want to thank the chairman for his perseverance again also the ranking member.

and i do want to thank again, senator mikulski who works with everybody with good intent, but we had a counter counter if i can find. allison, do you have that or do i have it? [inaudible conversations] >> okay, just to make sure everybody understands we want cms to inform and disseminate, we see now senate reports and recommendations are prohibited from being used by any government entity for payment coverage or treatment decisions. and then we thought that that would be more precise. so i still believe that the board prohibit certainly is the

intent of what we are trying to do here on behalf of an awful lot of doctors and people who do not want hatchways taken away from the patient and the doctor and i would be happy to yield to dr. colburn if he has any comments. >> i was trying to write because they don't have it in front of us what is the amendment? >> it would be on line five it says senate reports and recommendations and then the following language would be added are prohibited from being used by any government agency for payment coverage or treatment decisions. i don't mean agency, i mean entity. pardon me. agent instead of agency. why don't we just listen to all

of the arguments i and others might make comments or perhaps we could move towards a vote, recognizing that everybody really is here today and present today? >> mr. which chairman? >> senator colburn? >> the thing everybody doesn't want to talk about is whether we want the government practicing medicine, and we said we don't, but then we hear the administration say yes, we do. we are going to use this information with which to make coverage decisions and treatment decisions so either we are or we aren't and there isn't a plan our word and prohibit. that doesn't deny the dissemination of this information. it doesn't deny the actual beginning of knowledge from the spread of good research that might cause us to save money. but there's a big difference between wanting to save money and rationing care and that is what we are talking about.

rationing care because cms will use the information to limit the availability of new and advanced techniques to save people's lives, to extend their lives to increase the quality of their lives because it saves money. and that is what the state is all about. it is about whether cns kits to practice medicine. and the intent of the administration has stated is that they want cms to practice medicine and what that does is puts the government in between the patient and the doctor. it denies the art of medicine. i readily admit we don't do as good as we should be doing in terms of practice protocols, best practices, things we can learn. but there's a whole lot of difference between incentivizing good behavior and allowing us to control cost by having the government stepped between a patient and their doctor and i

think we have to have a clearer provision. if we are not bring to have it what it says by default you admit you want cms to control the cost, so it is either we do or we don't and we are dancing around words here, but the fact of the matter is before we allow cms to ration care or not and that is the whole intent either we put a provision strong and say no, we don't want cms to stand between the patient and doctor or yes, we are going to allow quick and i think center roberts first offer a clear prohibition that cms will not practice medicine, and i might relate eyeball to repeat the stories about in the medicare and all of 1965 here is what they said, exact language you had originally. nothing shall be construed to exercise any supervision or control on the practice of medicine.

guess what? we are not paying attention to that right now. that's why we need a clear prohibition is because the cms is practicing medicine today and we gave the example of the virtual colonoscopy or the use of a pigeon, so let's vote, we either one the government to ration care or we don't because that is what this vote is about, rationing care and the government stepping between a patient and their position. >> there's a fundamental disagreement. we have offered a counter offer it allows exactly the middle ground you're looking for. i think senator coburn made a very good point yesterday that physicians and providers ought to have access to as much information about making those very personalized decisions and providing the best quality of health care for their patients. we are looking at is of course information coming out of institutes of medicine from various disciplines