who wants to run numbers. this is not what the doctor-patient relationship is about and that is the only thing that this is about. my comments have no bearing on politics or what it is to this point. we are now at t-minus 20 days and counting. the doctors and the patients are going to be having extreme difficulties in accessing care and yes mr. cummings i agree with you, it's nice to carry a plastic insurance card to say you are insured. it's quite another thing to access to care. to ever allow the insurance companies to devise the current plans and how they are structured on the affordable care act and i might say affecting small businesses as well outsider off the affordable care act leaves a lot to be desired.

and i'm glad that i was put in the middle of this because for everything that something good comes of it and that is why i'm here today. as a small business i insured my family and my two employees and i had wonderful insurance. i was pleased with it. it was a small business plan and i might tell you a little fact now that you will find surprising. in 2008, just as you said, those premiums raised ridiculous amounts every year. one year was 26% for this great insurance plan. i was in sticker shock. it got to the point in $2008 that each individual in my small business plan to have a fully comprehensive plan would have cost $859. these are $2008. i did the math and i said, i

can't possibly afford this so i contacted my insurance broker and i said what are my options? he mentioned the consumer-driven health plans. not very familiar with it, a little bit leery about the concept, i explored it. it took me two years to sign on however. what i did in those $2008 without the affordable care act legislation, the insurance company took my premium of $859 dropped it down to $300 for the same plan. so why? it did that because we had to assume a $2000.1 pay deductible expense. that is where the risk of the put. the insurance company lowered the premium by increasing the deductible. we didn't have the deductible for in network coverage. we had a very modest deductible

of $500 to go out of network and i was left, yes with an out of network plan. i continued this plan for all those years and i was pleased. i was not pleased when i received a letter dated september 21 that my plan was going to be canceled, that it was not in compliance it said with the aca. i have not read that 2000 page document. i'm assuming the insurance companies telling me the truth. they said that the plan would be replaced by something comparable and i trusted them for that. i have been with this company for years. i was a participating provider with them. just like patients have trust in the doctors patients have trust sometimes in their insurance company too and i was one of them. the new plan rolled out. it took away my out of network benefits, which i might say i

might be able to live with because under the high deductible plan the n. network deductible is $2000 for an individual but the out of network was $3500. i was less likely i must say even in my position and certainly my staff to go to an out of network physician because those first dollar amounts would be ours to bear. being a responsible individual you should take care of your bills. the new plan does not give out of network benefits, not just just to me that to all small businesses. the affordable care act insurance does not ensure for individuals out of network benefits. what i also noted with my new plan that was developed was a very crafted letter that implied that even though i was going to happen in network plan presumed we have the same level as my current day plan but only a network, it would now be called

in atl. the apl plan was not going to have the same network of physicians that my current plan did, both apl and ppos have the same network. the hmo physicians were a smaller, different network so some doctors by their contract have the ability to be in one or the other network but by some contracts they had to be -- products. what happened now was there was this term that i needed to inform my employers -- employees that they need to check to be sure all of their doctors that they currently sought in network -- mind you the same insurance company makes this a bit difficult because you would assume if you're doctor was a network before why wouldn't you doctor in network afterwards but that is where the catch was. the new network was given a fancy name. it was called pathway with

variations. pathway x, pathway x enhanced or simply pathway. i didn't understand that. i'm a participating physician and i had never heard pathway before. i just knew i took care of the apo and ppo levels. they take care of the hmo and pointed services but i didn't understand pathway. i went to their web site and i looked this up. what i saw was that actually these pathways were very restrict it. we have now an inability to refer patients as an ophthalmologist i will need a neurologist. if that neurologist is not enough network, going to give the patient with optic nerve at us and sudden loss of their site the ability to see a fine physician that i have sitting on my right? we have to fix this and that to fix this now. we have no time to play with this. patient's lives are at stake.

acute care situations need a specific doctor to refer the patient too. it's not enough to send them to an emergency room and by the way many hospitals are not in these networks either. thank you so much for your time and i hope i can count on you to fix this. thank you. >> thank you. dr. novack. >> sure chairman and members the committee thank you for having me back again. when president obama made the case in 2009 at that the u.s. needed to lower-cost of health care i agreed with him. on june 23, 2009 i told the house subcommittee on health that quote the system within which you are allowed to provide care is as important to the delivery is the people providing it. if we are not willing to put the same level of attention to detail into signing the system it is doomed to fail. during the same hearing congressman engel announced that he quote would never presume to tell somebody how to take out an appendix or replace a knee but he does know a little bit about

drafting the law. he has been doing it for 50 years. since then the health care law has failed to deliver on nearly every promise including if you like you doctor you can keep her and if you like your health care you can keep it. the problems and failings have certainly extended. in february 2013 the obama administration made clear their position about access to care for medicaid patients in a court filing in the ninth circuit. quote there is no general mandate under medicaid to reimburse providers for all or substantially all of their cost unquote. as children's defense fund president marian wright edelman said at the same hearing in june of 2009 talking about a child unmedicated died, quote his mother could not get that dentist to take them because of low medicaid reimbursement rates. in addition obamacare is architect research and austin frack's research suggested -- will lose private insurance as

it is crowded out by medicaid. in arizona according to 2013 report most hospitals receive 70% of medicare rates for medicaid which is unsustainable. while some will benefit from the expansion the losers will far outnumber the winners. to respond to congressman dingell he may not be saying how the surgery gets done but he is certainly impacting who will get it and when. the access problems do not end with. as i wrote in august 2000 health care exchanges are just a variation of arizona's 100% medicaid managed care system which the last time it was expanded has actually cost over four times what was predicted by supporters. the policies available to the exchanges even with subsidies are far more expensive for many than democrats and the president promised in many higher deductibles co-pays and coinsurance and narrow provider networks.

a group of over 70 muscular to to -- musculoskeletal providers not have a single exchange contract to choice. one reason is the required grace period for policies. this means we can provide two months of care thinking the patient has coverage and then we are on the hook for payment and insurance have no responsibility arizona is not alone. at least one major phoenix area hospital system is not yet have a single exchange contract in large part because the rates being offered are at or near medicaid rates. i recently spoke with a retired professor. she feels obamacare is morally right but she notes proportional doctors take medicare let alone medicaid are willing to make a moral stand and not go to those doctors. the professors claiming the doctors and seeks to have government force them in hospitals to accept her for payment the government decides even if they go out of his is doing so i strongly suspect we

will hear variation very soon from the administration. those who do not wish to defend the failures of the law say what is your solution? i want to quickly mention three areas that should contrary to the many larger proposals that do exist. this year arizona passed a first in the nation blog. i would add with significant byte orders and support the law extends constitutional rights to spend your own resources for legal services but also in strike pay based upon insurance status. this law goes into effect on january 1. ortho arizona since its inception 1994 is focused on quality utilization and costs. we show repeatedly repairs that local physician accountability is a reproducible and effective way to lower health care costs while maintaining high-quality

orthopedic care. intelligent insights a software company with whom i work with a company that revised platform that takes automatically collected data and provides analytics on the data combined with other sources of information, getting better more at great unbiased information in the hands of everyone from transporters in the hospital two.year's, to health care ceos to you for policymakers in the country has never been more needed. ultimately they must move the policies that ensure patients and families maintain control of their health care decisions and that includes access to quality physicians. >> thank you. i think all three of you. i will recognize my cell for a first round of questions. dr. english he said very well in five minutes and i just want to make sure i asked the question that makes it clear to all of us under the affordable care and what was often called rationed

care is occurring simply because you are being told that if you take an expensive practice you could be locked out. well a doctor who is casting off the kinds of people you deal with -- and edwards a neurologist with says anyone who gets ms i'm going to dump them. dr. english costs more and i'm going to keep my costs down by not having those patients. he or she wins, you lose under this rating system. is that pretty much a wrap-up for what you're dealing with? >> correct, that's my interpretation. >> but you can fix that. you simply provide marginal care into less mris and so on and you will be okay, is that right? [inaudible] >> you cannot take these difficult patients and the same with an oncologist. i'm going to go into practice

where i deal with people up into the time they have a serious cancer event but up until that time -- after that time i'm going to dump them. under the current system unless we change it they find themselves undesirable to get full care which costs more for quite frankly to get to the doctor at all. that is what you are dealing with unless we make a change. >> yes. >> dr. novack transparency is a good thing and certainly the person who walks in and writes a check for hands out cash for the service should not be disadvantaged. what happens though and i support that. i from the bottom of my heart find it hard to believe that your cash customer pays more as they do in almost every hospital in america and they know they are paying more because there is no transparency but what would happen to the hospital system if everybody walked in and paid the

medicaid reimbursement if that's a low straight? >> mr. chairman in my conversations with a variety of hospital systems over the last few months for the most part they feel that they need to be able to be profitable at medicare rate which major hospital systems meaning they need to cut their operating costs by 30%. i can speak your zone where the average hospital medicaid reimbursement is 70% of medicare and so for example the average commercial payment is $24,000. medicare pays 14 and medicaid pays eight. were that to be extended further there are simply no way that basically and that basically and if the hospitals and certainly in the phoenix area and i guess it woke up once around the country, i would know by the way that is in that unique of the statement because if you look at their port that came out there is an expectation that up to 25% of the hospitals won't be able to survive this decade anyway anyway.

>> one of the things we have to do is figure out how to stop cost-shifting. in other words anyone including the federal government getting a rate less than what it takes foreign entity to stay in business unless we are willing to work with that entity to make sure that they can in fact live with their great? >> that's correct it is important to note the issue of transparency as a brief aside more than 100 million americans get their insurance through self-funded payer so in the same example of transparency what we found out was again in arizona using hospital association data that the commercial payment was $24,000. in arizona to pay cash for a total knee replacement it was $19,000 so that's one of the executives of a privately held large-company, in exchange for doing everything right for our patients and our employees and their spouses we are paying by thousand dollars extra. 20% more for that knee replacements so we look at the price transparency listeners on

a. it creates a mechanism where not only can we protect the uninsured ultimately we are going to protect the folks who are insured by hopefully lowering the difference between what they are going to pay. >> one quick question and i'm going to respect a five-minute clock. the fact is that we are all seeing something else that belief and i would like a yes or no if you have observed it. the federal reimbursement for a particular event at a clinic or hospital is almost always less than in a hospital. wright's? >> correct. >> so one of the interesting things is if a doctor's hospital is more efficient than a hospital a doctor's office is more efficient than a hospital, we don't say we are going to try to get people with the most efficient rate by paying a fair rate to the doctor but instead simply pay less to the doctor or the hospital and is causing hospitals to buyout doctors

practices which means we are paying more. is that correct in your experience? >> yes. >> yes. >> the gentleman from maryland mr. cummins. >> i thank you for your testimony and i appreciate the passion for what you do. it's so important. dr. english you talked about work that you do with multiple sclerosis patients and i'm very familiar with that whole area. the office is met death in the middle of my districts i spent a lot of time dealing with that issue. you also discuss the costs associated with it was about -- and that is a hefty price tag. ms is of course a terrible disease and i appreciate your work treating no space since afflicted with it. i have serious concerns about

what happens to the 20-year-old woman or the 40-year-old woman who is diagnosed with ms. you agree with the affordable care act prohibition in discriminating against people with these conditions? i can't hear you. >> yes. again everyone agrees i think with the majority of the opening statement about the need to fix the health care system and pre-existing. >> a person with ms were seeking health care coverage in the individual market prying -- prior to the aca that person would marry a mucky. >> in my experience at least in my state the majority of my patients had very good access to care. those that were uninsured there were methods of adding them care. the cost to see me is cheap and

the medications are expensive. >> they were allowed to discriminate against people with existing coverage and that is a fact. do you think people would be a get health insurance or would it be so cost prohibitive that they would have been able to afford at? >> again i would agree with your original statement that we need to handle pre-existing conditions. what i'm seeing here as dr. mclaughlin says as is they get a card get you some access to nothing could that i want to the solve the problem and i'm on board 100%. now hopkins has taken is right. >> you are from maryland? >> fantastic. i'm a maryland graduate too. >> we need to solve that problem.

my experience in what you heard here this didn't solve the problem and we will see these unintended consequences in the near future including from your constituents. >> dr. mclaughlin i couldn't help but think about the things you said about your mother. a member of my immediate family, they found some precancerous cells with regard to the and they could not get it. for four or five years. this was a young woman. as they listen to you we all seem to understand the problem. on the one hand we want to make sure that treatment that is provided beasley met. i know you have heard doctors

take too many tests and all that kind of thing but at the same time we want to get the result so that people can stay well or get well if they are sick. if they have to keep coming back it will cost me more treated the last thing you said in this is going to be using every cell of my brain. you said i want you to fix fix . that is what you said. what suggestions do you have a sub on the things you talk about today about fixing it? >> thank you so much. the real problem with this besides these networks being set up that are so restrictive, i also got a letter dismissing me as if her to sedating provider from the insurance that would cover patients on the aca. no one here intended that to

happen i'm sure that is what's happening to us as physicians. or we are being put on these panels without knowledge that we are because of contracts we sign 10 years ago that had clauses. you might assume as someone who owns business that were paid ex-number of dollars by the insurance company as a british sedating provider would and should be offered the same fee simply because you are taking care of the new government law? that is not the case. they are coming in with fees that are sometimes 50% of medicare. as businesses we can't survive so back to your question. the other problem here is these deductibles. guess they are a subsidy but that is for people who qualify for it. maybe this is not universal across the nation but in a large city like new york city a studio apartment is $2000 a month. how is a person earning $50,000

which by most standards across this country is not a terribly small amount of money, but someone earning $50,000 in new york city paying $2000 rent for a hole in the wall cannot afford the 3000-dollar deductible for a plan that is being advertised as affordable because they take the bronze plan. the fronds planned in new york state for something like emblem has a 50% coinsurance after that patient reaches that 3000-dollar deductible. what we have found only went back to the 2008 level is that this simply having these high deductible plans slowed down health care utilization because patients were afraid that they would have to pay that first deductible amount. other patients saw their physicians and went to the hospitals in collections.

we can't have a whole nation patients in collection and we can't have a whole nation of physicians offices and hospitals fighting the system to get paid. this is unfair to the patients. so when there is rumor about a single-payer system, i think in my heart the quickest answer to help us in the next 20 days is to eliminate these networks. let everybody who has signed up stay on those plans and those insurance companies must he made also to be transparent about what they will pay which by the way up until this point they haven't. i have colleagues that have no idea that they are even on these panels and they have no idea whether they are going to be paid. so, let the insurance companies, so not to hurt their business operations because we all want them to stay in business too for the rest of us, let them pay that same dollar amount as the access reference point.

and then a loud a negotiated fee between the patient and any doctor they want for a value for that service. who is hurt by that? he will then establish a competition between physicians to keep crisis controlled unless you want to have one of those often spoken about concierge practices that charge enrollment fees of $24,000 for a certain 1% of this nation but everyone else will keep their prices in check with this negotiated amount. the doctors will be able to remain in private practice. keeping them out of the facilities that are going to cost everyone more money and the patients will have the ability to see someone for a modest fee if that is available or they can negotiate some other fee. that's the only fix right now but get rid of those networks and allow the doctors to stay in business at the same time.

>> thank you. i ask unanimous consent that the article today in "the wall street journal" or yesterday in "the wall street journal" entitled junking the obamacare is stats will be placed in the record. without objection so ordered and i now recognize the g-men from florida mr. buy. >> thank you for putting that into the record. the title of the hearing is obamacare is impact on premium provided networks. let's talk generally about the impact on premiums on the people who have been affected so far and that we know about. so far a gentleman in "the wall street journal" said yesterday that between 4,000,005 .5 million people have had their plans liquidated. is that your observation that most of these people are now going to face a higher premium

dr. english? actually the higher cranium and lower deductibility or higher deductibility and higher premiums both. would that be your guesstimate? >> i think they're so much variability as we talked about. >> but these people who have had existing plans now have been notified that they are not getting and with the new mandates in them. for example my dicta the bulls have doubled or tripled in my premiums are up and i think that is 4.5 -- four to 5.5 million people have seen. >> i am reading what you are reading and i can give you personal experience. so many of them don't know yet. >> again with more mandates the cost of the premiums are more so

they have shafted as many as 5.5 million people. dr. novack and he, and? >> clearly we are seeing that the number of net losers will substantially outnumber. >> 364,000382. >> we don't know if those are -- the country starting out with a $5.5 million negative number so we don't know who those people are. >> let alone whether not. >> let's jump to the impact, the title here. the impact on networks. ..

and what is going on in the marketplace; is that correct? >> yes. i think congressman issa mentioned the draft and the law on the talk show talked about paying more to see doctors on the plans. the state exchanges are set up. there's different exchanges in the sate. your providers are in a different area. you companied move out of the exchange to see the people. >> what we're seeing is absolute turmoil in the marketplace, doctor. seniors now and they're the most vulnerable in our society and probably need the most medical coverage. instead of getting coverage,

they're certainlying for a doctor to serve them as doctors have been thrown out in the cold. doctor? >> absolutely, sir. i can tell you in new york state we're such a large state. and the behavior of the insurance state has been different upstate new york as opposed to down state. in the down state area 2100 physicians were dismissed from united. >> it's not just florida. >> absolutely not. >> you're sighing it across the nation. >> there's a, for that. it's a link to the aca because the crments budget to the manage care companies was decreased from 17% to, i believe, the figure about 8% to manage the medicare beneficiaries. now with all due respect to the business organizations of an insurance company when nay have a cut like that in their payment from the government to manage these patient, as a business, they have to do something to cut their costs. morally and ethically none of us

in here are happy with that. but i can understand where that came about. >> doctor, you mentioned the panels that are being set up. i hear from seniors that these rumors that certain ages, certain type of care is going to be cut. do you envision that happening? you know, -- >> i heard rumors 73. you don't get cancer treatment or there's a possibility of not getting transplants and things like that. what do you see? >> gentleman's time is expired. may answer? >>. >> may i answer. >> of course. >> a lot may be hearsay at this point. we have heard rumors. but clearly rationing care is something that has to be part of this to make it work. it is not the appropriate answer; however. so i'm not quite sure what the facts are about what procedures will be limited.

i would not dare say think it may not come. >> thank you. >> if i can unanimous consent to followup for 30 seconds on this, because when the word -- is used. doctor and others have a real problem with it. doctor, you do agree, i believe, all of you, that millionly sensible decision about what whether to use extreme health care options or not, in other words, decisions that are not always to do the most expensive and thorough do change with anal. and medical froms need to make those decisions. so the term death panel hopefully does not mean that doctors don't make a decision that extraordinary measures sometimes are not appropriate for the elderly. i want to ask that. because i think both republican and democrats found the word to divide us rather unit us.

yes a i don't know, if you can. >> the simple answer is most of us who are physicians will have a talk with the family and advise them what we feel is medically appropriate at the time. we'll do everything possible to sustain life where there is life and to allow the family to make a justization. we hope most people will do advanced beneficiaries notice so the individual has the choice and take the burden away from the family. and if there's anything we can do as a society, we should be pushing individuals to make that decision. thank you. >> i appreciate that. i didn't want that to divide this panel. i think we're united on the need fix health care. the gentlelady from illinois, ms. duckworth. >> thank you, mr. chairman. thank you for the comment. as somebody who is accused of being involved in death panel of the va where they certainly use outcome-based analysis to deem

what is appropriate for veterans. that is a very sensitive statement. thank you very much for bringing that up, mr. chairman. doctor, i wanted to follow up with you a little bit. the goal of giving americans access to affordable, quality, life saving health care is critical. t not only the moral thing do to make sure that getting sick in america doesn't lead families to bankruptcy but as far as i'm concerned, it's common sense for our country's economic competitiveness and government's fiscal health. i personally think that the affordable care act need big steps in the right direction. as you have mentioned, there have been some real problems that need to be fixed. and you spoke a little bit about the issues with cms, for example, and how they ratted your use of mri and incorrectly compared your use to others. i, myself, how different types of therapies will differ, and associated diagnostic equipment

you need to do to treat that. are you saying in your testimony that the cms decisions on how you are evaluated with your -- is specifically to the fact? are you saying it's just part of their trying to improve the medicare medicaid system? >> i believe that the outcome measure a major part of the affordable care act. and using model like that. some of those things predate with the stimulus package. some started with the affordable care act. that's a big push. when you look at the medicare cut for the future. how will we evaluate outcome and physician and bonuses -- that's part of the affordable care act. it's a combination. >> do you support outcomes base decision making and medicine in term offing a grate treatment and various treatment for your patient. the particular procedure works better than others? i know you come from a cutting

edge institution that is, according to you is progressive and aggressive in treatment, which i had manslaughter that's what i want. do you support looking at outcomes? >> i do. i think when they come from as far away from where the patient care is occurring, the more mistakes are made. i think the aca pushes this coming from d.c. which was the wrong way. i really wish special societies were encouraged to come up with metrics given a few years to say what is appropriate care manslaughter, what is appropriate care in knee surgery and et. cetera. that would have been a better way, in my opinion. >> what i'm hearing is not so much that looking at outcomes is a bad thing, but the way cms is going about it using accountant to look at it versus relying on the health care partitioners to be the one that inform the process of developing what those guidelines are so if they're going evaluate the outcomes use outcome-based evaluation of physicians who deal with

manslaughter. they probably should have some manslaughter decisions that inform that process of developing those guidelines so your use of mri is perfectly in keeping with other positions who treat ms and institutions like in your setting; right? >> as i stated, i think the affordable care act, again, have all the unintended consequences from the top down up, graduate ground up. whether you like the law or not, i want you to understand these things, these unintended consequences are going to happen. and they're not unforeseen. >> i happen to agree with you we need to fix the unintended consequences. i would be able to love to continue to focus on that. i don't know if we're repealing the law or unfunding it or defunding is the way to go. i agree there are many things that need to be fixed. there are good things with it. you know, i have a preexisting condition. i would assume someone with ms is considered to have a preexisting condition if they enter the marketplace to find their health insurance now.

have you had experience with ms patients reaching lifetime gaps? -- lifetime caps from insurance companies or their treatment? first of all, i would say everyone in the room has a preexisting condition. some of us don't know it yet. >> good point. >> that will follow you once it happens. everybody had their own insurance who have lost the coverage from their own insurance company nap is very different. i'm glad you can get the care to the patient. the fact is the matter is you're using other technique. i would think it would be better

if the patient had so they didn't have to rely on charity. >> i thank you. we go to the gentleman from michigan for his questions. >> thank you, mr. chairman. thank to the panelists for being here. thank you for the work you do as well. doctor, let me go back to some questioning beforehand. and specifically what are your views on the independent payment advisory board i think in the comments of the members applyies that what the ipad can do is determine effectively how much

you get paid for it. and if the payment for something drops to a point where you cannot stay in business or keep your doors open if you continue to provide it. less is going to be available. so i think it's a bit of symantecs. i think some of the words can cause division but the ultimate reality, the ultimate goal of the independent advisory board if medicare expenditures go up faster than inflation or 1% above inflation is to reduce the cost. they're going go where the money is. they're going go to the expenses of the patient with ms and say we're going pay a lot less. we think that centers like doctor english's we'll not just make services available. that's how they lower the costs. >> it takes away decisions from the patient and the health care provider. >> correct. >> to a great degree. >> correct. i would assume, from what you say, is a negative to the health care system. >> i think that ultimately, the question is that how do we get

the best health care to the mom who brings in the child after they fall in the park. >> the best health care -- >> what we deserve. >> is trying to get patients and families involved on multiple level l to help try to make the best decision for them. certainly in my world taking care a number of fractures and injuries. i don't have the luxury of long-standing experience with patients and family. so you need to be able to get data it to families can make the best decision. >> do you have any evidence, doctor, that competition and voice is a better way to increase value and reduce cost in government bureaucracies? and the expertise? >> sure. obviously you have examples in stern part of medicine where it exists. but i think even look for example in california more recently what they have done with -- by changing the structure they lowered the cost of replacement by 20%. i think less than two years.

in your testimony, you mentioned ten medications for ms patients. "washington post" article from two dais ago said one way insurance plans under obamacare are keeping costs low is by not covering widely used ms drugs. and requiring doctors to prescribe drugs in a certain order. which would compel patients to take drugs more toxic to them potentially. have you found that to be a case? >> this is our major concern. i can't impress upon you enough how invariable patients are on

the drugs they need and without the ability to move quickly to one and switch to another. if i can't do that anymore that's get me out of medicine not want to reimbursement. >> what does do to your patient? >> my teacher paralyzed i know i can do something for but i can't. >> it puts them at risk for the very least. take drugs that don't impact them positively let alone produce the change necessary. >> correct. you stated obamacare punishing you because you care for the most vulnerable patients. how does it do that? >> let's look that the. i think congressman issa mentioned too. it might have been congressman cummings about, you know, if our center closed down and i was looking far job at the hospital, and 5,000 expense of patients were coming that was going to bankrupt my hospital. which ones do you think would sign up to take me on? i want to work trait ma center. i learn there. it was incredible taking care of

the sickest of the sickest. i love doing that. and i don't see how under these payment models any hospital incentivize by taking care of the sickest patients. it will be disincentivizes based on outcome. the two-tier those who can't afford it. or specialized treatment and have the money do that and all the rest of us. >> correct. >> i thank the gentleman. we got gentlelady from new york. >> thank you, mr. chairman, and ranking member for calling the hearing. i thank all the panelists for their testimony and participation, particularly dr. mclough lynn from the great state of new york. which i have the privilege of representing a portion of it. and i do believe that you have raised some important concerns, but i truly believe that the affordable care act really is important legislation. it's by no means perfect. it really addresses some of the massive deficiencies in the

nation's health care system such as coveraging preexisting conditions and providing coverage to over 30 million americans that did not previously have coverage. there are some successes, but i

want to acknowledge there's room for improvement and any mess of any change and something that is complicated as health care is going have to face many improvements and need to be willing to work together correct deficiencies and challenges we see during the implementation process. but doctor, i would like to understand i want to make sure i understand your situation. you stated that you received notice last month from the insurance company stating you would not be extended participating status on the new insurance plans and the pathway networking. is that correct?

>> the way it works the insurance company can only approach the physicians that happen to be already networkinged with them under contract to them. fence i'm not the emblem system. they cannot approach me or do anything to me involuntarily. and that's important to understand. >> can you approach them another insurance company? would you be willing to participate in any plan on the exchange? can you approach another plan? >> i'm assuming the door may be open; however, what is clearly evidenced by the plans i'm already under contract to, blue cross for the main one they made a decision for whatever reason they had enough participating physicians to form this pathway networking which i might add by just looking at the ophthalmologist serving in manhattan in the list with no

affiliation to large group contracting forces. so these physicians happen to be under contract to that company to the lowest reimburstment for the same service for another physician part of the faculty practice or the large group practice would get. insane as it sounds for doing the same work, physicians are paid differently in the current system depending on how large a group. >> have you appealed the decision? i know they are trying to save money. in fact, the new york state testified or released a report saying that the people that had enrolled 100,000 were seen premium rates as much as 53% lower than the rate in effect in

2013 for comparable coverage. that's great news for them. they are looking for services that are a more affordable. but you can appeal these decisions. as you know, and particularly in new york it's being run by the state and the state insurance is regulated by the state. you can appeal to the new york state insurance commissioner, and i would be happy to work with you in setting up such meetings if you would be interested. have you appealed your the decision? >> there was not an opportunity mentioned in the letter for appeal. it was a unit literal decision. there was no notice in there that i had a right to apeople. i must say also that i had an amended contract to my united health care participating status and that also because i was not in an oxford liberty current networking i would not be put on to the affordable care act insurances. so that was an automatic opt out

en-- not an automatic. i wouldn't be in it. and those doctors who were in the oxford liberty current plan once they see their fee schedule they could opt out. >> you can also gate navigator to help you or broker to determine the plan what would be best and help you with you appeal. >> i thank the gentlelady. we go 0 to the gentleman from oklahoma. mr. lank ford. >> thank you, mr. chairman. >> thank you. for what you do and taking care of patients. you are going through a lot of paperwork and process right now. i can imagine the incredible a. frustration every day you get a new regulation and rumor every day. all you're doing is trying to take care of people and patients. i want you to know from us we appreciate what you're doing. and how you try to focus on taking care of people. the problems are very, very real. you are experiencing on the ground we hear about them our offices all the time. the numbers are out for the

first two months of enrollment and the affordable care act in my state in oklahoma are now up to just over 1,600 people have been able to sign up in my entire state. it give you point of reference, 1400 companies got a letter two months ago their insurance was canceled because they were in a small business group just in oklahoma city. so just in one town in my district 1400 companies received a letter in the same day they were cabled because their association is no longer legal and out looking and now we've had 1600 people total in the entire state have been to be sign up. one of those was a small car dealership in oklahoma state with 14 plays. they have to select different insurance policy a different company. as the owner of the car lot told me, we can either select a plan that is much more expensive than

what we had last year, but keep our doctors or pay the same as what we've had last year but switch doctors. but we can't do both. we can't both keep our plan and our doctors or keep the prices. we have to choose on it. and it's been a very difficult process as a small business as it is facing a lot of small businesses across the area. and doctor, you mentioned that even with your own practice that's becoming a big issue. st one of the many things out there. let me ask a couple of questions about process claim. by one count, the law creates about 159 new agencies. we have to congressional research service to try to determine how many boards or agencies are created by this they said it's not knowable at in point exactly how many. doctor you mentioned multiple times the difficulty of decisions being made in washington, d.c., and getting passed on to you. i have direct family members that have ms. i'm familiar with the process and the drugs and what is going

on. and so i'm trying to process through 159 different agencies that are all setting different rules. you goat instructions about how to take care of your patient. what does that do for you day-to-day? >> well, let me give you an example. i have had for the first time in my career patients healthy. peevely not walking on a medication doing great who were crying in my office. people are really afraid, as you're seeing as well. they don't know whether their medication is going to be covered. i'm filling out forms patients stable on medication but they're not on the list anymore for the restriction providers. >> we talk about people currently on medication, doing better, stabilize the process that instructions are coming down them to say we may stro switch the regimen to a different drug or treatment when currently stabilized right now. >> correct. >> that sounds like someone in

washington telling you how to take care of a patient doing women with the treatment and saying we're going experiment with a different way to do this with your patient? >> and the george city exchange we have no idea what medications are available to the patients. and again, we're less than month away from patients coming on those insurance plans. and the current system as set up, there's a discouragement to take a more complicated patient. the more complex the case is, the more it's discouraged financially and every other way from the federal government and from the systems; is that correct? >> yes. >> doctor, you mentioned before all the issues with medicare that are out there based on the reimbursement rate and the number of physicians that do that. half of the people that have now signed up for national hurricane

center nationwide are in state state medicaid programses. they have access to care on that. >> the first issue, it's something we can't discount. jonathan who was really the architect of romneycare. it was the architect of the affordable care act. his own research originally in the '90s and repeated in 2007 showed half the people showed up to 80% of the people who get access to will end up on expanded medicaid will lose their private health insurance. when you look at the smaller networking and the lower payment rate that discourage people accept it or create long waiting lists to get access to it. i think again there will be a few winners. but ultimately the number of losers are greater. and orthopedic in arizona that

access to certain kind of equipment. access to physical therapy after an injury in term of limit, certain medication all of those are severely restricted under medicare relative to what is existing. dismp there's a tremendous difference what it is on the ground. i yield back. >> i thank the gentleman. we got gentleman from pennsylvania, mr. carte right. >> thank you, mr. chairman. for all the witnesses who are appearing today. i believe the affordable care act is landmark law. it's obviously by no means perfect. we need to rom up our sleeves to make it better. i planned to ask all the witnesses questions about provide ore networks including dr. fader but unfortunately the

majority decided to change the panel structure today. they didn't inform dr. feeder either. he was here and ready to testify at 9:30 and i would say the fact she's here and waiting for the second panel while we're not including her now is disappointing. but doctor, i was interested in your testimony and your comments. i would like to follow up on some of the things that congresswoman covered with you. my understanding the large part of your testimony surrounded the fact you got dropped by empire blue cross and blue shield. you are stit still waiting to hear about larger employers whether you'll be included in

the coverage. >> no, i'm completely in that. >> you are? >> for now, yes. okay. so we want to look in to why these things happen. you have less than a full explanation from empire blue cross and blue shield, am i correct in that? >> yes. and everyone who is on my associated hospital staff had the same letter. this is not an isolated letter. this is clear across the board. >> right. so if i'm not mistaken. you have the empire blue cross blue shield letter on october 29th of this year. am i correct in that? >> yes. i want to talk about what efforts so you made in the couple months since then to go over what the situation is and see what light you can help us shed on the situation. so i think saw about 150

anytimes of ophthalmologists who are included in the system. is that correct? >> that's correct. did you make an effort to compare different sets of fact, for example, i would assume you're board certified? >> it's not based on nap we're all equal. what the base is clearly is the original fee schedule of the networks that the doctors are in. and as i said, if you are complete sol low practitioners. not part of a large group who negotiates the fee schedule with the insurance companies you get what is called the standard rack rate from the insurance company. these doctor that are on the networking. they are the lowest paid physicians nap is clearly what the decision is.

that's not what this is about. you think it's about pricing it's just about money. it. >> it's clearly about money. let's have you compare the pricing. have you compared how much it costs people to get treated by you and the other people who got dropped versus the people who got accepted in to system? >> first of all, i would no way to compare that, you know, there are quite a bit of regulations on us also as far as fee schedules. we have antitrust regulations, and we're not allowed to collectively negotiate. so in honesty, i would have no idea to know pure facts as to what someone is being paid compared to myself.

.. and i want to ask you, hadn't you heard this? hadn't you heard what i had erred, you would protect yourself by joining medical groups? >> the gentleman's time has expire. the doctor may answer. >> let me share this with you. i had been eight years full-time

faculty member at major hospital in new york and enjoyed my time there but i also saw the benefit of being able to be a physician, to make choices for the patient care in a way that i see fit and the best care that i see fit for the patient that works for me and my patients. i don't want to give up that freedom by joining a larger group that has a non-physician administrator telling me how fast i have to see a patient and what i can and can not do for them of that is a choice i have in this country thank god, and i want to keep it for my patients sake. >> i thank you. we go to somebody who knows about patient care. first on the list. dr. gosar. >> thank you, chairman. dr. novack, can you discuss for me the confusion your patients are feeling about obamacare, your services? also touch a little bit about urban and rural. we're from arizona. so there is definitely a dichotomy going on here? >> sure. i think there's one term that

regardless of your political party preference that describes what it is providers or patients or administrators or staff. it's confusion. because no one really nose and i have 100 patient as week coming through, the bulk of whom will actually ask that question because i know i'm involved in policy issues and my answer is, why we just don't know. they don't know what plans will be available. they don't know what services will be available. they don't know what medications will be covered. they don't know what hospitals they're allowed to go to. the shire here is -- issue here is basically abject confusion. no one knows with will happen january 1st. and to say that that was an unforced error because of political realities, the great tragedy, are really the tens of millions of americans and hard-working american families that have been suffering emotionally because of the uncertainty the law created because of work that was not

done, the lack of transparency, the unwillingness to release regulation. i have patients who work for insurance companies and i was hearing from them throughout the summer that large portions, they didn't even know the requirements that they were going to be forced to put into the software they had to write. we're hearing they're being required to be responsible for the data on these servers but not allowed to get access to the servers to test the integrity of data they're being held responsible for. so at every single level, unfortunately the claims that were made to pass the law are not the reality and losers, this is not about the three of us up here. it is not about the dentists. it is about the fact that we have, we do need to do something about preexisting conditions but that is with a small part of the population the same amount of people basically that folks recently have been saying, oh it is a small number don't worry about them, getting their policies canceled, it was really

only 10 to 15 million people addressed connick conditions. instead we totally uprooted essentially everybody. real quickly about the medicare advantage issue, there is nothing tangential to the change in medicare advantage as regards the affordable care act. remember that the affordable care act cuts between 130 and $150 billion out of medicare advantage this decade and that's why you're seeing cuts to medicare advantage networks. >> so when you got, when you're talking about preexisting conditions, and i'm going to ask you and dr. english, we just exchange as ranking member talked about, a prejudice to preexisting conditions, we just traded one prejudice for another? would you agree with that? >> correct. >> dr. english, would you agree with that. >> correct. you haven't, in my opinion increased care. you shifted care. that is quite obvious. >> i want to get to that. i want to applaud you. you have family members and dear friends that have ms. so thank you, very, very much

there is this prejudice now because we're talking about acute care versus chronic conditions right, dr. english? >> correct. >> so you're handicapped when we're talking about chronic care, are we not? >> correct. >> and so we're asking you to decrease time, reduce reimbursement, reduce the possibility of drugs, reduce your opportunity to standardize or to individualize individual treatment modalities, but i got a question for you. did you see any tort reform in this bill? >> no, sir. >> hey, dr. novack, did you see tort reform in this bill? >> no. >> dr. mclaughlin, how about you? >> absolutely no. >> have you ever heard of solving a problem without putting everything on the table, dr. english. >> say that again, please. >> have you ever heard of solving a problem but not putting everything on the table? >> no. >> it's foreign to me. >> and the law actually approved opportunity for demonstration programs for liability reform but in the law, plain language

of the law you may not do any demonstration program that includes any limits on non-economic damages. so, the constraints were fairly significant. >> you know, dr. mclaughlin, i want to go back to reducing time for physicians to see their patients. we're reducing the reimbursement rates. we're reducing the panels, all choreographing hurting the patient, would agree? >> absolutely. >> you made the comment thaw want to practice medicine your way. you want individualize that, take your time, how you see fit. individualize the treatment, right? >> yes, sir. >> how do you feel most patients would like, would they appreciate your thoughtfulness? >> absolutely because over and over again i will have patients returning to me perhaps even out of network as they go to some of these larger group practices where physician extenders are employed to process patients literally through a quicker

assembly line so that facility can reap more benefits costwise out of the poorer reimbursements but they may actually only have two to three minutes of face-to-face physician time in that. and, most people are often told to bring a companion with them because when you're the one that is seeking care, you're only observing half of the response from that physician and you're losing the other half which is why most of us actually face umpteen phone calls after the fact because there is something they forgot to ask or something they didn't understand. so you can only imagine how that problem is magnified with only two minutes of face-to-face time with the doctor. patients are generally nervous under those conditions. >> thank the gentlelady. dr. novack, i want to make sure the record's clear, when you were talking about what wasn't in the tort reform, micra,

limitations and compensation for actual loss, correct. >> correct. there is a little money for demonstration project in the states but in the law it actually says those demonstration project may not include any demonstration that is includes any limits on non-economic damages. >> thank you, gentleman from nevada. mr. lorsry. >> thank you, mr. chairman. the title of this hearing is obamacare's impact on premiums and provider networks but the majority of the opening testimony has largely focused on inadequate reimbursement from medicare and medicaid rates which private insurance companies use in large part to set their own rates. so wean the issues related to reimbursement rates under medicare and medicaid issues for the provider community before obamacare and the affordable care act were even law? yes or no? >> there is no question but i think, and i'll speak a little bit, is that if the title is,

about provider and provider networks we need to look at, this is not about us right? it is about how do we get the maximum number of people the best personalized health care we possibly can and the practical reality is, our large group employed nearly 500 people -- >> with all due respect, my question was, are medicare and medicaid reimbursement issues issues that the provider community were dealing with prior to the obamacare, affordable care act ever becoming law, yes or no? >> yes. >> for the rest of the panel. >> yes. >> yes. >> and yes. >> and so isn't the real issue that you all as provider community want this congress to focus on as many of the doctors in my district in nevada have talked to me about is the need to reform the reimbursement rates under medicare, specifically the sgr?

isn't that the focus that would help to address a large part of this problem? >> i'll speak for myself and i would say, congressman, i don't think so. this isn't about creating a new washington system to how to figure out how to pay people to provide care. this is much more broadly about how do we establish policies to allow patients and families to remain in control of their health care and health care decisions. so -- >> why did you guys bring up reimbursement rates under medicare and medicaid as one of the reasons why there is this lack of adequacy of network providers within some of the plans? >> i would say it is one of the reasons. >> okay. so it may -- >> if congress could help address the reimbursement rates and reform sgr, would that help or hurt the process?

>> i think it all depend how it is done. again i refer you back to the position of the obama administration who said in a court filing this year, saying that there is no general mandate under medicaid to reimbursement providers, including hospitals and that for all or substantially all of their costs soft the position of the administration -- >> sgr is focused on medicare. >> but i'm saying -- >> this is the not same thing. you're giving me a reference that is not my question. my question is on the sgr. which is largely the basis for how reimbursement rates to doctors are established by the private insurance companies. >> i think that things would be improved if there was not an annual uncertainty every year for us to say that on january 1st, 2014, we're getting a 25% cut. so we tell our patient that is under those conditions we can not continue to see you. so we have to decide if we're willing to see medicare patients until congress chooses to fix the problem every year. >> so if congress worked to fix

the problem with the lack of reimbursement to cover the costs to the providers providing care under medicare and medicaid that would help, not hurt, correct? >> i think it would, it would depending upon how it was done it might help but there is always the possibility that new policies could not be helpful. >> okay, today, later today, we will be voting on a budget deal that includes a rule on the sgr extension for another three months. not reforming it. not increasing the reimbursement rates like doctors in my state of nevada want us to do because they're not covering their costs. it is just extending it for another three months. so i would just hope that at some point in the government reform part of this committee we would work to bring forward those bills. i have signed letters with my colleagues on the other side in

favor of these reforms. i'm reaped to -- prepared to work on legislation to bring these needed reforms forward but instead we're having, you know, kind of these dog and pony, kind of show hearings that don't get at any of the real reforms to make the law work better or to address other issues that are unrelated to the law. medicare and medicaid reimbursement issues for doctors were a problem before obamacare. before the affordable care act was put into place and so, to somehow suggest that it is because of the obamacare that these issues are happening is to fail to recognize the history of the problems in the health care system to begin with. >> would the gentleman yield? >> no, mr. chairman. i just want to conclude -- >> the gentleman's time has expired. we now recognize the gentleman from tennessee, dr. --

>> thank you, mr. chairman. i would be happy to yield a minute to finish your thought. >> thank you. i was only going to say, that i wasn't here in 1997 when they scored a big savings based on a theoretical reduction in the cost of doing business. you weren't here. it is something that agree with the gentleman. we need to realize that simply paying doctors less and then reneging on agreeing to pay them less when the real cost savings didn't occur because we never legislated or did anything to help drive down the cost of delivery is in fact a very good point. i in fact agree with the gentleman that fundamental change which was scored before you and i got here is not about just paying doctors more because we did say, well we're going to find ways to be more efficient end in what drives their costs up. so i look forward to working with the gentleman on that. it won't come to our committee but i certainly would be happy to work with the gentleman to

try to drive down the cost of doctors delivering quality health care. and i thank the gentleman for yielding. >> reclaiming my time. i will also add we just had a doctors caucus meeting this morning as you know. there are markups pending in ways and means and energy and commerce dealing with an sgr replacement. there will be a three-month patch but we're working with the 15 members of our gop doctors caucus as well as our dentists and nurses. we'll try to find something that has a sensible approach to reimbursing physicians, unlike the sgr which over the past 15 years yielded nothing but a 1.9% increase. i think most industries would have a hard time making that work with a rising costs in other areas. i wanted to post or put up a video if we could. >> we will keep this promise. to the american people. if you like your doctor, you will be able to keep your

doctor. period. [applause] >> if you are looking for, if you want coverage from your doctor, doctor that you've seen in the past and want that, you can look and see if there's a plan in which that doctor participates. >> have unlimited choice. >> simple yes or no question. >> did he say if you like your doctor you can keep your doctor? >> yes. but look, if you want to pay more for an insurance company that covers your doctor you can do that. >> okay. i'm sure this is probably something most everyone this room has seen or heard and maybe everyone across america and practicing primary care medicine for 20 years before coming to congress i know at that a lot of my patients who had insurance probably believed the president. if you had an insurance plan that you liked and had a doctor you liked and you were given that clear assurance over and over and over again right up through 2012, right best election, i'm sure a lost your patients were secure that maybe this health care law wasn't going to impact them. now they're finding out that is simply not the case.

so i would ask you, we can go down the line what are your patients finding and feeling when they have all of sudden realize they have been duped? >> well again, there's fear because they have had an established relationship and, you know, patients will follow their doctors. what is wrong about the last part of that video is as i said, if you're in a different part of georgia and your exchange does not have me but then you go into that exchange three hours away, now your primary doctor is three hours away too. you can't just pay more to see us anymore. we're excluded if we're not on the list. unitedhealthcare's website says i'm non-preferred. you can still see me and you have to pay more because your doctor is being pen liesed because he is taking care of sick people. >> the, the patients are numb. i think that's about all i can say. >> okay. >> and many of the patients who had a state subsidized plan in new york called healthy new york, received that letters that plan would end and they

would have to go into the new york marketplace. i actually approached many of those patient that is were in my practice. they never bothered to open the mail. they didn't even know that their plan terminated. i was one that informed them. so these patients are numb. they're upset. and, as you know as a primary care doctor you don't work alone. you work with specialists. so what rahm emanuel had said you can pay more for a plan that has your doctor it may have your doctor, one of them but may not have the four or five specialist that is you see also. so there's a discontinue ages of care no matter how you look at this. >> dr. novack i will finish because you bring up a great point. supporters of the health care law claim 30 million people gain insurance. can you explain difference having health insurance card particularly one for government program card and having access to care? i will preface i came to tennessee in '93 a year before tenncare which is model what what experiencing now and it didn't work. i think you know very well that

somebody coming in with that card and they need maybe orthopedic surgeon and if you're in rural area and all they may have to go to 100 miles or more to try to find that doctor. you might have to hire extra staff to stay on the line at night after clinic hours trying to find a referral or someone who can accept it. what are your experiences with that? you think it's a good idea to reform idea based on expansion of medicaid? >> i don't think the data suggest that is is particularly good idea. and i think it is unfortunately reality and to touch on what you said, congressman gosra last time made that point exactly in his opening remarks what we're seeing unfortunately is that a plan that was supposedly designed to help those with some, who need the most, we're seeing rural areas, there are fewer and fewer doctors available and we're seeing in inner cities, the closure of clinics, the moving out of primary care doctors, the near complete absence of specialists in many cases. and so unfortunately groups that

really want to do things to be able to help, unfortunately the law, while well-inended we need to recognize is not doing what it said need to be done. this is beyond tinkering to make it better. this needs essentially a complete revamping and address the real problems. >> i thank the gentleman. we go at gentleman from virginia, mr. connelly. >> thank you, mr. chairman. and thank you to our three panelists. one might be forgiven looking at this panel, and the theater of it, frankly if democrats had had the chance to put together the three, panel of three doctors, i guess we could ask you to wear your white coat. and i guess we could find three doctors, i know we could, who would praise the plan. but the idea and this doesn't in any way disparage the value of your opinion, or your

experience, but the idea that your experience is to be generalized as universal is false. and it's a false premise and it custodies service, in my opinion, to this discussion. none of you are policy experts. and none of you universally speak for your profession. you are asked at one point one of our colleagues how difficult it is to sign up. well, if we're going to go through anecdotal experience i can tell you that i and my entire staff must go on the exchange, on obamacare. all of us signed up. met the deadline. [inaudible] i know there was an accident. if you're under a certain age in my staff the average premium cut, ranges from 30 to 70%.

they're happy as clams. the deductibles are comparable or better. the co-pays are comparable or better. i can tell you in my district, there are small businesses who are crowing about the fact that when they went on the exchange they had better choices than they have currently, and they're going to save, i talked to one the other day with four or five employees, he will save 7 to -- 6 to $7,000 a year. it isn't an honest intellectual dispute to deliberately cherry-pick fact as and to deliberately put together a panel of critics of a piece of legislation that is admittedly complex. you were asked about tort reform as if tort reform was dispositive on the cost of health care. it is not. it is a factor but of course what the questioner didn't say,

as a pray laud to his question was, of course, on our side of the aisle we decided a priority, to oppose it no matter what was in it. we didn't give it a chance. around the fact that an entire party decided to take a powder on a major piece of the legislation precisely meant tort reform would not be at the table in meaningful way determined by them. of course not. we had a prominent republican senator on the other body who said, if we defeat health care, this is before we even knew what was going to be in it, didn't matter, it will be obama's waterloo. that tells you everything you need to know. it wasn't about health care. it wasn't the quality of health care. it wasn't about whether you are in a plan or you're properly reimbursed. it was a about a political game to try to make him a one-term president and it didn't work. i hope some day we have a

substantive hearing where we actually, as republicans and democrats try to find out what is working and what isn't and make it better. that is the history of transformative legislation in this field. unfortunately it is no the history here. we've spent 46 votes in this congress to simply repeal it, defund it, or gut it. not based on substantive analysis, not based on experience. but based on a political predilection to oppose this bill and this president. even though there are elements in the bill that actually came from republican think tanks. the individual mandate being one of them. not a democratic idea. a republican idea. so i'm glad you're here, certainly have enjoyed listening to your testimony but i have to, i have to put it in the different context. you will forgive me. and it is too bad that the panel couldn't have been more balanced

and it is too bad dr. fader is kept waiting when she was under. impression as we were she could join this panel to provide a different perspective. i yield back. >> i now ask unanimous consent that the gentleman from virginia, mr. connolly's website, which i'll put up there from 2010 be placed in the record. in which he says, for the past years my constituents have told me, we want health insurance reform but only if it meet certain tests connolly said. will it bring down premiums for families and small businesses. will it reduce the deficit and will it protect choice of plan and doctor. without objection, so ordered. we now go to the gentleman from -- >> could i inquire of the chairman? >> yes. >> is it going to be practice of this chairman to start to actually, individually put members websites into the record? because we would be glad to return the favor on this side of

the aisle. >> i have no problem at all. i asked for it because it was germane to your anecdotal statement of objection to their anecdotal statements. so it just seemed appropriate and good staffing as you know, jerry, somebody looked and said, heck, jerry used to be for what, these people are testifying we're not getting. that is all. >> i stand by the website. those were the three criteria i used and that's why i voted for the bill and continue to support it, mr. chairman. so happy to have it. just wanted to make sure -- >> no we put it in was historic piece and can i didly requested -- candidly the requested individual from your side of the aisle is on the next panel along with all the other non-medical doctors. that is reason divided. medical doctors giving their anecdotal examples what they see as current practitioners and think tank crowd will be next. hopefully you will not desmarriage the think tank crowd

for not being doctors. >> absolutely not. there was no disparagement much doctors. >> mr. cummings. >> just a cry of the heart some democratic doctorings we would suggested one. >> i would hope we not engage putting members campaign websites stuff up or whatever. >> this is not campaign. no we would not put a campaign website up this is in fact a, an official, this is property. house of representatives. >> i understand. >> i want to make sure. i'm just so concerned we stay focused on this and not being distracted by certain things and that i thought it was website, campaign. and so. but thank you very much. -- >> no i appreciate it. the reason we chose this was because it was said on the floor of the house. it is on a government site. and it's pursuant to exactly why we chose this question which is what is the impact to doctors and you know. . .

we thought we could simply pay less for the federal docket on medicare and medicaid reimbursement. these are problems that are long-standing. the reason i had here today as i agree with what you said to me in the sidebar which is, when a bee going to start fixing some of the individual parts of it? the affordable care act is not going away in totality but these

doctors, and they take doctoring particularly are telling us about the chronic problem which is our doctors being incentivize not to take the tough patients. in some cases and mr. cartwright alluded to this, in some cases it's our government reimbursement. in some cases it's how insurance companies are reacting and i will pledge to you today i will treat how the government acts and how insurance companies act the same in trying to get these doctors to be able to practice what they do and we can have a discussion about how much reimbursement comes out of tax dollars. hopefully today both the first and second panel we are dealing with what's happening currently so we can fashion some legislation that has to be bipartisan to fix fix it. >> thank you mr. chairman and i just want to make sure we stay on track three at i keep on mentioning what dr. mclaughlin said to you to fix fix it and in be fixed.

by the way i appreciate what you said two congressman horsford because he did raise legitimate concerns and i think it's worth the bipartisan way we can help the doctors be efficient and effective than what they do and help american society so thank you. the gentleman from georgia. >> thank you mr. chairman and i thank you all for being here. my colleague from virginia characterized his obamacare is critics. i would not characterize you that way. i would characterize you as patient advocates in effect leads you to be critical of the obamacare is legislation then fair enough but to the gentleman's point i thought he was exactly right. find out what is working and what is not and make it better. i wish that had been the counsel this congress have applied before the passage of the president's health care bill because each of you has made testimony about patients that you had, patients that were receiving care, patients that

were getting the individual care that they need who will no longer because of this new legislation. those folks weren't having problem. we created those problems. you are all in a caretaking business much more than i am but the stories that you tell that touched me the most are the tales of the problems that we create, the uncertainty that you mentioned dr. novack. there is no way to take those fears away. those fears are real for those families today in six months those fears turn out to be an realize we still won't deal with take away the payments frustration -- frustration those families feel today. health care costs were rising too fast and many americans do not have reliable access to care. i thought he crafted exactly the wrong solution to do that. i think we can work together to solve those problems. the concern is that certainly

from your testimony and the experience of my constituents we have created a whole new batch of problems. i want to ask you to her english you know my good friend todd williams -- todd williamson. he is in her august as well. he is a little bit older than you are. here we are the largest county in the southeastern united states one of the fastest-growing. he said he has been in practice for more than 20 years. he has not in a new neurologist come into gwinnett. i try to look at the ages of folks in your practice. are you the youngest in your practice or have you found young neurologist coming in? >> i originally was. that is one of those challenges. i look at the dollars and the president's health care bill. just today the headlines "chicago tribune" only 7000 illinoisans enrolled in obama plan in the first two months. hhs awards in every $58 billion to obamacare is navigators.

the list goes on and on about the record in new jersey and stuck in health care limbo. at december 23 deadline 398 alaskans pick a marketplace plan despite untold millions spent there. oregon signs of just 44 people for obamacare despite spending $300 million. what would have happened if we had spent those 300 lion dollars on community health clinics i happen to have a huge committee health center and i believe folks are entitled to a level of care and i believe we can revive that on a sliding scale and ability to pay. we have such a mechanism in place. my colleague from virginia called this a pony show. when the question came to you dr. english does obamacare is i met your patience treatments and the answer came back yes.

i don't know why that's not the end of the conversation. i don't know why they are not 435 members of congress who say we care about people and we care about people having access to care and we want to improve the access to care for folks who don't have it but if you have access to care today and we are doing things in the lobby that limits the medical professionals ability to treat their patients, why can't we all decide that's wrong and that we should go back and take another crack at back? the affordable care act is important legislation i heard from one of my colleagues because it deals with access to care. i want to ask you since you characterize obamacare is critics, is there even one of you who does not believe that we should deal with pre-existing conditions and we should improve access to care and i will start with you dr. english.

have to do those things, have to do those things. >> physicians have always given charity care in the love of their heart to people who can't afford it. always did and always will continue to do so but what this has created sir robot. the high deductibles imposed on these patience is nothing more than them not having insurance and we understand that. >> dr. novack. >> i agree with you. >> mr. chairman my time has expired but we have found that collectiocollectio n of ideas on which we can agree and i agree with my colleagues on the other side of the aisle. we should be working towards those goals and i yield back. >> i think the gentleman. we now go to the gentleman from massachusetts for five minutes. >> thank you for being here today. i wanted to ask, think it was dr. mclaughlin that made the comment that her patients policies were insurance

companies did not renew patients policies and this result that was an issue here if i wanted to ask you whether not when you have this discussion with your patience there policies not reissued by their insurance companies whether or not it those old policies had as part of their coverage the following services or benefits. ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services including behavioral health treatment prescription drugs, rehabilitative and ability of services and devices laboratory services preventative and wellness services in chronic disease management pediatric services including oral and vision care. if the patients in each case have all of those benefits and services? >> i can only speak of my small business plan. >> let me ask you, you gave me

information about your patience in what you thought were their situation so i'm asking you before you reach a conclusion or opinion on that day to look at their policies to see whether not they covered all of those benefits and services? >> the policies are referred to is state run and yes they had all those benefits. >> all of the services were in-house? you're going to tell me now but that policy had each and every one of those services? >> absolutely. >> did you look to see whether not any of the patients you are talking about have been advised by their insurance company that they could go to an exchange and compare and contrast what they now were offered with whatever else might he on that exchange is an alternative? >> they receive notification of that, yes. >> do you know whether or not they have gone and checked that out? >> i cantelli with the patients do. >> do you know whether your patients were eligible for subsidy in other words if they

were foreign to present a poverty? >> again, we don't know what a patience earnings are but i can tell you from the careers i have seen. >> that wouldn't be fair. >> did you ask them whether not any of them qualified for subsidy and if so how much? >> i can speak to my own staff who are covered. >> these patients you have covered. >> some checked and some have a subsidy and some did not. >> okay. do you know which of them are which and how many of each and whether or not you covered all or some with the increase of the policy? >> the closer that an individual these patients get to the upper limit of what qualifies for that subsidy they were told that they would only save about $5 a month on their premium so a subsidy doesn't cover everything. it depends on how far away from the maximum that is covered. >> and a sliding scale subsidy.

>> correct. >> did you also talked your patients about the medical loss ratio part of the affordable care act that insurance companies now have to use updated some of their premiums for actual health services as opposed to overhead management and things of that nature? >> with all due was up to the patient population they don't understand the medical loss ratio. >> do you? >> i do. >> you are aware and 2012 consumers saved $3 billion? my question to you was if you are familiar with the deep understand in 2012 consumers saved $3.4 billion through lomer premiums? >> understand that, yes. >> understand in addition companies that did not meet those received $500 million in rebates? >> i just want to close out in

our not going to use all my time on this but with respect to the comment made earlier from someone on the panel here about the history of this bill and this was not a committee of jurisdiction. i was one of the committees of jurisdiction and my memory is during the debate of this particular bill the tremendous effort was made to try to be bipartisan measure. he reached out and asked for participaparticipa tion on both sides of the aisle. one side decided not to participate an incredibly even when certain provisions that people thought were generally good, bills that were drawn by republicans were asked to be introduced and republicans refuse to introduce them even when some 12 to 15 of them were put in the amendments. those people that drop most original ills voted against them. there is some indication of the effort that has been made to try and have this be a joint effort all across the aisle and everybody working on this in the early parts of this whole exercise. i think one part to not even be

involved and not participate in trying to make the best project they can possibly be and that is is. >> would the gentleman yield? >> i'm afraid i'm out of time mr. chairman. >> the gentleman's time has expired. the gentlelady, you are cut off several times. because of limited time but is there anything you did not understanunderstand? >> mr. chairman is it your turn to question? am i missing something? you just asked me to yield and i have no time to yield. >> no, the prerogative of the chair under the rules is to make sure that there is a roll and complete clear answer and to correct the record if necessary. >> that is not at all accurate. >> this is a long-standing practice under republicans than democrats. the gentleman had limited time. the gentleman in his limited time cut you off several times. if the doctor had anything she felt was germane i have always

allowed witnesses to continue answering even after the time has expired. was there anything doctor you need to fully answer that there was not time for? >> the purpose of this committee is to talk about the limited networks and whether premiums were indeed lowered or not. was it not? >> that's correct. >> as i said to mr. cummings, we have 20 days to fix how we are going to provide care to patients with limited access and there is no debating that. we talk about ms. i will talk about a mile g. for a second. >> i apologize. i just want to give you time. something he had asked which included subsidies and we cut you off during your statement on occupations of your patience and so on. please, i'm only trying to make sure the record is full. if there's anything you wanted to say about your patience and

so on, that was the line. >> mr. chairman -- >> the witness was asked to move to another subject because she was not being responsive to my question. if you want to ask any question and. >> the gentleman is not in order. >> well neither is the chair. i think we have an issue. >> thank you. limit yourself to anything he felt that was asked that you are unable to answer. i certainly want you to be germane. that is why i did ask you to stay to what the gentleman asked he is the thousand dollars that believes the income in new york to obtain a subsidy. $45,000 living in new york barely makes it so most of the people who are going to be getting these insurance plans will not receive a subsidy and they are going to have a difficult time paying these deductibles and paying their

premiums. thank you. >> thank you. the gentleman from georgia is recognized. >> thank you mr. chairman. look, i just have a couple of things. i have a daughter who fits the special needs category and i appreciate you being here from our home state as well as the rest here. i just want to ask a varied rod sort of question and a personal experience here. i've heard it said many times and i think one of things that is said here is you fix -- there are a lot of things out there to fix. this is one of the fixable laws that is apparently flawed and that's a disagreement that both sides the aisle are going to have. there are things that can be done. we have to deal with reality and the reality is that as in the case of my daughter who has spina bifida early in life, she had it for six years old she had

30 major surgeries, three of which were eight hours and plus just a vast array of different things. now she is fine and she is 21 years old and she rules the house. but doctors in her life especially early on were very important and they still are. we are making the transition and i had a chance this morning to speak with dr. english about the transition from pediatric to adult and that is hard for a father so i will just leave that at that but she is a young woman. the problem i have here and i'm going to stop here and open it up. if you don't have a lot to say then fine we will be done and move forward with this plan -- the plants are hurting the very ones i believe you were intended to help and especially with the zones in the areas of access and especially on borders and especially those who need multi- directional or multi-physician care. could you speak to that, not the

politics of this thing but speak to what happens to a father who has a daughter named jordan who may not yet 21, they may be at six. they are trying to get everything they cancel their daughter or son can live within the limitations of what you are now saying and can you speak to that are just a moment? >> i will start. this is a group of patients that we need to provide for. the problem is and they know your area. you are about one hour from us without traffic. that is not a far place to go for someone to see if pediatric surgeon. going to boston is not a big deal for anybody going from massachusetts but if you are the exchange you don't have access in patients like your daughter will not have access not to mention we mentioned the mayo clinic in walter reed in all those places where subsequently

patients have to go. my concern is you have the card but because where you live that will restrict your access to the provider that you need. >> that actually increases costs because you don't have a collaborative effort that you have in a clinic setting or someplace else and maybe have experience. >> it is a team approach in many illnesses and the whole team has to be with this because this was allowed to be created now is all in network coverage. besides the high deductibles, all in network coverage. that's not saying you can't go to see a specialist like dr. english but you would have to pay for it and that won't go to satisfy your deductible or your out out-of-pocket so there are flaws in this and i'm not against the affordable care act. but there are flaws in those that are increasing the cost to the patients, the very patience that you wanted to help. this needs to be fixed.

>> there will be some families who will see some improvement. what we have changed with the law is really the set of who the winners and losers are. there has been frankly not a shred of real-life evidence that the number of losers, the number of winners are going to come close to approaching the number of losers. >> i think that is the concern. it's just a natural outflow of this and there are things that have to be addressed. it's a passionate issue not just for the folks on capitol hill but in fact for the 535 plus on capitol hill and we are just reflections of really the people in our districts who are dealing with this everyday. the hearing on provider networks frankly i appreciate the chairman and ranking member being here and the differences on both sides but i would just have to say obamacare is impact on premium is an impact on the lives of people and families.

if we ever disconnect our their discussions on the insurance and health care for the very people who need it then we have made a mistake and that is why this hearing is important because it's dealing with the people they need the help of the doctors they need for day-to-day living. i appreciate it mr. chairman and i yield back. >> thank you sir and we now go to the gentleman from illinois mr. davis. >> i'm pleased to report that i just came from a markup in the ways & means. while a vote of 390 we voted to do a fix for three months of the sgr and kind of looking after the needs and concerns of doctors. i also want to take a moment to just associate myself with the comments of my friend from georgia mr. woodall who just spoke willingly about the community health centers and the

accessibility as well as impact that they have had. i happen to have worked for two of them in civilian life and also had the good fortune to be president of our national trade association at one time. i certainly think that they are a tribute to what can happen in the development of ambulatory care. so i just want to thank them for that comment. i want to make sure that we don't lose sight of the fact that many of these policies that we have talked about do not include basic services such as hospital care and prescription drugs. they are what many people called junk policies that provide bare-bones coverage that would result in catastrophic medical debts with policyholders if they became seriously ill. back in september young woman

requested to testify at a hearing before this committee. although she ultimately did not testify, ranking member cummings read part of her statement into the record. like millions of other americans she had a pre-existing conditiod disorder. in 2005 she had emergency gallbladder surgery and suffered complications due to her condition. although she had insurance at the time, her insurance company dropped her, refunded her premiums and left her with a 50,000-dollar hospital bill. although she spent years trying to appeal this decision she was not successful. eventually the hospital she was treated at decided to forgive the bill. my question to each of you, all of you are in the business of

providing health care. you clearly have a directive with insurance companies and know about insurance. was this type of policy decision, and prior to the enactment of the affordable care at and what were your experiences in each of your practices? we can begin with you. >> in my 13 this end five years of training in the seattle area i have not seen it and i have taken well over 1000 days of on-call in multiple hospitals. most states have laws already in the aca that prevented appropriate decisions so that's a different issue that i think it's being being completed a little bit incorrectly. laws against canceling people's policy because you get sick that began against the law in states

for a long time and that's a different problem. the idea that people who have pre-existing conditions not being able to find affordable insurance there is not like they have person i have ever come across in my 25 years of taking care of patients it doesn't feel like we need to do something for make policy changes to address that. in conclusion however is that the policies put forth through the affordable care act are actually making these problems worse and not better. >> dr. mclaughlin? >> it was illegal to cancel the publicity because of an increased utilization for a serious medical illness. this wholesale nonrenewal of policies is shocking. it has been reported that the insurance companies felt small businesses were losing proposition to them economically and this probably became a great

opportunity to rewrite those policies which is why we are where we are today with some so many small-business policies not being renewed. hospitals again advise taking care of acute care conditions when somebody is uninsured but we have to fix the problem we are facing now as much as it is laudable to see the people that things -- pre-existing conditions can have insurance. >> i don't have much more to say than dr. novack and obviously we agree that there are changes that need to occur and we are just pointing out that unfortunately this plan is having huge amounts of unintended consequences. >> mr. chairman with your indulgence can i simply simply asked the panel if they would agree that many of these policies were in fact junk policies that we have been talking about? >> i don't think there's any evidence to date that the 5.5 million people canceled.

i haven't seen what percentage of those are quote junk policies. a lot of those didn't contain some of the mandates in the law. >> no one in my practice at a john policy. >> i have nothing else to add. >> i think the jamman from illinois and i would like to recognize the gentleman from illinois mr. bentivolio. >> mr. chairman we now know that you can't keep your insurance even if you liked it then you can keep your doctor even if you have seen them for the last 30 or 40 years and you can keep your hospital. premiums are increasing and we have hired that the pulse. obamacare rated 700 million in for medicare including 300 billion for medicare advantage alone to pay for the aca. 2250 positions were terminated from medicare in connecticut alone. most of the orthopedic surgeons in dayton ohio dropped. in florida, 250 physicians from

one medical center dropped. in january mr. chairman i'm sure we will discover thousands if not tens of thousands of people to their dismay that they thought they signed up for the aca but because of the glitch in health care.gov did not. mr. chairman the web site itself is in question. a web site at that as the most personal intimate questions is not have the proper security protocols to ensure the personal medical data of our citizens that are safe and secure. obamacare created a panel of 15 unelected bureaucrats called the independent human advisory board to the power power to control attempts at treatment seniors received through medicare and according to dr. jason fullman and mr. -- or dr. david rats are this unelected body will have the unprecedented ability to

single-handedly change the allocation of health care resurgence should medicare spending exceed medical inflation which for the record it consistently does. dr. novack what are your views on those ipaa i believe it's called the independent payment advisory board? >> as i mentioned earlier it's a serious area of concern. for those of us and from those families creating another new layer of bureaucracy making determinations about accessibility suspect in the right direction. i would add i think there is fairly significant bipartisan opposition to the independent advisory lord because of the way it's structured. their decisions effectively have the ability to bypass congress. >> do you have evidence that competition and choice is a better way to increase value and reduce costs and the government

bureaucracy and experts? >> i think there's a fair amount of evidence that if we increase transparency and provide more information to patients a lot of patients will make better decisions and that's also trauma physician side. a lot of the solutions are simpler and cost less than the 2.5 to three chilean dollars we are spending on the affordable care act of the next 10 years. >> thank you and you think many people signing up for coverage don't know their doctor for their children's doctor will be in their network and still be able to visit their family doctor? >> i think the evidence of this panel is not only do the patients know but we don't know either. >> mr. chairman we are consistently hearing distortions of the poorly conceived law. dr. novack what do you anticipate will occur next year when people go to their doctor and find out they are no longer covered? >> congressman again it