abundantly aware the numbers speak for itself. they are hard numbers of what was sent out versus the maximumm allowed by law and you're looking at it more than a year later?seey a >> sir, i think these evaluations do take time. they are rigorous. they're designed to be rigorousi >> oh, they do?me do you know how many doctors have had to stop their practicer and answer nothing but questions because you take their money and then they try to get it back?dok isn't that correct?ng but q >> i wouldn't characterize it as stopping their practices. >> no. i'm telling you that doctors in some cases have to stop their practices because the audits for small practitioners are isn't incredible detail.>> n they don't get their money back until they prove their innocence through the process.pr let me go through this again.eye you have the right to stop payments in your state based ont a good faith belief that they got over $15 billion. and then they can spend legions of time to argue why they should get to keep far more than they were supposed to receive. couldn't you? arg>> i wou

>> i would have to look into whether or not we have that authority, sir.he >> well, why don't you look into it, doctor? and while you're looking into 'u it, pursuant to congressional l action under the small businesses jobs act, you owe enc -- subsequently, we get a copy of it. you owe a report, a second-year report on predictive modeling, don't you? >> yes, we do. >> and you've owed it since october?>> y >> i believe the report has been due since earlier this year, but i take your point. >> no, you don't take my point. we did away with a bunch of pot reports through the wi congressional action. we ran it through the house. the senate may have acted on ite we ask for reports we don't always need.d we didn't just ask for the report. the we ordered the executive branch to deliver it. it is extremely important because the kinds of thing thati the gentleman from nevada were about.g about. auditors going out half you know

what, being wrong and on appealr being dramatically overturned dc even to zero dollars, in some cases, after physicians and clinics go through a great process., ins. much of that would go away if your predictive modeling went and looked for the fraud where it is most likely to occur. mr. richie, are you concerned that chase manhattan can see your credit card perhaps being misused and calls you, but the e organization that you're auditing has no such capability? >> that's definitely a concern. we do think that the fraud prevention system has taken steps and shows promise. i know, tie in to the other question with the rac work. one of the things that cms does when they look at the rac audits is they identify vulnerabilities if the cumulative issue is over $500,000 and they need to address those vulnerabilities and assess them.il one of our recommendations was to fully do that.sess we found once they identifying

recovery payments you need to set up the safeguards to prevent them from occurring in the to future so you don't have the problem. up tprob >> has the ig looked into the excess payments requested by and given to the state of new york m that this committee earlier had as to whether or not any criminal charges could be brought?as >> i'm not aware of that. i don't believe we have looked at criminal charges.. i do know that we have -- >> but they knowingly overcharged more than the maximum and cross-funded that payment to other services not even covered by cms, in many cases. the question is, is it worth taking a look to see whether or not the threat of criminal just might get new york to return $15 billion in excess payments? ten times what your audits that we're talking about here today in part are revealing? >> personally, yes. i think it's worth it. i'm not the enforcement person,n but my office and audit, we've o done a whole series of audits in

new york that we've shared with the committee.ed with i can go back to the office and talk to our investigators about this and our counsel and look into it. t >> mr. chairman, i appreciate you giving me a little extra .ime i will say that i'm deeply ng m concerned that reports that are required by congress that t are ultimately are necessary in n order to improve the system are clearly done, but are being held back so they can be sort of looked at again and again.sot ai this is the politicking of releases. i would only suggest to the chairman that we have the y to c authority to compel the work , documents, if we need to, if that report doesn't come in a oo timely fashion from here on. i yield back. >> dr. agrawal, before i yield,l this was a pending question from the chairman.as a pen when will that report come?ill t we know it's months late. when? >> so, as you now, the small business jobs act requires us not only produce a report but have -- >> when? us >> -- results certified by oig.

we are in the process of working with the oig to achieve the certification. that is taking some time. i hope to release it as soon as we can. so >> that doesn't answer a when, does it?t do >> i cannot give you a specific timeframe right now.no >> can you give me a week or a decade? >> it is less than a decade, sir. >> how much less? this is a report that all of us want. it matters to all of us.rs to al it deals with what we're dealinh with, with providers, trying to shift us to where we all want to go. when? is it a month?month? is it two months? this is a simple question from the chairman. when?th >> i cannot give you a specific date. however, i think what is important for the committee and for, you know, the american people and public transparency is that we not only release a report but release it with certification from the ig, so people can trust the numbers anu base future decisions upon a certified report. the importance of that is clear,

so we are working to achieve that. ach >> mr. chairman, only because the doctor did say public transparency, public transparency would be releasing all the work documents that show the reason for delay, the political correspondents, the nh loop to the white house that o occurs on each of these reports. i rather doubt we'll get the transparency. >> mr. chairman, would you yield? >> i would yield. r, it' >> doctor, it's a pretty simple question. if you can't give us a precise date, is it three months, six months?cise and what is holding it up?mentie >> as i mentioned, you know, again, we are working closely we with the office of inspector e general, as required in the law to try to achieve certification for this report.fo i think the importance of that is very clear.f th so people cannot only get a report but trust the numbers that are in the report. >> and, you know, we're not stupid up here'r. we understand when people are trying not to answer a question,

so if you would, be kind enough to answer the question. is it three months away, six wad months away, and what is holding it up? >> i cannot give you a specific date. the reason i cannot is because it's a process that is being worked in collaboration between cms and the office of inspector general. sp >> you can give us a precise date.ou c you need to maybe ask someone else, but we expect to know. we have the right to know. i mean, if there's a problem holding it up, we have a right to know what's holding it up. >> it isn't an issue of holding up the report. >> do you have a draft report that is complete? is it just being agreed to by various parties that then makes it available to be released? >> again, i think our -- >> just answer that question. >> our -- >> answer the question. >> we are working with -- - >> is the draft complete? >> there is a draft report that is -- that utilizes a that uti methodology to arrive at numbers

that the office of inspector general is reviewing or is in iv the process of reviewing.ie we hope to be able to release that report in the next month or two. i cannot be more specific. >> that's helpful.s helpfu that's a lot better than earlier. that >> miss duckworth. >> thank you, mr. chairman.. i would like to follow up a little bit on what the chairman of the full committee, mr. issa, was talking about, these rac audits.e, m i agree that combatting medicarc waste and fraud is a critical goal.au in fact, there are studies that show as much as $50 billion are wasted each year due to waste, fraud, and abuse in medicare and medicaid. we need to go after that.. but it's also become clear to me that the well-intentioned efforts of the cms are not of tc working and are in bad need of reform. i want to talk specifically d an about how these audits, these ok rac audits affect the process throughout the industry and theo patients they serve. i heard from providers from all over the country, many of whom

are small businesses. how they're being targeted by overzealous and misdirected audits that are threatening to put them out of business. they're having to wait years and carry hundreds of thousands of dollars on the books that they're not getting paid for and these businesses cannot survive this. taken collectively, the stain on the industry undermines access to critical services for patients who have suffered from limb loss or limb impairmentbu.e oftentimes these businesses are the only providers of prosthetics and orthotics in their area which means the s orm patients can not get access ande must go without the medical equipment that they need for their lives.etic the volume of audits lead to a huge backlog in appeals for providers who feel they have been wrongly denied payment for legitimate services. i'm particularly concerned thati cms has chosen to deal with this backlog by suspending for two years the ability of providers to appeal decisions at the administrative law judge law.kl

with alj siding with providers in over half of all decisions h and increasingly audits, it's simply unacceptable to deal wit the problem by denying the providers due process.naccepta they're continuing the audits. you're taking these people's money by not paying them and nen saying now you have no right for appeal. you have to wait over two yearst that's not the way businesses o work and you're going to drive these hard-working americans, small businesses, out of business.rd and you're going to leave all of their patients out there without the limbs and the equipment that they need in order to live their lives.s at the public hearing on this issue, the chief administrative law judge griswold gave an ice f explanation of how the office on appeals -- of their position but really offered no short-term remedies that would restore the right of a timely due process to providers.ofs. if you are going to suspend the hearing by two years, then suspend the rac audits for two years.the

give them their money back and collect it two years later. it seems blatantly unfair and unamerican to take these folks' money and not give them due process.se does cms have any plans to restore fairness to the system for our providers? >> so, just to clarify at the outset.t the third level of appeals or the administrative law judge d e level is outside the cms.l it is overseen by omaha. we have district oversight over is the first two level of appeal. by omah >> okay. >> everybody is afforded, you wv know, any over determination whether by a mac, rac, or other contractoraf. providers are afforded the opportunity to use the appeal process as part of their oversight of us to make sure that the audits are being conducted properly and the right to determinations are being arrived at.ng >> what is the backlog at the first two levels? how long are they waiting to get into the appeal process and getting it resolved? >> at the first two levels, the second of which is an independent level of appeal, ort oversight, the oig published a e

report that shows there's no substantial backlog. at the first two levels of appeal. the backlog issue arrives later. on average, we are within the time frames that are required of us.on a i would say, you know, in you k addition with respect to the prosthetics issue you brought up earlier. it's clearly an important area. if there are, you know, issues of access to care with respect to specific beneficiaries or companies, i'm happy to work n . with you on that. that's a priority for us. nt. >> excellent. i will have the orthotics and th prosthetic industry come in and sit down and talk with you. what you're telling me is that n the third level of appeals is holding everything up, and s they've suspended for two years the right to due process. and even though this is being caused by the rac audits that t cms is continuing to conduct, ol it's not your fault, it's se's u someone else's fault, but you'ro still going to shove more people into the system who now have no access to this? n it's kind of convenient, don't o you think, that you're pushing

people into the system with u' t these aggressive rac audits, but on the other hand you're saying it's not our fault that they can't get through the third level.t thug what are you doing to work withg the administrative law judges to fix the delay in the appeal process?ad >> sure. so we have taken a number of ta approaches to ensure that number one the audits are being conducted appropriately and whenever we can to help address appeals issues.ely wo we are actively working withrk omaha on their backlog and s in trying to arrive at solutions in conjunction with them. the fro i think on the front end, where we have more direct oversight ye and authority, we've implemented strategies to ensure that the audits are being conducted correctly and with high are accuracy. as one example in the rac program, we do have a validation contractor that looks behind the racs to make sure that the racs are following cms requirements and payment rules and guidelines and all of the racs have achieved well-above 90% accuracy rate of the findings.

that goes a long way of assuring the rac activities are being monitored. we want to make sure the initial determination is accurate. >> that's a guy failure rate. i'm out of time, mr. chairman. there's a statement sent us to. i would like to put that in the record. t >> no objection.like t >> i want to follow up on that.> you're acting like you have nothing to do with the backlog. i think that's an unfair characterization.to do you not agree? you have nothing do with the backlog? youth the >> i think that clearly, i providers would not have a lot to appeal if we didn't -- c >> let's's look at the inspector attorney general's report. they said the overturn rate at the appellate level is anywhere

between 50, depend on how you read it, 56 to 76%, according the oig. they don't get to that adjudication level without you doing something, correct? >> we have a number of steps --m >> you have to review them first before they get here and they are overturned between 56 to 76% of the time according to the oig report in 2010? >> no, sir. >> you do have part of the reason why we have a backlog eng because on the front end. so you are just denying claims and denying claims. i've talked to physicians, hospitals, health care providers.ve they say the first fair hearing they get is at the h administrative law side of things and that what happens is you guys are just denying them

and you're saying it's tough. tm you have to pay it. and wait for your turn in the queue. >> i don't think that's a fair characterization. >> this comes from hhs.gov website. y'all changed that within the last 30 days. / what it says is appeals are in 356 days.at it do you agree with that?ppeals for fiscal year -- ou agr >> sir, you're talking about thc third level of appeal or alj level. >> i couldn't comment on that. >> well this is your site. fiscal year 2014. average appeal time is 356 days. would you agree with that? for fiscal year 2014. >> i think if that's what the data shows, that's what it shows.

>> fiscal 2013 hasn't even ended yet. >> sir, i'm not sure what data you're look at.yo >> it's on your site. we can give you a copy of it. somebody in your office knows because you changed it within the 30 days. because what you are saying is they are not being assigned for 28 -- i will give you, 28 month they weren't being assigned and that's been changed.you, who changed it. o change >> i think issues you are describing, hopefully this is >> accurate, they are the third level issues. what i stated earlier is we have oversight of the first two levels of appeals and we are abiding by the time lines of those appeals.e fi >> moms and dads back home could care less about the internal division.in they see it as all part of cms. one in the same. they see it as the government. here we are for the budget request that we've got that says backlog will reach 1 million. r1

at what point does it become a crisis? in at what point? when do you start putting companies out of business because you already are, when does it become a crisis that you're willing to do something about? this is your document.dosi 1 million backlogged by the end of this year. is that a crisis. >> sir, if there are individuals put out of business by the audits -- >> i've already called on behalf of some of my constituents. that would be a great response but it's not true.y i've dealt with jonathan plum. i've called to make sure that e kathleen sebelius knew about itj i've called the white house. you say too bad. whatdo i tell the moms and dadso who lose their jobs because theo don't get a fair hearing. what do we tell them?

>> sir, we are able do what we are authorized to do?. so whether it is an alternative payment arrangement or something al else working with a provider --a >> you've got five years for -- alternative payment arrangement. i know this stuff.e i've been studying this stuff for the last six months. five years. been so if the backlog is ten years.a what do they do?st just pay it? because right now, a million ca people at a million appeals, your rate, best rate from the cr adjudicators is 79,000 a year. and even with your budget en wit increase, that would still be a ten-year delay. that's a taking in my book. would you wait for ten years for your salary? yes or no? >> we do what we are authorized to do to work with providers and make the -- k wit >> what do we do. >> stretch out payments, change things in individual payments.he we cannot overstep the authoritt

that's been granted to us by congress. >> something changed. you know what? the audits went from 1,500 a week to 15,000 a week. so what did you change? it's in your documents. i'll be glad to give you that too. it's worse than that. it went from 1,200 and change a week to 15,000 in appeals aweek. what did you change? >> again, i think it is important to level set on this. it is our obligation to audit. we have payment you have heard about from other witnesses that you heard about from the rest of the committee. it is our obligation to go after improper payments, reduce the o rate and make recoveries whereao possible or where they should be played. that is an obligation created in law.po we audit far less than 1% of all claims that we receive.1% in fact, all of the overpayment determinations made by racs mads to the public are less than -- >> my time is expired. r would like one answer to this.

the law says that they need a decision in 90 days. is that law being violated? and who makes the choice on what laws we enforce and what laws we ignore? enfo the law says 90 days. >> i cannot comment out of jurisdiction -- >> this is in your jurisdiction. >> that is omaha -- is in >> no, this talks about qualified independent contractors which is under youru and the alj is after that.whichs 90 days after that. >> great, so as far as second > level appeal, the contractor level, there is recent reportint from oig that shows we are remaining on track as far as expectations of how long it takes go through that appealat.g >> jonathan blum said you gh changed in 2012. what did you change? >> sir, i was not part of that conversation.chhange? >> do you know of any changes iw 2012? i'm out of time. i yield back.tif any i apologize mr. chairman. >> we will come back in second

round.ll come i would like consent to have ranking member spears opening statement entered into the record. without objection. >> thank you.s t i apologize for my late arrival. we had a memorial service at arlington for military women.l. i felt obligated to be there. let me say out the outset, i o have local hospitals embroiled i in the rac situation. i have a hospital that is teetering on bankruptcy right now and the rac experience exacerbated it.e i also think it is really important for those of us who sit on this committee to recognize that we have a si obligation, beyond just beating up those who come before us like this to recognize that if we

want to fix the backlog, we've got to pay for it.tie th there is a backlog because in 2007, rac claims amounted to 20,000. today that number is 192,000 a year. that's ten times what it was in 2007 and we have not added one single person. to respond those claims. so if we want to deal with the backlog, erase it, we've got to recognize that you cannot expece people to do ten times the worko with the same number of work hours. now let me start with mr. richie, if i could. you've got a pretty remarkable run in terms of the efforts by

the health care fraud and abuse program. which resulted in $4.3 billion in recoveries.illion to the treasury in 2013. that represents 8-1 return. is that the highest level of recovery to date, mr. richie?evl >> yes, that is. >> how is that achieved?chieve >>d? we partner with our other partners in enforcement in the e program to fight fraud, waste we and abuse through investigations, through audits, through evaluations that we've done. the recoveries in 2013 were record recoveries. >> i think in your testimony you reference that sequestration ris will result in 20% reduction in medicare/medicaid oversight, is that correct. >> unfortunately, yes. >> what does that mean in terms of what you're going to do and w what we're going to see in terms

of waste, fraud and abuse being properly handled?n >> for our office, not good. less investigations, less audits, less investigation. i'm not the budget expert but i live this everyday. b i'm acting in charge of our evaluation office. act at this point between 2012 and 2014 medicare and medicaid outlays went up 20%. during that time my office me reduced focus on medicare and medicaid by 20%. it is really challenging given e we have $50 billion payment, 10% error rate we are dealing with that it means less auditors, investigators, evaluators on the ground to handle this. i've been working in ig for 27 years and i never felt as i challenged looking ahead to see what the growing programs and responsibility, how we go abouti doing those.re >> should we just roll out a ret carpet for the fosters of this country? >> i would certainly hope not.

in our office we pick the best topics. we make our budget request and e for us personally, the best thing is to fund the budget request to get us back on target.me emplo it has definitely gone down by 200 fte, full-time employees over that time. we have had to stop evaluations and audits and top investigation leads. >> is it safe to say that because of the reduction, there are investigations that haven't moved forward that probably would have resulted in savings to the taxpayers in this country?blyuld >> absolutely. investigations and audits.>> we have to make tough decisions everyday for what we start and don't start and it is difficult in sort of looking at this.ons you think you are making tough choices with things that look good. look

you do a risk assessment and feel there is so much to look at but you only have so many resources and those resources are declining and we've had a hiring freeze for two years and people have left through buyout so we've just been consistently reducing. >> so give us an example of the kind of case that you had to let drop by the way side.mp do you drop big cases that get in the way and the big fraudsters get in the way of the little fraudsters? >> i'm not there. i do know that our investigatiol office told us that they close 2200 investigative complaints since 2012. i think it is a mix. we try to put the best on the cases but we can't afford to do all that. i know our strike force cities we've had a reduction in resources. so it's been across the board in every aspect of the enforcementn >> my time's expired. i'll follow up on the second round.ery w up o >> mr. chair?n

>> thank you. i appreciate the report you put out. i want to go to the first complete page.ylete p this is the latter half of it. i will read it to catch everybody up. for example, cms hired contractors to determine whether deterers and suppliers have licenses, meet standards and mid have legitimate locations.ns. also contracting for checking for criminal checks. however, cms has not implemented other screening action authorized by the affordable care act that could strengthen provider enrollment. can you help enlighten me where you think they have not ldid implemented other actions to strengthen the process? >> yes. i think there are a few things that we point out.prothat w one is in relation to a surety t

bond, establishing a regulation regarding surety bonds for certain types of providers. one is in not publishing a regulation that has to do with disclosure of past actions that have been taken against tions providers such as payments suspension. >> so, doctor, why not do that?? >> i think these are great ideas. we are finding out where our vulnerabilities and weaknesses are and doing something about them.tinue there's nothing wrong with these recommendations. we continue to have the conversations. we have to prioritize -- >> we are trying to get rid of waste, fraud and abuse and h--o authorized by the law, why haven't you done it? d >> absolutely. it isn't, i think, a disagreement over the objectives.ne disagr we have done a lot in the last couple of years to really, you , know, beef up our approach to screenings. some of the stuff like fingerprinting is just coming on-line now. oerprinti there are limitations in terms l of what we can get to and how in

quickly based on resources, based on budget. >> is there a list or summary so we can understand what you are prioritizing, what you're doing and not doing. >> i think you are seeing td i priorities occurring. >> but where do i find that? is that something you can provide the committee?thing yo >> i don't know that we have a list. i'm happy to have further conversation -- >> can you create a list? we are trying to get transparency, exposure, which you say you are in favor of. you're saying you're not doing all you do. crelistry you have to make choice.do. i want to understand what you have prioritized and what you are doing and not doing. is that fair? to put that on a piece of paper and share with congress? >> it might be useful to get your insights. >> no, no, no. you want me to run your agency, i'll run it for you. gao is making recommendations.

authorized by the law to do these things. i'm not looking for a 700-page report. i'm looking for a couple page summary to understand what you're implementing and what you're not. a gere not. you've got to have some kind of document. i didn't expect to spend five minutes asking about a list to a find out what you are working on. is that something you can or ut cannot provide to congress? >> sure, we will provide it. >> when is a reasonable time to get that document? you come up with a date.ll>> >> can you give me a few weeks ? >> sure. give me a date. >> a month.ve we'll get back to your office within a month. >> the end of june.>> t >>he okay. thank you very much. one thing we were working on is providers. are we engaging and allowing people with serious delinquent tax debt to be engaged in the process. there's a big government-wide problem. we have contractors with serious delinquent with tax debt.

i don't expect you to understan. the answer to that question. it's something that i personally and the committee would benefit from understanding. what are the policies you have there.had thom uwhat are it should be a key indicator if you're not able to pay the federal taxes. why do we give you more and more business.do the president has been in support of this.ha when he was senator obama. i think it's a bipartisanship tl thing the committee dealt with . bill specific to that. if you can also provide me information about what you do with that and the answer may be we don't do anything with that. i would just like to know the a answer to that question.ju can we shoot for the end of jun. you give me that information is that fair? >> i think that's fair. but i think just to comment on that a little bit. i t we have all kinds of information we could collect from providers. i think the question often, you know, we have is what information can we collect that is actionable for us.we so there are some clear bright lines in the program.e cl you wn

if you don't have the right license to practice medicine in the state in which you want to enroll, you don't get to enroll in that state.ce there are certain other types of disqualifiers like certain felony conviction. i think it makes a lot of sense to include as much risk ink s as assessment data and analysis ase one could to look at providers. i think we have to -- there's in just a sub set of those k potential risks that push over the line and allows us to take action.ju if the provider, you know, thetp exclusion list or the -- usthe - >> i'm worried about the contractors you're engaging thaw are supposed to help on this. that are supposed to help you engage with the people. those are some of the specificse that i would like to see as well.e ecific it's not just -- i'm not talking about the providers about w contractors, it's the contracting that you're contracting with in order to be make these things, thank you very much, mr. chairman. i yield back. >> the second round for questioning. during this time, there's full interaction. you can jump in at any time.to there's no clock run at this time period.during

for our witnesses, if you have . specific things you want to get. in the conversation feel free tn initiate the topics to make sure you're clear.ng is to m the goal is to make sure we bring all the issues out and find the areas that need to be resolved and the timeline for resolution on those things. you're free to be able to bring them forward and make sure we have clarity on this.. i want to reaffirm. let me first take first crack.e this panel is committed to how do we deal with fraud. there's $50 billion in unaccounted for money possibly overpayments in fraud. we affirm that we are pursuing the fraud. it's the taxpayer dollar. taxpae it's essential. the solvency of the program and the taxpayer themselves.ti so continue to do that.tinue i think the frustration is the prepayments side of this we know it's the direction it should goc we're not having to chase and that's why we want to know the w report, we want to know what is happening at this point and how do we get ahead of this in the

days ahead and not having to goe back to constantly good providers and say we're going to hold the providers.ind and for them to have a portion of their cases pulled and not paid for for an indefinite period of time as they go through the appeals process is untenable to them. i want you to hear it from me and us. we're not opposed to going after fraud. we're opposed to the methods. there have been changes in the o audit process as cms learned the way through this. the mdit pr we're proposing additional changes in this.y th to say what can we do to help expedite the process and make te sure when it's right and overturn the appeals and get the money faster and have fewer people engaged.peopgh let me run through a couple of these again. we're going through the revalidating process. ss is that complete at this point . for providers nation wade.

we've done fingerprinting, background, re-enroll. is that complete at this point? what stage is that in?at >> the revalidation process was initiated after the aca puts us on a five-year cycle s.he i believe the latest number is we have revalidated over 770,000 providers at this point. this po that puts us on track to being i complete in time for the first cycle. the >> two more years? >> i think that's about right, h yes, if i remember correctly. h >> then the prepayment pursuit of fraud? we have a report due to us. obviously we discussed that.ssea it's coming in the next couple of months to give us the details and progress on that. we move into the post payment.pn do you make any comment on the prepayment side?t. >> well, i think just that clearly the affordable care act did provide us a lot of provide authorities to make changes on the prepayment front.ments such as, you know, payments suspension which we are able ton leverage against the worst actors. i think the only point i would make, congressman, is to ld differentiate what we do when di we're going after potential

fraudsters, criminals, the worsc actors from those providers, the vast majority that are perhaps producing waste or producing inefficiency in medicare not quite following our rules. but have the intention to follow our rules.ll are trying to do their best. i ask to keep the framework in mind. i think it sort of determines t for us what tools we utilize so they're not overly pejorative. payment suspension is a great tool for the worst actors. is not a great tool for legitimate actors. it's essentially suspends all the payments they'd be getting. d right.it's it's the hammer down in the area. even for the high risk areas. there's a moratorium. some of those areas may have a deficiency of number of good companies that are actually providing.. ide youfi see more people entering n medicare. there's a need for providers. that's an incredible hammer for

that region. a lot of small businesses that won't start up during that agre period that could be legitimate providers.t of c >> it is. i agree with you. it's a notable piece of authority we implemented with a lot of care and over time. it took us years to go from having the authority and the acr to implementing it for the first time.us t the i would say the areas we try to address, the geography and home health services as well as ambulance services, are areas ws knew there was a lot of market saturation. there was very little concern. we have been looking at it ern. continuously about access to cot care issues.care i you know, home health and lth a ambulance services and texas and south florida are areas of a lot of agreement with the office of inspector general, the department of justice within inp cms, within state medicaid ag agencies there's just a lot of o market saturation sort of 3 to h times the number of providers o. average. so while access to care is clearly something we care about and looking at in realtime to i. make sure the moratorium does

not have negative impact. we're currently not seeing it in those areas.in >> let me come back. i would like to get a timeline for everyone the length of time. you said they're on schedule. let talk about appeal number one. someone has a problem.ppeal nu the rac caught it. the appeal number one is to who and how long does it take? >> sure. i believe the first level of appeals providers have 120 days to file the appeal. there's a 60-day time limit. >> they filed it right away.co their responsibility is their responsibility. you have 60 days to respond, correct? >> correct. ho >> who is responding they're appealing to who? >> i believe in almost all cases it's the mack administrative contractor that handles the first level. >> so you have the rac folks making a decision, and then the mac folks that are making the response to the appeal, is that correct? >> correct.sponse so there's 60 days to respond. t

you're saying it's on time. >> right.'s >> they disagree with that. they come back on the second level. who is that. how long does it take? >> the qualified administrative contractor.fi they have 180 days to file the appeal. the the provider does.peal.ays to we have 60 days to make a decision on the appeal. m >> and you're saying it's on time as well. >> so i have average times that are below the 60-day mark, correct. 53 and 54 days for most of the appeals.th e >> do you have the overturned rate on both of those? >> it would depend on the specific audit. so is there a particular audit you're referring to?peals. >> either one.ve the the first or the second level. g >> and rac audit, sir? >> yes, sir. >> i would have to look. i think while i'm looking. let me say the overall overturned rate for the rac audits are between part a and b about 6 to 7%. bit it's the latest data that is public. publ

>> you're talking through the alj process?th you're talking through the first -- that's what we're trying to figure out. get a cumulative number. we get to see a cumulative o mber. thr >> no, i believe, i believe that the 6 and 7% numbers are all the way through are ever overturned. >> okay. i'm trying to figure that out.ii the latest number on the alj is between 56 and 70 some odd percent in that level. >> correct.nd 7 if i can perhaps explain it a bit. the rac, you know, make determinations. i think the latest public data is 1.6 million claims found contain overpayment.t. providers make a decision about whether or not to appeal those overpayment determinations. and basically at every level of appeal as you go through one, two, three, the number of claims going to the next level comes down.two, the overturned rate might vary between the levels.

i'm not finding the level right away.the ov that's helpful. thank you. the first two levels, we're seeg seeing a 9% overturn rate for the rac in specific. >> both of them or each one? 9% -- >> no at the first level of appeal. 9% for part a. >> part b?>> 3 >> 3%. >> all right.for for the second level of appeal? >> at the second level for partf a is 14.9%. >> so 15% basically? and then part b? >> 0.5%. no, i'm sorry. i don't have it called out. i have the percentage of appeals that make it to the second

level. i don't have the overturn rate o for second level. we can get it to you. you. >> that's unknown. after that they have done 60 had days in the first and secondon one. they disagree with that as well. and now we're heading to the aljs.e he which is as commented on now could take ten years to get to that spot.dependin depending on perspective you get there. we've heard 28 months. it's pretty ambitious based on the number of people and the number that is typically handled. i know, you've said over and over again it's the responsibility we'll visit with them on this. it's the next level. and the fourth level is what if they disagree with that? >> there is another level they can go to which is, i think, e t federal district court level. >> okay. y. >> i'm sorry it's the departmental appeals. >> cor after that is federal district court.k yoi >> that's a fifth level. >> correct. >> okay.waev

thank you. i want to get the context for everyone. jump in at any point. >> i guess my question is so let's look at part b, d and e. what is the overturn rate for that? which would include, you know, some of the other stuff. let me add, i have a report here from your office here on april 2nd of 2014, that says that tha overturn rate is about 52%, is that correct? is this report correct from your office? would it be about 52% for dme overturn rate?turn rat >> i think it depends on what t document and what level you're looking at.nd w if you look at all dme claims. it's about 7.5% of all overpayment determinations. >> we're talking about on the appellate report.th this is office of medicare hearings and appeals.re their report.eir re

it says the overturn rate is 52% is either fully favorable or partially favorable. 24.87 was unfavorable.d so w and so with that, it would indicate that the overturn rate is much higher than what you would indicate. >> well -- on dme. >> there's a calculated overturn rate at each level.ch lev what i communicated about the so first two levels gives you the overturn rate for the levels. l >> i'm trying to figure out how does your report say 52% here h and what you testified said -- r where is the difference? help me understand that.he >> generally, as you go up at the various levels of appeal. providers make a decision at each level whether or not they appeal to the next level. we see general trends.t th providers tend to -- the number of claims appealed at each level tends to drop.of and the overpayment or the overturn rate can increase. so at the third level of appeal, at the alj level.

the overturn rate -- i can agree with what is on the piece of paper. that it probably does approach 50% for dme. >> all right. pr all >> but at lower level of appealc given there's more claims that r are appealed and fewer decided in the provider's favor. the overturn rate is much lower> >> that makes sense. out of the 1 million in backlog that your budget request talked about.ke how many of those would you anticipate based on this rate are going to be overturned? mili out of the 1 million backlogged appeals going to alj?on >> i think that's an individual case-to-case determination. ual >> it is. deter but based on historical evidence, how many would be overturned? >> sir -- t >> 520,000 of them. based on these numbers, wouldn't that not be correct.that n >> based on those numbers. >> let me ask you one other question.k is the american hospital association, they have rac facts.fa per rac track, which this is all

greek to me, 47% of hospital denials are appealed and, quote, almost 70% of these appeals are overturned. is that incorrect? >> i can't really speak to their data, sir. what we know, what we track the data, of course, very closely internally.at c our numbers would not agree with that.d if you look at the first level l of appeal for part a. we see a 5% appeal rate that makes it to the first level. fie >> mr. ritchie, if i could interject.interjec there's a problem here. why is it that if you've got enough money to go to the third appeal with the alj, if you can hold out that long, if you're not a single provider, if you're a big hospital, you can hold out -- if you go to the alj you have a 60 to 70% chance of winning. n why wouldn't everyone just go tu that appeal process, if they can afford it?th the question i have, why the

discrepancy? what do you know about the alj t system that allows for such huge swings in the determination? ok. >> okay. we looked at prior to the backlog. i think it's still relevant. we looked at the aljs and at the time 56% overturn rate. this was 2010 data. for the prior level to qualifiei independent contractor there was 20% overturn rate.01ctor t the big differences we saw, cess again, i mentioned earlier the unclear medicare policies we pc think are a trigger to a lot of this. at the alj level we found they tend to interpret them less strictly than at the prior level with the quick level.evel because they're confusing and complex policies. l they're open to interpretation. the other thing at the level it's more specialized. they have specific people looking at part a. specific people looking only at part b. they have clinicians revealing that.

at the alj, they deal with everything that comes their way and relying on documentation and testimony of the treating physician to make their decisions.tion and so the process is different. we have seen the case files are different. s are it's more of an administrative thing. the things they're maintaining and holding in the case laws are different from level to level l and creates some of the inefficiency. the alj level is still on paper. the quick has everything electronic s.tieverythi they have to print it out and send it to the alj. they have to get papers from contractors and sort them out. it is to clarify policy and to create one system that's electronic. >> if i understand you correctly, at the level, they are very specialized, they knowt what they are looking for and e they make their determination because they are trained to lood for certain things, i guess.cau i guess that's part of what you're saying?gs, i >> correct.

we didn't assess and look at which level is better.sayi they are very different.better but we have seen they have clinicians looking at it and eya specific of a complaint or appeal comes in, it comes into a part a, it is going there. complaint or appeal comes in, g specific to part b it's going there, where as to alj they've got -- >> and aljs aren't clinicians and they're using discretion in interpreting the law. >> in terms of interpreting the law, then they're relying more . on the treating physician's ev at the quickid level they're relying more on their own cl clinicians to interpret the documentations.nt >> it speaks to a couple larger issues.nt t i want to get back to what are t the real overturn rates? are we targeting correctly and o what can we do to improve the system so that we're not harming we're harming just the fraud

beneficiaries going after wast fraudulent and wasteful behavior. medicare is an incredibly st the reality is if we don't starr dealing up front with the medicare complexities, we can nn chase this all day long and go from one extreme to the other n and we're going to find abilit significant flaws in our ability to hold providers accountable and to support providers to do a better job. and what we haven't done in thih conversation is -- i'm as concerned as anyone else about getting it wrong, overpayments. i'm also concerned that your i'l part a providers are large providers. pa though we might have hot spots with the dme providers, that h e they can't afford to go throughd this process.at in that regard your data is skewed for one group, and i'm not trying to vilify one group over another. but hospitals, large hospitals and large hospital groups can afford to wait a decade rge potentially.

smaller hospitals, as congresswoman speiers identified, my colleague from california, cannot. i want to get back to maybe a couple of things, one, and then yield back. can you give us some recommendations? you talked about the predictive modeling.predic you said we're identifying prescription practices that are clearly problematic.areas. is there a way to be targeting those areas and is there way to start targeting areas where accs we've got real issues with a access?we'r cms has a responsibility to ensure access.is we're only doing one side of this. we're eliminating access and nof response about that. >> so i'm sorry, could you t isu clarify, recommendations for what?hat ther >> a couple.area the first is you identified in your testimony that there are o areas that you've identified anr that we could start looking at much more directly.could do and aren't. so we could do predictive

modeling in terms of where folks me we've got potential fraud. and two you identified in that discussion, i don't know if it was tied to the predictive eithr modeling, per se, but you've identified prescription practices that are clearly problematic. you said i think you've got folks who are not prescribers, u as an example, prescribing medications for beneficiaries. why aren't we focused more in those areas. and then i wanted either ha dr. agrawal or someone else to talk to me about what we're doing if you've got hot spots for fraud, what are you doing to shore up mistakes, so that we re don't lose those providers by providing better education and support to those providers, and creating in low access areas frontier and rural states, what are you doing to assure you don't lose providers. eral onks for clarifying.er au we make thosef representations all the time finding

questionable prescribers and home health agencies. in all those cases we take the ones that we've identified that are extreme outliers based on df the statistical tests and give t it to our investigations office to see ifio they want to furthe pursue because we share with contractors to take appropriate action. and we always recommend that owt they takehe the questionable d e criteria that we have and implement it.at's m ien know the prechbs system is n starting to build that in we saw $5 million without authority to prescribe massage therapists and things. i have to look at this because it was late last night that i got it, but cms requires prescribers of part d drugs to enroll in the medicare fee for service program starting next lc june, june 1st of 2015.medicare

this will allow cms the plans al be contractors to verify that they actually have the authority to prescribe because now they aren't -- a massage therapist isn't billing medicare but theyu could write the prescription for drugs that we found that were pretty severe.soation >> what we're interested in -- and i'm taking too long -- is to get that information to the committee so that we can weigh i in on how you're balancing these issues, and in the chairman doesn't mind, can we get something on the record. what are you doing to ensure that small providers aren't discriminated even further in this process because of the size of the provider and the capacity of the provider and have you

thought about treating them differently like we have tiered regulatory environments. what is your thought about making sure that access is protected?ders >> yeah. again.by s and i appreciate the question.iz that is an extremely important area for us. we do currently tier providers e by size. we actually have medical record request limits, specifically fo the rack contractors based on to the size of the provider. i had also mentioned earlier a future solution where we would ratchet down the number of the reviews that a particular provider would face if the favo reviews are generally in their a favor. they're basically following the rules. solutio we're putting that solution into our rack procurement process right now so it will be part ofi the racks going forward. in addition to that, we do take -- if there are overpayment determinations, we have a process for the provider to work with us and change the payment

rate in order to still meet our requirements and still meet the requirements of the law. but to be able to afford them a longer opportunity so we don't put providers out of business unnecessarily. i would also say just on the front end, we are undertaking a lot of efforts to better educate providers about our specific payment policies. i think the dma or the home health agency face to face is a good example of that. where the improper payment rate is very high because of this new requirement. providers need to be brought up to speed. we are trying to do both specific audits that will look at that issue in order to educate both the home health agencies and the related prescribing providers. we also have just more general education materials that providers can take advantage of. we try to be very transparent on the front end about what audits we're conducting. so once a new audit area is approved by cms, we put that information on a website that providers can look at to show up their own ought its to make sure that their compliance programs are working and be prepared for audits in those areas. we hope that all of this helps to make the process more open.

>> and if it doesn't, what do you do to assure access? >> right. i think, you know, part of it is we have an open door policy for providers. we do want to hear about the shortcomings of these programs if there is an access issue or -- >> and you don't think the providers by and large are going to be concerned about that open door policy particularly in the context of audits and your efforts for fraud, waste and abuse? because when i was the secretary of health and secretary of aging, i appreciate that mind-set. we're here to help you. and by golly, no one believed that. and so i didn't really find that to be an environment that was very productive, particularly when somebody came to us and in fact they were fraudulent and we did our job. that certainly precluded that kind of a relationship. can you please collect data for us, if you don't already, and

provide it to the committee so that i can see, we can see what the percentage of small providers that are engaged in any level of these appeals, versus the large providers? >> yeah. and i think -- we can do that. and i think it would be helpful to work out a definition for small provider that we can focus on. >> the last thing i would say, i'm trying the patience of this committee and i'm sure our witnesses, but i would -- i would, again, this committee wants you to ferret out fraud, and to stop those bad actors. and actually, move those to criminal prosecutions and to prevent those folks from ever being able to engage in any of our health care systems, or any government contracting ever again. we're that serious about fraud. and we also want waste addressed. but i'm getting very concerned really about that access issue and this is completely imbalanced. i'd like you to consider and mitigate that by telling us what the risks are about changing the withholding of

payments for the third level of appeal taking into consideration a new definition potentially or a refined definition for small providers. and to entertain that and maybe come back to us in writing about what that would look like. thank you, mr. chairman. >> dr. agrawal, the passion of which you heard me today is not meant to be directed at you. it's a passion based on a number of people back in my district that potentially will lose their jobs. and i for one, nor you, do i believe you want them to lose their jobs because we have a system that is broken. when the chairman called this hearing, it was really a hearing about making sure that those who steal from seniors -- because that's really what this is about is fraud. those who steal from seniors get caught. but in the process there are a lot of potentially innocent people that are getting caught

up in that dragnet that we have to find a better system to do that. i would ask you to submit to this committee, if you would, two legislative changes -- if you are saying that your hands are tied, what are the legislative changes that you would support and recommend for this committee to perhaps have the chairman introduce where we can fix it to make sure that we do go after waste, fraud and abuse but those that are innocent don't have to wait forever to get that innocent verdict. and in the meantime, potentially go out of business. i yield back to the chairman. i thank his patience and his foresight in having this particular hearing. >> let me ask a couple of questions to follow up on that. it goes back to what mr. meadows was saying as well. good actors we want to keep. our seniors need to know in my neighborhood, in my community, in my town, in my county, there is a good actor that's there. we have all talked to folks --

i'm sure you're aware as well, on several areas. last weekend i had a gentleman that came to talk to me that wanted to tell me about the last year of his life because he was a durable medical equipment provider. was. he's now been put out of business. he was a good guy. he was willing to meet the price that was out there made publicly available in the competitive bidding process but was not allowed to join into that because, as this group knows well, when the competitive bid was put out, if you didn't get the bid, you're out. and not just out. you can't join in even at the new low price. you're just out of business. he's one of those that came to me and said, i just want to tell you about the last year of my life when my family business went out of business and closed down a company and laid off employees and here's what that looked like. i have individual providers that come to me and say, i had a group of files grabbed not being

paid for that are going through the appeals process and i'm fighting my way through that and then as i'm fighting my way through that, i had another group of files that was grabbed, and now i'm fighting through those and i'm in a different time period. and i'm not making payroll. i understand the comment of saying it's 1% or 2% of files, but if they start getting a set grabbed and then 60, 90 days later, another set grabbed and they're still unresolved from the previous one, they're not going to make payroll for the smaller companies. these are very real issues. we want medicare providers to be there. we want our seniors to have access. we want individual health care folks to know if you take care of seniors, the bills will be paid. that certainty is disappearing at this point and that's a bad formula for where we are five years from now. six years from now. that's why the urgency of this is extremely important that we

get ahead of fraud rather than constantly chasing it. because when we're chasing it, we're also hurting companies that are the good actors, that are trying to do it right. we are all for shutting down bad actors, aggressively going after that. knowing the good actors made a mistake, an error but now they're having a difficult time making payroll on it. we're losing the good guys in this and that's going to hurt us long term. let me shift a little bit. with the rack audits. dr. agrawal, you and i talk briefly earlier about this. the incentive for them to -- if there's a question that this is going to get lost in an appeal for them to not pull that, for them to actually work what that. i will tell you -- you probably heard the term as well. providers call the rack audit folks bounty hunters. they come in, land, go through stuff until they find something because they get paid based on what they find.

the incentive is not to be able to sit down with someone and say, you made a mistake on this, let me show you how to do this different. the incentive is i got you and i'm going to get paid. that's bad relationship that's forming between our government and the people that we're supposed to serve. now we've got a set up an environment where the incentive environment is for them not to work with someone to find and work this out and how to learn on it but to punitively pull a file. that's a whole different set of relationships there. so the question is how do we get back to the incentive with the rack folks to be helpful rather than punitive but we still go after fraud? ms. king, do you have an idea on that? >> sir, if i might, the other types of contractors that do postpayment reviews, the macs, the cert and the z-pics are not paid on incentive basis. they're paid on the basis of cost under contract. the payments for the racs were actually established by law. and how they were -- >> correct.

>> so that -- if you're concerned about the incentives, it's something to consider. >> i think that's a very helpful point. i would also say, you know, we do provide -- so i think -- let me make two points on this. one is we provide oversight to the racs. so the characterization that they might be on a fishing expedition or making judgments just to receive the incentive payment is, i think, not accurate because we do do that validation work behind them to make sure that their accuracy rate is very high. that accuracy rate -- >> is there an incentive to be helpful while they're there, to teach someone how to do it better or is the incentive to be able to pull it? >> i think there's two kinds of incentives that work in the favor of providers. one is the racs are equally incentivized to find underpayments to providers. they get the same contingency fee if they return money to a provider that they deserve, as they would when they make an overpayment determination. that's just one. the second thing is we have made

it a priority in the program both for racs and macs and other auditors to use education as a tool. so when deficiencies are identified, they can communicate those to providers and hopefully providers can, you know, rectify that deficiency going forward. >> are they paid for the education? >> well, the racs are not specifically paid for that. but the mac contractors do work very closely with providers in all of their regions to, you know, teach them about medicare policy and payment requirements. we also utilize the results of mac and rac audits to alter our programs, you know, be more specific on policy issues where necessary. make changes to processes. so that is a priority for the agency. we do try to use the outcomes of these audits to alter our interactions with providers. >> what is the incentive for them to educate? >> i think what racs have been able to do is take areas that we know have high improper payments in them, again, differentiating improper payments from fraud. >> right.

>> racs are not necessarily designed to go after fraud. those are other contractors and other areas of work. what we've asked them to do is focus on areas of high improper payments and make recoveries where appropriate. along the way they do identify educational needs, or, you know, clarity deficiencies that we can address either through other contractors or directly. >> mr. norton. >> thank you, very much. mr. chairman, thank you for this hearing. when -- perhaps because medicare is a necessarily costly program -- i say necessarily. we do the best we can to provide maximum care for the elderly when they are ill. there is particularly

concern when there are reports and they are always quite sensational, reports of fraud or particular abuses in the program. i know that the affordable health care act gave the cms several new -- or at least expanded authorities to deal with fraud. i would be very interested in hearing about how you deal with those at higher risk and how you deal with them when they apply -- when it applies to providers and suppliers who are newly enrolling and those who want to revalidate their participation in the program. >> sure. thank you for the question. so as a result of the affordable care act we've been required to implement a whole new approach to provider enrollment and screening that takes into account the risk level of that

category of provider. higher risk categories of provider like newly enrolling dme or home health agencies are subject to greater scrutiny. that scrutiny can include or everybody certainly gets certain data, analytical work to make sure that providers of all types have the right licensure, have the ability to practice in their provider category. higher levels of scrutiny include site visits, criminal background checks, fingerprinting most recently. as a result of those activities -- >> have you done fingerprinting before? >> fingerprinting we are just bringing online. we procured that contractor last month and we are -- >> all providers or for the high risk? >> the high risk provider will be subject to the fingerprinting requirement. as a result of those activities, we have revoked -- and through the revalidation process, we have revoked over 17,000 providers since the aca, and deactivated an additional 260,000.

>> for example, for what kinds of abuses or fraud -- or is it fraud? >> all manner of activities, really wherever they do not meet our requirements. so lack of appropriate licensure would result in a revocation. the presence of certain felony convictions on criminal background checks would result in revocation. failure to disclose information required on the medicare application, or to report that accurately. >> would these providers be barred period, permanently barred? >> we -- the actions that we take, of course, are governed by the authorities that we have. revocation allows us to remove these providers for, i think, i believe up to a maximum of three years based on the infringement. beyond that law enforcement has exclusion authority that lasts longer and is more sort of widespread in its impact. we do work with law enforcement on utilizing that. >> have you had occasion to refer a number of these to the u.s. attorney or other law enforcement? >> yes. we actively work with law enforcement on referrals. but also even prior to the

referral. so i think we've given law enforcement an unprecedented access to cms data, realtime access to our systems the same that we utilize in our analytical work. as cases develop we're in regular connection with law enforcement about cases they may be interested in and ultimately do make formal referrals that they can choose to accept. we work with them on the entire investigational process as they deem necessary to provide them additional data or any assistance that we can. >> i'm interested in this temporary moratorium. this is apparently a new authority under the aca for a new medicare providers and suppliers. what would evoke that and how does it work? >> sure. so since the aca we have implemented essentially two phases of the moratoria essentially against home health agency or newly enrolling home health agencies and newly enrolling ambulance suppliers in a few different geographies across the country.

before implementing that moratorium, this was a big step, because it is a, i think a notably important piece of authority that we were granted. before implementing it we worked very closely with law enforcement to make sure we were looking at the right geographies, and the right provider types. we work with state medicaid agencies and across the agency, across cms to ensure that we were going after the right areas and also not having or potentially would have a deleterious effect on access to care. what we ultimately chose, both the geographies and the provider types, the market was saturated by these provider type. roughly 3% to 5% higher market saturation in home health agencies and ambulance suppliers than the average, you know, geography across the country. so far the moratoria have been in place for -- first phase was put in in july of last year. a second phase in january. we continue to monitor both cost issues as well as access to care, and we have not noted any access issues thus far.

i would say the moratorium has been a useful tool. i believe law enforcement finds it a useful tool as essentially a pause in the program so no new providers enter a geography and bad actors can meanwhile be rooted out. just as examples of work that we've done, we've revoked over 100 home health agencies in miami alone, more than half of those during the moratorium period an 170 revocations of ambulance suppliers in texas. >> how do you keep beneficiaries from being affected, particularly with that large number in one location? >> right. that is absolutely a priority of ours. we started by choosing areas that were very saturated to begin with. these are not areas where access to home health services or ambulance services was threatened in any way. even med pac had agreed that both of these provider types, as well as the geographies were appropriate to go after. since implementing them we've

stayed in constant contact with the specialty societies that oversee these areas. we've worked with state medicaid agencies with cms regional offices that directly receive complaints from either providers or beneficiaries to monitor for access to care issues. and as i stated earlier, we have not identified those issues so far. >> finally, ms. king, have you had occasions since these new authorities to look at their effectiveness and their implementation? >> we have not. we evaluated the enrollment process just as these new authorities were going online but we have not been back to look at yet. but we concur that front end strategies on the enrollment side that making sure that the right providers are enrolled and the ones that are at risk for being fraudulent are prevented from being enrollment is a very effective strategy. >> thank you very much.

>> let me run through some quick questions and we're nearing the end. the end is near. i want to confirm again the percent of patient files pulled for a rac audit. you've used the 1% number several times. is that accurate around 1%? or do you say 1% or less? >> the 1% actually is not just the rac audits, it's all post-payment audits. >> that's every category, durable medical equipment, physical therapy, hospitals, labs, whatever it may be? in every category it's 1% or less? >> yes. well the aggregate number is less than 1%. >> that's what i'm asking. for each category. are there categories that are higher that are considered more high risk so there are more that are pulled in that category? >> i don't know the answer to that. >> do you know, dr. agrawal? >> i can't answer the claim question. but in terms of prioritization we clearly do focus on high improper payment rate areas. i think that's a requirement of the contractor itself of the

program that we focus on areas where the improper payment rate is much higher than in other areas. so you would expect to see greater portion of audits in say, for example, durable medical equipment or home health agency services because those are where a lot of the improper payments are. >> that's what i'm trying to figure out. is that category higher than 1% of what's pulled? >> you know, we can -- we can look into this, but i believe that most of the rac audits are focused on the -- on the part "a" side. even though that the rate of -- the rate of improper payments is higher in durable medical equipment and home health providers. but the actual dollar amounts of the improper payments are higher -- >> sure. it's a larger bill as well. part "a" is going to be larger than what's going to be in part "b." and most of the smaller providers. i would understand that. but it may be large to them. so if you've got -- again go back to the physical therapy clinic, privately owned, fewer number of patients there, it may be a very big deal to them to have 2% of their files pulled.

than it would be to a hospital. as far as just general overhead. dr. agrawal you mentioned as well about good actors in this. the possibility -- and i heard a lot of, you know, variances of that, to put in the maybes, possible. we're looking at statements in it for good actors that are out there. once they gone through, they proved to do well, they didn't have a lot of inaccuracies. how do we slow down the process so they're not coming just as fast to them? again coming to, again, an entity that's set up to do compliance now more than it is to take care of people. where are we on that? give me the process. >> sure. one solution that's been proposed is to lower the volume of medical record requests that could go to a provider that in previous requests has had a low denial or overpayment determination rate. that i think is a good idea. we've heard it from a number of sources and we're implementing that approach in our next round of rac krlts precisely so that

providers that have been audited and have shown that they're following the rules will face fewer audits and lower volumes going forward. >> is that less frequency of audits or they're grabbing a smaller number of files when they come? they're coming just as often, they're maybe just doing half of one percent, rather than 1% or they're coming maybe once every two years so they're in their building less often? >> i'd have to confirm. i know that the volume per audit will be decreased. but i have to confirm if the frequency would also -- >> i would recommend to you both are important especially to part "b" folks. they're trying to run a business and if they prove to be good actors in this, the frequency matters to them, when they have to stop -- obviously the volume that is being withheld from them, not being paid to them, makes a big difference for them making payroll. but it's also extremely important they're able to focus on their business and not every 60 days, 90 days, have to stop and do another one of these if they've already proven they're doing well, they're following the rules. so i would recommend to you both they're examined on both

frequency and number of files they're pulling. has there been a study to look at the compliance cost for the providers? mr. ritchie mentioned before around $700 million has been recovered this year. is that correct? >> yes. >> do we know what the compliance cost is? has anyone seen a figure for that? >> not to my knowledge. >> most of the regulations that are out there when they're promulgated there's an estimated compliance cost for the promulgation of the rule that has to go through based on the requirements. the question is do we now know with more certainty what the actual compliance cost is? where would i get that? >> i'm not aware that such a study has been done. we have not done one. >> okay. >> we haven't either. i'm not aware of it. >> i can go back and look at the beginning, when it was originally promulgated there had to have been an initial estimate that was put out at that time as well. i'll go back and pull that. we'll work through that on our side. we don't know when another one has been done since then. and then last set of questions

here on this. the pausing the racs. mr. chapner and i have had a conversation that when there's an intermediary change, very typically when the intermediary changes to a new one, the old intermediary starts losing employees quickly and they're trying to maintain the rac audits with fewer staff and everyone's leaving because that company is shutting down and shifting to a different spot. the other company is trying to fire up and get ready so it's very slow. but the speed of racs can be the same across that. though the old intermediary can't keep up and the new intermediary can't keep up and you've got a drag in response time. my conversation is can we reduce the number of racs during that transition time when the intermediary changes. if the authority exists to do that, where is the authority to slow down the process to allow us to catch up on this backlog somewhat? to say we're still going to continue to do this but we've got to slow this down because if we're approaching a million files sitting out there with more still coming, they will

never catch up. it doesn't matter how much we fund it. we're not going to catch up. and that's a lot of money to be held from individuals. what is the conversation out there related to that? >> we do realize that as we procure the next round of rac contractors that there is a sort of transition issue. what we've done is pause the rac program during this transition. what we don't want to happen is for one contractor to initiate an audit, and for a second contractor to then complete that audit. so we are working -- >> happens all the time. >> we are working to avoid it this time. so the last round of audits were initiated or permitted to be initiated at the beginning of february. those audits must be completed in a timely manner. so that -- and then the racs, the current batch of racs can wind down and then the new batch of racs can wind up. during the pause we're using it to -- taking advantage of it to alter the rac program based on input that we've gotten from providers and other stakeholders to make it more transparent to

providers, to provide more education, and to make sure that it's focused on all areas of improper payment. >> and when will that be public? >> the procurement process is going on right now. we're following sort of standard federal procurement requirements. there are statements of work that in order to actually get proposals, that either have hit or will soon hit, you know, public transparency and contractors will be able to respond to. >> okay. any final comments? bill, i appreciate you -- >> no, sir. >> i appreciate you being here and for the conversation. your work is extremely important both in transparency and helping us deal with improper payments and fraud. i think you've heard from this committee pretty clearly we need the balance. we need providers. right now with what's happening in health care across the country, we're losing providers. and anything that discourages a provider from continuing to stay open makes the problem worse.

we have more seniors every day joining into medicare and we have a problem with providers staying in based on reimbursements and based on just sheer compliance and the frustration of that. this is reaching a really bad spot and we've got the make sure we're working with providers to keep the good actors and then weed out the bad actors and educate those that just made a mistake rather than push them out of business. with that we're adjourned. tonight on c-span3, programs on campaigning and voting. we'll hear about the latest innovations in social media, a recent debate on campaign finance laws and an event focusing on voter i.d. laws.

it all starts at 8:00 p.m. eastern. >> our campaign 2014 coverage continues with a week full of debates. on c-span today at 7:00 eastern, live coverage of the florida governor's debate between incumbent rick scott and former governor democrat charlie crist. and at 8:00, live coverage of the kansas u.s. senate debate between incumbent senator republican pat roberts and independent greg orman. and live on c-span2, the delaware debate with democrat chris coons and republican kevin wade. and live coverage of the third and final iowa senate debate between u.s. representative democrat bruce braley and state senator republican joni ernst. friday night the wisconsin governor's debate between republican scott walker and democrat mary burke. c-span campaign 2014.

more than 100 debates for the control of congress. just a note that thursday we'll show you an iowa senate debate between congressman bruce braley and republican challenger joni ernst. the final debate. here's some recent ads from that campaign. >> i'm bruce braley, and i approve this message. >> take a closer look at joni ernst. in the state senate, ernst sponsored an amendment to outlaw abortion even in cases of rape or incest. an ernst bill would have banned many common forms of birth control. >> i think that providers should be punished if there were a personhood amendment. >> joni ernst, radical ideas, wrong for iowa. >> expecting her to fulfill campaign promises. >> joni ernst promises shut down the department of education, hurting iowa students, abolish

the epa giving polluters a pass. that's why sarah palin and the billion nar coch brothers want her in washington. >> joni ernst, promises to them, too extreme for us. the league of conservation voters is responsible for the content of this advertising. >> i get very upset. >> are you ready to apologize? >> you're damn right i read the bill. >> that individual had no college education. >> i find it ironic that there's this big push to shut down the house. >> do you have any advanced degrees in economics? >> there's hardly anybody working down there. >> i get very upset. >> you're damn right i read the bill. >> there's no towel service. >> a farmer from iowa who never went to law school. >> we're doing our own laundry down there. >> i get very upset. >> you don't have a master's or ph.d. in health care policy? >> one of the most important places i go is to the house gym. >> have you published any

scholarly treatises in a peer review article. a farmer from iowa that never went to law school. i get very upset. are you ready to apologize. you're damn right i read the bill. i get very upset. >> recent polling has listed the iowa senate race as a toss-up. see their final debate live thursday at 8:00 p.m. eastern on c-span. >> now a discussion of the annual international aids conference held in melbourne, australia, last summer. panelists review the latest scientific developments and future funding for aids research. speakers also comment on the malaysian airliner shot down in july over ukraine. some of the passengers aboard the plane were traveling to the conference. the kaiser family foundation and the center for strategic and international studies co-hosted this 90-minute event.

>> good afternoon, everyone. welcome to the kaiser family foundation and to our joint event with the center for strategic and international studies to look at the outcome of aids 2014, which is the 20th international aids conference which wrapped up in melbourne a couple weeks ago. we have three distinguished guests with us today who i will introduce in a moment. to discuss this as well. and also a very large audience. thank you. i first want to acknowledge and thank csis and steve morrison specifically for this ongoing collaboration. we have come together, our organizations, for five conferences, the major conferences afterwards to do this kind of gathering with d.c. community to really take stock of the conference and try to understand what we learned from it, what it means for going forward. so thank you so much for doing this.

and second, given the large audience that signed up for this and that is actually here, i'm just curious how many people in this room went to the conference this year? raise your hand. so most of you did not. understandably it was far away. so this is good. this is why we were trying to do this, so we could bring you together. but on a more serious note, i just want to say a few words about the tragedy that befell all of us as we set out to get to the conference and that's the crash of malaysian airline mh-17 on july 17th. literally the day that most of us were traveling to melbourne. i can't speak to how it felt here on this side of the world, but i can say that it can't be separated from the experience and the meaning of the conference itself. we are, all of us, collectively lost six incredible people who devoted their lives to fighting aids en route to do this very work. i actually want to name them all. they were joop lang, the science

director at the amsterdam institute for global health and development and former president of the international aids scythe. jacqueline van tongeren, pim de kuijer, martine de schutter, lucy van mens, who was at the female health company, and glenn thomas of the world health organization. this experience shaped the beginning of the conference which was somber and serious and full of a lot of shock and some pain. it also reminded all of us something really important about our community and the response to hiv, and that is the community. it's a community of scientists, of activists, advocates, of patients, politicians, many times embodied in the same person. so just to remember these individuals, i'd like to quote a friend of mine who worked very closely with joep and jacqueline, dr. kate hankins as a reminder of who they were and

what this means for our community. and also, you know, frankly to recognize the act of violence that occurred that took them. these are kate's words. they were a tribute she just gave a few days ago about joep and jacqueline in particular. as she said, it is incomprehensible that people who worked so hard to save the lives of others should be shot down and be collateral damage in someone else's war. each of us needs to reflect on how to celebrate their memories by taking forward their visions. this world is a better place for them having walked among us. let this be said of each of us, too. so with that, i just want to say a few more words about the conference itself which was anticipated to be smaller than prior conferences because of where it was. and it was in terms of the attendance. and not expected to necessarily have scientific breakthroughs. it didn't. but nevertheless, it had an incredible richness that i am not sure was felt here and an incredible depth in what was

presented and the coming together of lots of communities. in terms of highlighting what many of us feel is an emerging global consensus on where we need to go from here that's not always been present. on emphasizing the importance of focusing on key populations, those who are marginalized, men who have sex with men, transgender individual, sex workers, injecting drug users and confronting stigma in all their forms around the world. the emphasis on the need to scale up treatment and what we know how about treatment and how effective it is, but also the power of prevention again, and some exciting new information about prep which i'm sure we'll talk about, among other things. so for now i'd leave it at that. i'd like to ask our three panelists to come up. i'm very pleased we're joined by ambassador deborah birx, ambassador at large and coordinator of the u.s. global aids program.

dr. chris beyrer and dr. steve morrison, senior vice president and director of global health policy center at csis. so please come and join me. so you are there. chris is here. that's my most important job today. okay. so as with usual in our events, i'll ask a few questions of our panelists and we'll pretty quickly get to your questions, and i hope this is a dialogue, especially for those who weren't there who want to get a sense of how things really played out because we know that the media itself didn't cover the conference extensively. that's been a trend that we've seen for a long time. so bringing that information here is really a critical task that we want to help with. so my first question is going to be the same question for each of but, but i'll start with

ambassador birx, is just to get a sense of your main impression and takeaways from this year's conference. what are some of the big themes and the ones you hope to continue as we carry forward this work. >> great, thank you, and thank you for having me here again today and thank you for all your information that you put on the kaiser website about hiv/aids. and every question i had from every applicant press over the last four days, they all referenced the site and how much they utilized the site. >> that's good. >> so aids 2014, when you start out with that level of heartbreak, it really required all of us to be very intro expectative -- introspective that entire week because many of us came from that time when there were so many unexpected deaths among our friends for an unknown reason back in the early '80s. it was tough to have that

reflection at the beginning, but every time i was in a planner or heard something, you were able to think about the history of hiv aids and where we are. to me it was historic content of our 30 years together and where we've been and where we've been together. so what started out as heartbreak i think came forward as very much as hope when the u.n. aids released its global report. hopefully you have all seen it. it is really a return to fundamental data reporting from u.n. aids with clear analysis that we can all understand. the first time we look at the graphic without a lot of subtext. you only have to look at the pictures, which i really appreciate. and you get a sense of where we are around the globe. and then i think to me the last thing was renewed commitment, and the sharing of that shared experience at the beginning of the week really -- when things happened and when advocates and activists spoke, there was a true resonating theme through all of us. when they were talking about they want to be undetectable and

it's important to be undetectable, we all agree with that and it's so important. so i think there was consensus. i will lead with my final impression. probably the biggest impact on me personally was a session done with individuals who have lived with hiv/aids for more than 20 years. and it was really -- i had somehow in my years of travel lost track of how those days felt and how sick those patients were. and hearing them relive the number of days they spent in the clinics, they spent in the hospitals throughout their 20s, throughout their 30s, throughout their 40s, they were unable to work, they were unable to access effective treatment. we had mono therapy and then bitherapy. fortunately all of them in that room made it to combination heart. hearing their life experiences

and what an impact it's having in their 60s and 70s and having lost their most productive work years reminded me why the united states turned to the huge epidemic in sub-saharan africa and said we can't stand by this. we're losing all the 35 to 45-year-olds. we experienced that and hearing their stories and understanding that their life journey has had a tremendous impact and we all need to resonate with that and understand that and understand we have a lot of patients now who have lived successfulle with hiv but don't really have the wherewithal to retire successfulle. it renewed my commitment to really understand all of the stages of the life experience from prevention of mother to child transmission all the way up into our decades that -- not you. me. -- are approaching rapidly and understanding and being able to understand people's life experience and respond to them.

>> thanks. chris. actually want to thank you, too, because this is i think your third of these that you've done with us. >> yes. >> just put it on your calendar for two years as well. >> well, two years from now we'll be talking about the durbin conference so we might want to come back to that at the end. i would just add to jen and debbie's reflections that, of course, the mh-17 tragedy changed all of our experiences. had a huge impact on the conference. to me the word that summarized the response of our community by about midweek we heard it repeatedly was unity. that this really powerfully brought people together, and i think this will be remembered certainly as one of the conferences if not the conference where the divides that we sometimes see between researchers, providers, community, politicians really truly got resolved in some profound ways.

it really was a unanimity of purpose and engagement which we all know we're going to need for the next phases of the response. i would say big picture messages that came out of the conference were certainly -- and debbie's talks, mark diebold's plenary, a number of other presentations, the u.n. data, there's a consistent theme of using the resources that we have strategically. focusing on better targeting of the response. focusing on the people. u.n. aids report shows about 50% of new infections going forward are predicted to be in key populations. that's an incredibly important thing because they're relatively small proportions of our communities but bearing disproportionate burdens and excluded from services, and that is a combination we have to change. we really have to work on that. so that refinement of the

response i think was really a theme that emerged. if i might, if now is the right moment, just go through a couple of the highlights from each of the tracks. of course, we have five tracks now at the conferences, and while there wasn't i would say any one or two single big studies, there were a number of advances in each of the tracks that i think are really important. particularly since so many of you weren't able to attend, hopefully this will be your 10 or 12 minute trip through the science. i will just highlight, certainly the kaiser site is a great place to go. aids 2014 is a great site as well. there are a couple of key talks. with track "a" which is our basic science where there's a lot of focus on cure, obviously, the big news in advance of the course was, unfortunately, the breakthrough after 27 months of functional remission of the mississippi child who is now 4 years old and doing well on

therapy, but unfortunately, was not able to stay off antiviral therapy. the big focus, of course, is on cure and vaccines and the cure plenary on the opening day is a masterful summary of that science. it's clear. she managed to do both things, not dumb it down and also really keep us all appraised of the science. you might want to listen to that. the big news from sort of the focus on cure is the concept of kick and kill, which is basically that you try and get hiv out of whatever latent reservoirs it's height hiding in. then use immune therapies, drug therapies to try to go after that reactivation virus. so there's quite a lot of data and information on that and there are a couple of early studies that suggest that this may be a way forward.

there's clearly a consensus emerging that the best thing from a cure perspective and probably also from a clinical perspective is earlier is better, and the people who are likely to be the most likely to benefit from cure strategy, however they emerge, are the people who are started on immediate or very near to immediate. and that, of course, includes this large number of children worldwide who have been started shortly after birth in places where that's been the policy. that's going to be a very important area. track b, the clinical track, the great news there is that the numbers vary on what time you're cutting it at. 13 million people worldwide are on antiviral therapy. with the new w.h.o. guidelines

another equal to that number or close to it are now eligible for therapy. there is an enormous still untreated population out there. but more people were started in the last several years really than at any other time in our response. a lot of that due to the global fund and also country ownership and that whole effort. in terms of treatment areas that emerge, there was a big focus on tuberculosis. die an's plenary on tb is a great summary and had some very important findings. there's new things that really look quite promising. there's an emerging area related to clinical care and smoking and particularly with thinking about chronic obstructive pulmonary disease, copd, is a smokers' condition but also has a

co-morbidity in hiv. there's a lot of interaction on that front. then probably track c, as jan alluded to, which is epidemiology and prevention, was the area where there was the most action because there have been the most new studies and trials out. a couple things to highlight there. first of all, the new w.h.o. guidelines on prevention, treatment and care for key affected populations were released just before the conference and then we had sessions on them. i should, full disclosure, say i co-chaired the guideline process with the dean of the medical school university of malaysia in kuala lumpur, a fantastic scientist. and those guidelines really made one of the strong recommendations based on the quality of evidence was for consideration of the use of preexposure prophylaxis, which

is prep, for men who have sex with men. this got very misconstrued in the media. very inflammatory headlines. w.h.o. says all gay men should be on prep. please do read the guidelines. they're a real advance, the guidelines for msm. there's an important recommendation for community distribution of nalaxa to reduce overdose deaths which have actually in countries where there's good coverage of arvs, overdose deaths have gone to replace hiv as the leading cause of death. a very important change. there was also good news on prep among men who have sex with men and transgender women who have sex with men which was the results released at the conference of the iprex, the clinical trial that came out in 2011. bob graham was the lead investigator. this is the open label extension. this is really the question of the effectiveness of prep when

it's not a placebo controlled trial. when people know what they're taking and they can choose to take it or not. the good news is the effectiveness was actually a little higher than the trial, 50% overall. looking at blood levels and at people who actually took the drug, it turns the out, first of all, that the efficacy was 100% as measured in people who actually took it every day. so it really works if you take it. but it was just as good as six times a week, five times a week, and four times a week. while that's a difficult message to put out there and we're not backing away from daily prep at this point because we don't have the data to do that, adherence doesn't have to be perfect for the drug to work. that's a real advance. the other thing that emerged is that people had a good sense of their own risk. so taking the drug daily was

much more common among people who actually had high risk exposures and less common among men and transgender women who didn't. so that isn't surprising. people are smart. and they know what kind of behaviors they're engaging in. the other thing that's critical is there's been all kinds of concern about risk compensation. if people are on this drug, they'll use condoms less. the same concern raised in using treatment as prevention in discordant couples. lots of science around this. turns out it's a theoretical, not a real world concern. condom use is better in couples one of whom is being treated. there was great data on that from zambia and no evidence of behavior disinhibition. there wasn't great condom use to start but it didn't decline. there also was encouraging news on voluntary male medical circumcision. the most important data are the

first real sort of empirical findings from the french group that did the first trial of the benefits for hiv prevention for women on male circumcision. lower risk of hiv and syphilis for women whose partner was circumcised. it really is very encouraging. i would say track "d," our human rights policy and the law, there was an enormous amount of work. michael kir bowe -- kirby, a distinguished australian journalist led us off with that theme. there were a number of presentations on human rights policy and the law and also some empirical data from the "lancet." they've been happening regularly with these conferences. this one was on hiv and sex work, and sex workers. i would encourage you all to read it. i also edited it, full disclosure, but it's a wonderful group of young investigators who

led those papers. really excited about the science but there's strong human rights evidence there for, for example, the potential benefits of reducing police violence on hiv incidents, model outcome, and also on decriminalization as an hiv prevention approach. and finally, in track e, which is the science implementation track, now has the largest number of any submissions. for those of you who worked for implementers out there, you are an enormous sector and doing lots and lots of work. there was great science. some very encouraging outcomes. also one or two warnings. and i would just highlight a couple of things. one was good news that earlier disclosure to adolescents turns out to really improve their adherence on therapy. that's an important finding because the cohort of kids who were born with hiv is now in adolescence and young adults and

happily in africa, many of those kids are surviving. but earlier disclosure to them matters. a challenging issue with plan b, which is putting all pregnant women with hiv on therapy which looks like their retention and care is not as good as we'd hope postpartum. they do great through the pregnancy and delivery and then they're falling off. that's going to be an important implementation ahead, particularly around breast-feeding. so i would say finally from track e, the other thing that really emerged was how much more granular and granular is a big word at this conference, we're getting about the data, strategic use of data. debbie alluded to this. and the importance of really targeting resources to where the virus is, where people need treatment, where transmission is ongoing, given what the global funding climate looks like and given the fact that we are

beginning now to really bear down on this epidemic. >> i have to thank you because i was at many of those sessions and i read so much of what's come out of the conference but that was the best summary of everything that happened. so you got the best summary right here. steve? >> thanks, jen, and thanks to kaiser and craig for hosting us and for this partnership. and congratulations, chris, for your ascent into being the president for this next two years and working and during towards durbin. that's very exciting. we'll talk a bit about that. i, too, was really struck by the convergence of opinion just in sitting and listening to deborah birx, to mark, to tony, to tony, to michelle. the degree to which there is a very mature and advanced consensus around what needs to happen is remarkable. this is not a community beset by

deep controversy and division. i was at times a little irritated there was not more debate, but this was really a sign of success i think, and there was a -- embedded within that was a palpable realism and focus upon results and implementation. there was a spirit of constructive forward looking progress to this and a sense of advancement and a sense of realism that all came together around those five or six key things that need to happen, and i didn't fully appreciate the degree to which that convergence had happened, and it's a real testimony, the maturity of these leaders. the leadership and the continuity of leadership. when you looked at the people that were up and eloquently making the case and you realized how long they have been in leadership positions in pushing this forward. it's a very unusual enterprise i think.

i'm going to say just a few words about the implications of the mh-17 because i think this was truly extraordinary and i will explain a bit about that. a bit more. we've heard some about this, but i think we need to tease out a little bit of the implications from it. first of all, we've never had a conference in which a geopolitical global crisis sucked the conference in and sucked the host country in. australia suffered the loss of 28 citizens and 8 permanent residents. 18 citizens from victoria state died. this became a geostrategic top priority, pressing, urgent matter for the australian government as it did become a pressing and urgent human matter for the organizers of the international aids conference.

there was no escaping the reality that this was going to become a dominant factor going through the week and beyond. and so thinking about what that means in the immediate and longer term i think is important. one is the mh tragedy will become a signature frame for thinking about this. i think in the future as we talk about this conference. secondly is it triggered a massive spike of media coverage, and bear in mind going off to melbourne was to pushing the aids conference off into the periphery and lowering the numbers and lowering the media presence and in a world in which the global media is shrinking in terms of its willingness to deploy to these kinds of conferences, the media presence was a lot lighter certainly than it was two years ago, but that tragedy spiked the media coverage in a period, but the

story line was not the substance of the conference. the story line was the human tragedy and the impact there and what that meant. far less was their coverage around -- as there has been in the past of the sort of programatic developments that chris and deborah have summarized. i do agree that the immediate impact was a slightly disoriented and dulling effect upon the population for the first couple of days. there was a somberness that hung over the opening ceremony, the delegates themselves individually, and the early panels and events. but what was interesting was there was a rebound effect that began soon thereafter in which you saw a community that had an unusual resilience to it. and it had an unusual capacity to absorb and process this tragedy and some of that has to

do with the historical legacy of hiv/aids. it has to do that this is a community that is familiar with loss. it's familiar with irrational violence and cruelty. it has the 1998 precedent of jonathan mann and his wife dying on an aircraft. so there was a reconciliation of a kind that began to happen slowly and moved people out of this dull and disoriented initial reaction. and then i think one of the key moments, and i'd like to hear from jen, deb, and chris on this, i thought the key turning point was president clinton on wednesday at midday, and this was not a conference that attracted a lot of big celebrities. it attracted bob geldof as a faux celebrity, but it really only attracted one global

personality and that was bill clinton, and clinton came in and the media attention intensified again and he really was quite deft i thought at lifting the spirits of the conference and defining the moment, and he was particularly i thought humble and eloquent in the way he went about doing that. he talked about mh 17 emanating from the dark forces of our inner dependence. he reminded every one of the 2,000 people there in the room to -- not to weaken their resolve in the face of this. he supported the dutch and the australian and the american positions that there was no excuse, that this was a crime and there was no excuse, and then he segued to talking about the vital point of appealing to the assembled community. that it had an obligation to honor the service and lives of

those who were lost and the children that were lost. and he said we have to remind people that the people we lost on that airplane guy their lives to the proposition that our common humanity matters a hell of a lot more than our differences. this was the kind of engagement and speech that was quite historic, i thought, and quite unusual and obviously driven by this tragedy. two other points about the impact. one is the australian government. the australian government was an exceptional host. they were gracious. they were well prepared. they were generous. they were cordial. it was very well organized on their side, but this was a national tragedy for them, and i think it completely consumed this government and in a way stole any serious high level engagement away from it because they were then absorbed in the security council, they were absorbed in getting the forensics teams into the crash site, and they were rallying and mourning and grieving their own population. during the conference on

thursday in the early afternoon, 1,200 opinion leaders from australia gathered at st. paul's cathedral which was just across the river from the conference center. so that was an important thing to remind ourselves, that in the midst of this conference was this other larger drama that was unfolding. the last thing i will say which chris can add more element to which has to do with putin's actions vis-a-vis hiv/aids. this mh-17 tragedy aggravated and further worsened what was already a trend line in which putin's seizure of crimea, the confrontations over ukraine, and the battles to regain dominant shares over central asia and the baltics and elsewhere which has grave public health implications was driven into the next stage,