get your package of information on part b and the other options. then you enroll. >> that takes me to my question. so you get your 90-day package, with medicare have a standard form that you would be having a box to check or do you have to not only consult with your position, and i hope your family, your chaplin, -- i have had to look at my own life in terms of the parameters with my own church and so on. it would medicare have the form? >> no, this does not portend to medicare. it portends that medicare would provide the information when they come in to register. they would consult with a family physician. i would suggest also that medicare makes it a requirement that people would respond both

in the house committee, the faith community, and other communities to have that information readily available. it is a great thing for everyone to have. . . as i said -- >> it saves the will federal government a ton. >> but i'm also thinking about not only saving the federal government money, and as you know, end of life decisions are fraught with enormously complex medical and ethical considerations. many of this, in this room have many of this, in this room have been through it with their own family, someone who has practiced medicine, someone who has been a social it would add an incredible burden to a 65 year old to be able to come up with this medical directive. the way you would have to do it is at least probably consult with the lawyer.

that is one issue. the other is, where would you get these medical directives if you are not consulting with the lawyer and how would you -- i am concerned that it will become a deterrent for applying for medicare. i am concerned that it is placing a tremendous, mandatory requirement on our potential beneficiaries. apart from whether we are in the appropriate area, i would be hesitant to endorse the bill even though i know what the gentleman from georgia is trying to achieve. there has been no hearings on this. i would like to know what a or b thought about this from the beneficiary side before we voted. >> what i would like to suggest, if we might -- and

what i enter stand the cost constraints -- >> i've understand because constraint. >> i think this is -- i like the concept. i think this has value. i would not want to -- this is one of these things that we will be out for a number of days. we go back to take a look at this thing. >> could we get a or b's take on this? could we get cbo and the gao to take -- to tell us because of the implementation? >> i would feel better if we had a little more time to look over this. >> let me see if i could. >> this is not a blow off. >> i know. i have respect for the question that you are asking.

there are two or three points that we will send to you. all 50 state's directed on the internet. this is readily available. no. 2, we rejected out of hand center greg's vote -- senator gregg's vote. we know without a shadow of a doubt that the cost it saves would be greater than the cost would be to implement it. it is pretty obvious from the medicare numbers. i would like to work with the gentle lady and the chairmen during the course of the mark up before we get to the end. i'm pretty serious about not slipping this. it is an opportunity for me as it is for a lot of other people to do things they have always wanted to do. i think this one makes an awful lot of sense.

i would appreciate the opportunity to continue to work with the lady. i will get the information on the web access. >> that think about it from the standpoint of 64 years -- you are 64 years old and getting ready to apply for medicare. who are you? what is expected of you? what is it that you need to do? how're you going to be able to do it? it is the how were you able to do it then gives me pause and concern in terms of making a condition of how much you validate. this is compared to a situation where you come with an advance medical directive we do not have to pay copays for three years. >> i want to clarify one thing. this will come up off and on. this was raised by johnny and

richard. in this bill, we've touched on jurisdiction. mustapha said this is a legitimate point. -- my staff has said this is a legitimate point. but we are not trying to do is change fundamental policies. we are trying to be careful about this. we are trying to be sensitive to the jurisdiction, particular the finance committee. the purpose is not a great new policy that would be their jurisdiction. i want the record to reflect that. we are not trampling all over jurisdiction without any reason. i am grateful to our colleagues from georgia. they you raise a very legitimate

point. i also have the directive like many of us do. it is a choice i made. i wash my mother go through this case a long time. i could almost hear her having no question in her mind. she was on life-support on the child. -- at the time. this is almost four years ago. is a very legitimate opinion. families wrestle with this all the time. i hope my children and family are very clear with what i had in mind. >> where did you get it? >> i've got it in connecticut. the lawyer did it for me. he also represented a local hospital. hospitals get nervous about this. what did he charged by the hour? >> i presume he did.

>> i cut him off. >> you make this sound terribly simple. the fact is that half of the advance directives are ignored today in this country because of liability situations. how many physicians can really tell you this? if we do not know, what do we do? today i have a phone conversation with an elderly father who been on a ventilator for 13 days because they did not know what it was. until you fix liability, until you address the court situation that provider space, we can do all sorts of things. it is not going to save money. we have another thing we are considering beside an advance directive. what do we do? what if the family is not there at the time we need to make a decision? when the question that goes

there every person's mind is, what is my exposure if i do not resuscitate, i do not in debate, if i am not aggressive? therefore, we put people through all sorts of procedures and machines, not because they did not have an advance directive, but because we are worried about what our liability is when they do and we cannot make a clear and convincing case. >> thank you. >> tonight is addressed three things? -- can i just address three things? there is that in that precludes a 64 year-old who walks in for that 90 period and says i want to do everything to keep me alive. two, medicare, we have a

requirement. you have to decide which plan you are going to be on. it a decision that we are asking every person that is going on medicare to make. we go further. we say that if you do not make a decision that we will put a 10% penalty on the. -- on you. i would ask the staff to look at page 101. specifically look at the small business verification. i do not believe that this is a technical language to interweave this into something else. this is basically a new dictate. we do get into finance committee's jurisdiction. >> senator hagen. >> eyes to serve on the ethics

committee of a local veterans' hospital. we deal with this is as near the end of life. i used to teach courses on the advance directive. a lot of decisions need to be made. whenever we do to incentivize and encourage people to fill these out, it really helps the physicians that i have dealt with you also have to be competent at the time that to actually execute one of these things. that might preclude any sort of mandate of a requirement. in looking at, you have to take that into consideration. >> what you are suggesting is more of an opportunity that is presented to people to do it than requiring them. >> sure. who wants to pay copays for three years? >> if the chair would allow us to work on this?

>> absolutely. >> i will direct staff. >> i saw connie walking in. that is right. you know a lot about this area. i am directing you to sit down -- >> jurisdiction. we have jurisdiction over local communities. -- we have jurisdiction over local communities. that is where a lot of elderly people often go. >> senator roberts, you said you had an amendment that was ready. are you ready? >> yes. >> white. to let us know what it is? >> number one --it is robert

number one. i will take it right now. and then you will not have to listen to me. >> is this an alphabetical order? >> it just says it cannot be lou used exclusively. >> if you wish, mr. chairman, i can begin. let me say, i do not know whose glasses these are. they were lying right there. it looks to me like they would be a pair of women's glasses.

i do not know whether they belong to someone on that side. if they do, i am not sure i want to give them the glasses. what are they rose colored? [laughter] >> they are more like cbo glasses. >> rather opaque? >> they are bent up. i do not know whose glasses these are. i cannot in it to anybody. i will be the right here. i will proceed. whosever these are, if you want to put them on, you can see your way clear to score my amendment, that would be great. this is amendments protect patients' choice and decision independence and making treatment decisions.

when we get sick, we want to make sure that the doctor in charge is mickey decision is -- is making decisions and not someone in washington. the amendment is identical to senator kyl's. the reason all this title was that together was because everything has to be an acronym in washington and this is called the patience of bill. after that explanation, the bill is endorsed by the american medical association. i am a co-sponsor. it ensures that patients and doctors remain in charge of making treatment decisions by prohibiting the federal government from using the results of comparative effectiveness research, cer, to

deny coverage under medicare or any other federal health program. it requires that cer be accountable for the treatment responses and preferences of individual patients. these provisions are required because current law does not prohibit the government from using the $1.1 billion awarded in the stimulus package for cost containment and to achieve cost savings but th. neither do the bills before us today. we've all heard the stories of the united kingdom national institute for health and clinical excellence, the acronym for that is nice.

still lying access and requiring seniors to go blind in one ad says before approving treatment -- this is a real thing. it actually happens. we need a safeguard to guarantee that this scenario will not happen in american medicine. i want to make it very clear that this amendment does not prohibit cer. i would never do that. i would never stand against medical advancement. we need cer. it is not interfere with the fda. i would never prevent the fda from fulfilling its mission of insuring the safety of our medical products. it for him is the government for rationing health care based on this research. it is to protect patients and protect seniors. i would ask that people would support this amendment. i might add something here from personal experience.

i apologize for going on. i said before that i have had the privilege of public service for a long time. i have said before that healthcare seems to be -- i do not know how it ends up under my jurisdiction in terms of a committee or working for a previous member or where ever in my career -- but that has been the case. i've also expressed considerable frustration dating back to the chairman hew and what used to be hippa. i do have a little blood pressure. i've not been down to the agency recently. i would like to pay a visit and indicate to them that i am not

exactly a total critic. they do have a very important job. i can remember that we were in the middle about two or three years ago of several big-time problems and we were trying to cut costs in health care. i know that there is a lot of concern about greed and sour apples in the barrel and a lot of things that doctors may or may not do to make up for the lack of what they think is a proper reimbursement that should not be done. having said that, there was almost a revolution out there at the health care delivery system. the one that really got me was a competitive bidding business with home health care. i know that is not directly on

this subject, but it is. one of the first reasons was kansas city. kansas city included parts of missouri and kansas that were not metropolitan areas by any means. it was supposed to the metropolitan area. there were 428 home health-care entities or businesses in this region in kansas. of the 428, i know 2/3 never even knew that they were in a competitive bidding process. they did not even know that that directive had come down and that they had x number of days to respond. i did hear from some of the bigger ones. they said that this was not the way to do business, we cannot do that. there is a lot of back and forth on that. finally, cms came down and recognized 24 in the bidding process.

if you have 428 people involved in home health care and you recognize 24 eligible for medicare, what happened to the other 404? that is where we were. if you have an elderly person who relies on home health care and they did not know about it and was a did they are trying to cash up and that was impossible because the number was always busy and when was not someone cannot answer the question -- it was a real problem with 404 of these entities out there. they cannot get medicare out there because of the e did. i was not happy about that. about that htime, been nominated a man to be the director of cms. i thought i would take the bull by the horns and i put a hold on him. i made public.

he naturally came in to see me. he was a nice fellow. he was from new mexico. he went to harvard, but you know, he could not help that. basically, we said down in visited about it. i prepared him a list of five questions that i had received primarily from doctors and primarily from hospital administrators and home health- care people, a clinical labs, etc., mainly on the reimbursement and regulations. he thanked me for it. he said he would get back immediately. he did. he said that a five page, single spaced, response. i thought it was cms junk. i called him back and said i cannot understand this. nobody on my staff could understand it. that was really his problem. he came back. he looked at and said, and would you are right on " he sai."

this is what happens when we turn things over to people and they are not even aware of what happens. he sent back about a two page letter that made sense. he promised he would watch very carefully for these regulatory overkills and the things that were driving our people not out there. i voted yes and hoped for the best. i saw him later on an airplane. and did not recognize him because he had a ball cap on. i thought as one deficit on an airplane and talk about cms for the whole flight. he proudly thought the same thing. everything that he promised, and nothing happened except the things we did not want to happen. i told him that. i told him that he promised me. he even got on the telephone and i recommended by people for him

to call. he said there for two hours in my office and talk to people that were on the receiving end. we have the same problems. it seems to me that if we are going to protect that patient /doctor relationship and protect -- and make cer do exactly what is supposed to do. it has an important mission. we need to least put the bill in here to protect the patients we will not have the problem that i experienced. i think he did the best job that he could possibly do. we have folks over there who have some pretty crazy ideas. when they come and visit, they breathe a lot of staff. i remember one staff member indicated that one way we could

cut costs was by age. and i said, by age? center mikulski -- senator mikulski, you need to listen to this. i use to figure it was below both of us. i said, what about these folks, should they get a knee replacement? that person said, maybe not. that sounds like that cannot happen in the system that we are trying to construct. i am telling you, it can. that is why i introduced this bill. i have run on way too long. i appreciate the indulgence of the chairman and my colleagues. >> thank you. senator mikulski. >> first of all, let me just say that this amendment offered by the senator from kansas -- if

you go -- we get into this repetitive wording. it goes well with focus groups, but it has no rationale here. if you go to page 323 of the actual bill, where it says in corp. -- incorporation, it prohibits anything related to the center for health outcomes, otherwise known as comparative and effectiveness. there shall not be construed as mandates for payments coverage for treatment. it is in the bill. this is page 323, line five through seven. please, take a look at it.

tell me about that. we say it will not be construed. it to build on the language that was passed in the american recovery act, in which we established a council and told to do comparative research. we said nothing in this section would be construed to permit the council to mandate coverage, reimbursement, or any other policy for public or private payers. it said none of the reports submitted under this section shall be construed as mandate or critical guidelines for patent covered or treatment. we do not go -- patient coverage for treatment. we do not go to the doctor/patient relationship when i was working on the issue of

terrorism and first responders, senator roberts always said, who is in charge? it was always the local sheriff. who is in charge in the doctor's office? the doctor. the patient must be involved. there is no government agency that is going to dictate how to practice medicine coming out of this bill. this is a myth. it is a fabrication. it is a misunderstanding of the banquet. -- of the language. i welcome analysis and insight. we could sharpen our language in the six or seven amendments that i read. they were actual improvements on what he wanted to do.

what the senator from kansas wants to do is not needed. the second thing, in terms of sharing, which is in the other part of this bill -- let me just say this. our provisions are designed to compare other procedures. it is research into scientific evidence about what works best. it leaves the final decision to a patient and doctor. it will not dictate treatment. we have actual language to say that. in all of the provisions, we never use the word "cost"when describing research