time of residents is counted. that impedes people from not doing hospital training. the teaching hospitals have asked for those rules to be changed. a number of those changes were included in the affordable care act. and so that's something that the teaching institutions themselves have asked for. take down one of the barriers. the second step is to make sure that those opportunities for non-hospital training are good experiences. rich experiences. . .

our recommendation is that new standards will go into affect in three years. if on this particular issue the secretary were to decide, oh even more than three years is reeuired to amp then we wouldn't object to that. but we do think we need to be moving. >> and on the referral issue? >> yeah. >> the report really does go into quite a bit of detail. it's really short on any recommendation. >> we lay out about half a dozen

options that might be considered. for example, loading self referral to services provided on the same day as the basic visit, packaging, certain imaging services for example with the visit payment. subjecting some types of high end imaging to prior authorization. there are i think a half dozen different options there. what we've done, each of those has pro's and cons. we've laid them out so that now we can get people outside to react to those options, help us deepen the understanding of their implications that we would expect next year with that additional information will come back and look at these six options, or maybe some new one. >> it will take a year for you to gather that information before you make recommendations? >> i don't know exactly when we'll take it up in our fall schedule. but it would be in the fall. it wouldn't be next june. >> i see, i thought you said it

would take a year to get them. >> the next cycle is what i'm referring to. >> thank you very much for your work and your testimony. >> thank you ms,eshoo. the gentleman from texas, mr. burgess. >> thanks, chairman. again, we're pleased to have you here. i want to be sure i heard you correctly when you gave your statement because we heard some discussion from the medicare and manage. i thought i heard you say we need a robust medicare advantage. we heard that from the head of scott and white, who also headed to be the a.m.a., who endorsed the health care bill. why the die cot my here? >> we cut medicare advantage, we said it was a good thing in the health care bill, but you're

saying we need it. >> i believe strongly in the market, and market signals. and how much you pay for something influences the product that you get. and, i believe very strongly that having the option of enrolling in a private plan is a good thing for medicare beneficiaries. but if we set the price too high, we get private plans that are not properly focused on increasing value from medicare beneficiaries. we make it too easy. the evidence i would cite for that is when the prices went way up, when we vastly increase the bench mark of medicaid advantage we got a huge influx of private fifa service plans, which added very little value.

>> i do have to interrupt you because some of the data we heard and never got in this committee because we never got the advantage. like the common wealth fund that are not just bastions of conservative thought. that medicare advantage did hold the promise. all the things you want, your care system of the future to do they were able to provide. so, i heard it at a round table with the physician group demonstration project. if you don't have medicare advantage, we can't do these things that you've asked us to do. i'm going to have to leave that in the interest of time. it suggests that in addition to the 21% cut that went into affect june 1, there's an additional 6.1% that will be shaved off, physician reimbursement that will kick in january 1, is that correct? so a cut from last month of 26%

by january 1. say that goes into affect, is there any way to delink private insurance reimbursement from what medicare is reimbursing? as you know, many of the private contracts are paying a percentage of medicare. >> as often the case, as you say mr. burgess, that private insurers use the medicare relative value system. but, typically, they will use their own conversion factor. so their actual price paid is not medicare. in some cases it could be higher or lower -- >> correct and in the interest of time, it's usually 110% medicare. but blue cross, blue shield, guess what? they get a big windfall through

stock holders and the doctors end upholding the bag on that. i do think that's something i would like to see your group look at. let me talk about a couple of things because they're terribly important in the health care bill passed, we got the creation of the independent payment advisory board. will that reppeder the sustainable growth formula obsolete, or perhaps facing the spector of both the s.g.r. and the board? >> well, my understanding of the legislation is that the targets established for the independent payment advisory board are sent from s.g.r. >> so the answer is yes, they could be hit with both? >> right. and the difference of course is that the payment targets are program wide, they're not just focused on physician. >> right, but that's one of the things i think need to be looked at with a great deal more

scrutiny. i'm getting these questions and i've got to believe the doctors looking down the road of what have we done to them are taking this quite seriously. you may find the numbers dropping off more significantly than anticipated the last thing, the chairman with a gick gavel, you brought up on the prior authorization on the imaging, why is it, and i hated prior authorization, i hated calling 1-800-california to get a procedure approved. why don't they look at that type of activity? you pay something and wonder if it was advisable to do so and then try to chase someone down. in the private world, you end up having to get everything preauthorized which is a pain, and sometimes overdone, but why not incorporate some of the lessons that have been learned in the private sector to hold down the cost in medicare? >> that's got to be the last question. >> i told you, he's quick with that gavel. >> yeah, go ahead. >> as you know, increasingly

prior authorization is used for expensive imaging services. there are companies that specialize in that business, running those prior authorization programs. it's an option that we will look at. obviously the concern is the intruce ziffness of it. the hassle of it for physicians. it also has some advantages. i don't know where it will come down, but we'll look at it. >> miss christianson? >> thank you. i had to step out when my colleague dr. burgess was speaking, but i have to get this off my chest. i really think that they have the whole provide ore reimbursement issue backwards. i just wonder if they ever considered providers who pay so

very low that they have to see so many patients to keep their lights on, pay their staff, keep the doors open, as well as take care of their families. it seems to be based on the assessment that the source with the problem. but i really think it's the low fees. doctors are really force sboot positions where they have to see more patients and is never really paid to sit down and talk or listen to our patients. so i just wanted to get that off my chest. >> in fact, we would agree that there are some physicians ho are paid too little. anddmay not be even the best message. but, on the other hand, we think there are other who may be paid too much. our views is more nuanced. we think there's plenty of money

in the medicare physician pool, but it needs to be redistributed to support high value care. that would mean more for some, less for others. >> as a primary care physician, i appreciate the fact that primary care is going to be given more attention and have perhaps admire reimbursements. but i don't see that should be at the expense of the specialist. when you need a specialist, the situation is generally critical. they have a specialize service provider. >> before i started doing this job, i was c.e.o. of a 500 physician multispecialty group practice in boston. and our physicians were all paid on the salary. we are largely at that point a prepaid group practice. if you look at the difference

between a primary care physician and a cardologyist or some specialist within a group like mine, or you do the same with kaiser permanent today, the range is much narrower. what we're suggesting is not that specialists be paid appropriately for their additional training in the like, but we do think that that gap needs to be smaller. >> thank you. let me try to get one other question in. my time is fast escaping. when c.m.s. is the least costly policy, provided financial laws, each time they describe a product that is not a product. sunlight to the policy or product that is more costly than

the blended reimbursement rate. what safe guards does medpack recommend to insure that patient access them important therapies is appropriately preserved? and what kind of clinical evidence should c.m.s. be required to consider before instituting that policy or bundling determination? and what exception should congress include to make sure patients can get medicare coverage for the more costly products when they're medically necessary? >> the decisions in executing options of that nature need to be informed by the best available clinical evidence.

and the process needs to be a transparent one. where by all interested parties have an opportunity to present their information to c.m.s. as we say in the report, we think in some areas like this, it would do to give them more flexibility than they have under law to execute these policies. that doesn't necessarily mean abdication by the congress either. you could imagine ways that the congress would reserve the right to override particular policies in the like. so, we would like to see the needle shifted, some towards more discretion, but only based on evidence, transparency and it could some residal congressional control. >> ok, i'm over my time. thank you.

>> the gentleman from kentucky, mr. whitfield, who has eight minutes. >> thank you very much for being with us today. we appreciate your presence. i want to revisit this one issue that there burgess mentioned, and that's medicare advantage. i want to do so because there are 13,000 seniors on medicare advantage in my congressional district. and my understanding is that there will be $200 billion taken out of the medicare advantage program. you talked about the need for a robust medicare advantage program. it seems to me that taking $200 billion away is the exact opposite thing we would need to do in order to have a robust medicare advantage program. and, i would just like your

comments on that. i have not had the opportunity to read all the brochure, but what do you say about that in this report, if anything? >> for many years now, going back to 2001, medpack had recommended reducing the medicare advantage rates. we believed that reducing them would steel leave arm resources for a well-run, high value plan to do very well in serving the medicare population. i've been senior executive in such a plan. i've run a medical group that had a lot of medicare. it was back then medicare plus choice. this was premedicare advantage. i know a little bit about such programs from the delivery side.

just increasing the rate was done by the congress does not assure a robust medicare plan. in fact, in crucial wayings it undermines it. by allowing signaling to plans, as the rates got very, very high, relative to fifa services, we had a large influx of private fifa service plans that were adding very little, if any value to the medicare program but that was not in the interest of the medicare advantage program. to allow low value performers to do very well. if you reduce the rate, yes you make it more difficult in the

first instance. but it's also the spur to finding ways to do things better that is needed. that's what drives markets. it's that spur, that pressure to find new innovative ways to produce a high value product. that had gone out of the medicare advantage program due to overpayment. and so, there is a lot of waste in traditional medicare. you know, we fill books each year documenting the waste in traditional medicare. an innovative private plan, well managed and really focused can find ways to provide medicare benefits, plus more to the medicare population for less money than fifa service medicare. i believe that. so it is your position that you can maintain a strong, viable medicare advantage program even

though you take that much money out of it? >> initially, you are likely to see a reduction in the number of plans, and a reduction that benefits higher premiums, fewer enenroll yis. it will begin to change the nature of the plan that participate, i believe towards a higher value, more worth while option for medicare beneficiaries. >> over the long term, would you get that there would be more medicare advantage programs? available? >> more individual plans offered. again, it's going to depend on your time. the first couple of years, i would expect that you'll see fewer. the easy money is gone and people will say my son went onto something else. but overtime, i think you could see those numbers start to

increase again. >> also, i noticed on page three of the report in chapter one, and i told you i hasn't read it, i read the first page already. but it says in this report that you describe the least costly policy one way that c.m.s. can apply in order to help contain medicare spending. yet when we were having the debate on the medicare reform, many people, including the president, were saying research is providing patients and doctors with the information they need to make the best medical decisions. and there was never any reference to being a mechanism for cutting cost.

so, this report basically does say that that's one purpose of the outlet. in your mind is there any inconsistency there that -- >> well, you know, i won't try to represent what president obama or anybody else says. let me just say what i believe. i believe that it is in the interest of patients and physicians, and the broader population to have more information about what works. that information as its developed can be applied in many different ways. one to inform policies like the least costly alternative. another would be to build into shared decision making programs, where a medicare beneficiaries and other patients can be more actively engaged to making choices over their own health care.

still another way might be to identify potential areas to reward through performance programs. there are a still another way might be to inform coverage positions. there are a lot of different ways to use that information. you add them all together, having better information is good for patients, and good for physicians. >> thank you mr. chairman. >> thank you. >> i yield 30 seconds. >> i just have one follow up question. you reference medicare plus choice, far between my time here, but that kind of went away because it was underfunded, did it not? >> the moment did increase, it went through a similar cycle -- >> the short answer is yes. let me ask you one more question before this other question. wouldn't it have been better, if there's more money going into medicare advantage that needs to go into it, and if we have these

additional dollars in medicare, wouldn't it have been better use of those funds to keep them in medicare and deal with the number one problem that's going to affect access for medicare patients in the future, that's offsetting the cost of fit fixing the s.g.r. formula? >> how to allocate funds is really above my pay grade. those are choices for the congress. >> we've got a whole book here about allocating funds -- >> all right, we've got to move on here. >> next is mr. barrett. ok, mr. green. >> thank you, mr. chairman. i heard there were questions earlier on graduate medical education, or in copping we call it g.m.e., because i want to make a response on it. in the health care bill that on a residency training because we have a great example in the houston area of the denver harvard clinic with agreement in

baylor college and medicine. greater accountability isn't a bad idea, though. and we need to debate exactly how we're going to go about doing that. because we don't want to hurt our hospitals or our resident programs. but we also like to make sure those positions, those medical students know they can make a good living by practicing and hopefully we'll grow them. but again i want to thank you like all the committee members for you being here today and the report. your testimony and the report discussed demonstration projects of c.m.s. and serp hurdles that these projects face, including low level of funds and constraints on c.m.s. and conducting these demo projects. i know many of us, i like having c.m.s. conducted demonstration before implementing a broad policy on everyone, simply because a test model will see how it works. and if it's successful, can you just address that? >> yeah. well, as you well know mr.

green, the health perform law took a major step in giving the secretary a broader authority in doing testing new ideas for medicare. we think that's a significant step in the right direction. in order to meet the challenges that medicare faces, of slowing the rate of increasing cost while preserving or increasing the quality of care, we're going to need to change how medicare pays for services. in the problem that we've had historically is that process for testing new ideas is painfully slow. from conception to completion, we're often talking seven, eight, nine, 10 years. at that rate we will never get the job done. we think the plan has the potential to accelerate that

process some what. we think that's very important. i would add, however what one of my biggest concerns. let's assume, i believe we all hope, that we can run some successful demonstrations and develop ideas that work. those ideas need to be operational by c.m.s. i worry even though we've given more funding for the research and demonstration, we are still chronically underfunding c.m.s. operations. and, if we continue in that pattern, we can have all the great ideas in the world. it won't get implemented, or implemented poorly and we won't be better off than we are today. >> that brings up the next question. you also mention the newly created center for medicare invasion, which was authorized under the health care health reform law. mr. whitfield and i have been

working on a demonstration project we think meets the criteria for the c.m.i. demo and provides them with $10 billion in funding to carry out these new demonstration projects, which in my opinion is a sizable amount of money. hopefully we will see lots of ideas that can deliver medicine. yet, it indicates there may not be enough funding to carry out all the demo projects. even though none have been taken up yet, because frankly it's been a short time. and that what are the issues that may call c.m.s., even though none of it has been taken up. it may cause issues with the fifa service modee. can you discuss your statement on the center for medicare invasion? >> i would agree, mr. green, the $10 billion funding is substantial, a huge increase come teared to what c.m.s. has

had historically for this activity. and so, i don't mean to be critical of that at all. i think it's a big step forward. i do thiik it's important for congress to be sensitive to the complex task that c.m.s. now faces. there are a lot of potential candidates for new projects. and, these new projects are still going to take time to set up operation, get running. it will take time to get results. so even with $10 billion, this isn't going to happen with a snap of the finger. and then there is, as i said, still the issue about let's assume the best case that we have successful demos. we still need resources and c.m.s. to operationalize. so it's a good step, but we need to be realistic. we've got problems still to solve.

>> mr. chairman, i have other questions, i know i've run out of time even without giving an opening statement. so if we could submit questions later, and get responses back. in your report you state about half of the imaging studies of reform the same day in the office visit, you state that this is a reason to re-evaluate the exception, and i assume you feel that is a low number, how does number 50% seem they were held by being able to quickly diagnose an issue by performing to study in the office. i would -- may want a patient to rest but then revisit it if the condition doesn't improve, would lead to imaging study done on a different day. if half are performed on the same day, it would appear that we're meeting the test for the need of the self referral exception of timeliness, conviencence and coordinate care

that same day diagnose allows for. do you feel that this is a low number, the 50%? or unrealistic, this would be considerablely higher? >> what we were trying to do is provide some data on what was one of the original reasons for having an in office exception to the self referral on. that was to allow same day treatment and imaging. so what we did was look at, in fact, whether that's the case. what we found was that for some services, covered under the exception, therapy services, it was rarely the case that they were provided the same day. for advanced imaging m.r.i., c.t. and the like, it was provided same day, less frequently than half the visits. and then for the standard imaging, that was about half the

time. and so, there's various ability depending on a particular service. but, i would emphasize that this is an area where we need to tread carefully. there are some legitimate rationales for allowing physicians to do these services. including potentially accelerating, diagnosis and treatment. making sure that the patients get the needed test and the like. in other context, we sing the praises of intergrated practice. so it's not so much the immigration that's a bad thing. not so much the physician, the ownership that's the bad thing. it's the combination of physician ownership with fifa service and often mispriced services. it's that combination that can lead to overutilization of services. so we're trying to figure out

problems without throwing the baby out with the bath water. >> i understand you have someone to give a bone density test literally in the office there, it saves a time for another visit to get a test somewhere else. mr. chairman, i would like to submit the remaining questions, thank you. >> i mentioned that any member can submit questions in writing and we'll ask for you to get back to us as soon as you can the gentlewoman from wisconsin, ms. baldwin. >> you spent a chapter of the report discussing shared decision making and its implications in medicare. i found it interesting that of shared decision making around care of living at the end of life. pspecially given my sense that there's a fairly profound amount of end of life care that is provided that is not necessarily aligned with the patients wishes or values, i wonder if this

omission is because you see these issues as being distinction, or could in fact you share with us, your thoughts on shared decision making between physician and patient to improve care at the end of life? >> what we did in the chapter is our staff went out and looked for some existing programs for shared decision making. it wasn't the whole universe of programs, where a representative sample, we went to a number of them. in the programs we looked at they did not tend to be focused on end of life issues. they tend to be focused on breast cancer and prostate cancer, some of those examples. the potentially rich opportunity for shared decision making is in what some people call representative care, where the right care is not something a

physician can decide. it depends on how the patient assesses various risk benefits, different potential outcomes. and so, shared decision making is a way of helping the patient express their preferences. given the under lying logic, it seems it could be applied to end of life issues. as we looked at the programs we described in the report, that was not there for the focus. >> in the report, i commend you for spending as much time and energy at policies to serve dual eligibles. these are folks who suffer not over from debilitating health issues, but also leaves them with often poorly coordinated care. in your report you mention special needs plans, and specifically you pro-filed a successful program that we have

in my home state of wisconsin. yet, there's also notation that these programs area significantly across the country. is it your requirement that they establish state contract will improve the policy and consistency. then i have a follow up question about the national committee for equal assurance and their role in this. >> a couple of years ago, i'm not going to be able to remember the exact date, we did a chapter focused on if special needs plans, and made a series of recommendations there. and one was that for the plans focused on the dual eligibles, that it was very important for their to be a contract with the state. that, specifies a lot of

important operational details. and so, we think that the requirements and the affordable care act that can be contracts is a step in the right direction. not just any old contract will do. it's important that the content be right to be sufficiently detailed in the like. we do think that's a step in the proper direction. >> then, you focus again on the importance of measuring outcome. yet, i think we lack information both on the best quality measures, and the actual outcome data from the plans. so, i understand that the national committee for quality assurance is developing some additional reporting. but who's responsibility should it be to collect and analyze this data? does there need to be congressional action to require this, or is it already within the powers of the agency and part of their obligation under the law? >> let me just begin first with

full disclosure. until very recently a month or six weeks ago, i was a board member at ncqa so i wanted to put that in record. >> thank you. >> in terms of who does the actual development and majoring of performance, typically in a ncqa program, they're specifying the data required, and evaluating the performance against that data. and then c.m.s. basically piggy backs on that. and so, i would think that's the way the process is working. am i misunderstanding your question? >> i'm just wondering whether there needs to be additional congressional authority at this point in time. is it already within the powers of the agency and part of their obligation under law to do this

analysis? >> rather than risk aner ror -- answer, may i submit that answer? >> yes there is broad agreement that we need some kind of a model to go take a hard look at medicare and try to save money. but when there was a proposal to expand, a lot of us, during the deliberation on the health care reffrm were very much against it, because a general sense that there's a buys against big city, a bias against education. and kind of re-enforces a certain tone deafness. i think the report does some remarkable things. but when it talks about a $3.5

billion cut, in the exact same document where it points out that many teaching hospitals have negative margins presently. and further ignores the idea we're in this movement as you've testified to of moving away to more and more people going into emergency rooms, and more and more people seeing primary care physicians. it just seems to me that it's wildly counter intuitive. not a question, but i would be glad to hear your response. >> first of all, i just want to be clear that we are not recommending a $3.5 billion cut. what we are recommending is that at a point in the future, at least three years in the future, that teaching institutions be held accountable for their performance. and that money be contingent on performance. the three year period would be used to engage both the teaching

hospitals, people in academic medicine, patient representatives, purchasers, health care delivery organizations, in the development of those standards. our fondest hope is that ever cent would be paid out because that would mean that good standard system developed in the programs are performing well against those standards ? >> our hope would be no reduction. >> i see. >> i would signify that the programs are achieving the jobs, being accountable for reform. >> let me spend a moment on self referral. you identified various numbers in the report, but something like 104% of payments we think for self referral.

there was some consideration and consideration of the health care reform bill again, to basically ban. you've shown that in your report, that an overwhelming number, the costs go up overwhelmingly for second and third day referrals. is there any reason we should still permit physicians who clearly are conflicted from doing raidology, from doing m.r.i.'s, these various things. the evidence seems so, it seems so clear that it's not that doctors are being venal but they've got this giant machine sitting in their office. they've got to make payments on it. it just seems like too great a temptation. isn't there a much more bright line recommendation to say don't permit those self referrals. no longer the type of thing, only if it has to be an emergency, someone walks with a

sprained ankle, which is the reason any exception exists in the first place. it seems to me we're past the point of dancing around this. i think that type of prohobition is in order. >> well, as i was saying earlier, before i took this job, i was the c.e.o. of a very large physician practice, 500 physicians. >> your career has not taken the best projector so far. >> we elevate choices. we, my group, brought high tech imaging in house. we thought that it improved our ability to effectively manage the care, coordinate the care, assure the quality of the imaging and the like. a lot of notions of where the health care system needs to go in the future, towards more

intergration. not having all these independent providers, but a more organized system. we don't want to discourage ownership. the problem isn't the ownership per say, it's the combination of ownership with fifa service payment and easy profit opportunities. that's the toxic combination. it's not one, it's the three of them together. what we're trying to do is identify options that allow us to preserve the good part of limitation. >> actually, my time has expired. let me just say, if we're going to get your organization to a place where we enforce what you're doing in the report, we have the institutional sense, and mr. palone talked about it,

this sense that you don't get it when it comes to teaching hospitals, but more than a few members have mentioned that.. but i yield back the balance of my time. >> thank you mr. weiner. >> the gentleman from ohio. >> thank you mr. chairman. and thank you for your testimony today. i come from a very rural area of ohio. very parse district in southeast ohio, exclusively rural, the largest town we have is about 27,000 people. we have historically suffered from an inadequacy of physician force. i think that's true for most rural areas around the country. especially for those which are relatively indigent or poor. can you talk about why this deficit is problematic and the contact of its impact on creating a rural work force?

>> which deficit are you referring to? >> the deficit referring to access, not just family physicians, but physicians generally. recruiting specialist, we have a very difficult time recruiting primary care physicians. i'm curious to your thoughts how that impacts creating the rural work force? >> well, clearly recruiting physicians is essential to provide quality care. and there certainly are documenting problems in recruiting, in particular to rural areas, but also some inner city areas as well. in a report, in the chapter on graduate medical education, we note that there are a number of programs authorized to this committee in the public health service that are focused in particular on recruiting people

into medicine that come from rural areas, or inner cities, or are drawn to certain minorities or ethnic groups. although the research trying to affect those programs is not as robust as we'd like to see it, that makes a lot of sense to us because there is pretty good research that a physician who comes from a rural area is more likely to go back there. >> i think you could probably add to that, maybe you have researched to corroborate this, but a physician who trains in a rural area is more likely to stay there. in fact i think i read that in your report. while we're on the subject, on page 117, figure 4-1 of the report, there's a graph that kind of outlines the third year internal medical residence

becoming sub specialists. it's actually quite remarkable from. 1998, we saw a dominance of internal medicine, somewhere in the neighborhood of 54%. that had shrunk to the 2007 level of somewhere around 25%. so i haae a sub question about that phenomenon. i think in your report quite correctly you need to do something about that. >> we do. >> it seems to me that in the end it's about money. it's about compensation, or the lack there of. it drives folks into that field. i think the same thing would apply to family medicine to

family physicians, primary care. short of increasing the compensation for, in this case, general internal medicine, or decreasing the compensation paid specialists or hospitals, what averages are available for congress to rectify what is a growing and increasingly large discrepency for those training to become physicians? >> well, actually one of our commissioners, dr. karen boarman had published on this topic of why physicians choose various specialties. she's a program director in general surgery. and money is certainly one of the factors, but it isn't the only factor. another important factor, and some cases even more important

in money is life life style. and do they envision living this job and often that's a draw back about primary care. physicians in training, they experience primary care while in training, and a clinic has way too many patients, way too few resources. and they say this life style is just not for me. this job is not doable. so, we do think that increasing payments for primary care relative to some specialty care is a step in the right direction. but it may also be necessary to change how we pay for primary care. that's part of the reason behind medicare home. that allow a primary care physician to build some infrastruckschur, hire some staff to make the job more doable.

even if that money's not take home pay, allows them to have a more robust, it can make it more appealing. then there is the recruitment issue. if you recruit people from rural areas into medical school, and train them in rural areas, they're much more likely to do family practice in your part of ohio than somebody who's trained in new york city. >> are there tools available for the medical schools? or even at the college level. where i assume some of this recruitment is happening. that would channel people early to take an interest in and begin pursuing a career in primary care? rather than waiting until their out of school and throwing them into the program where they might be more inclined to focus

on financial issues. >> there are a number of programs in the public health service that are designed to intervene earlier in the decision making process and recruit people into medicine of diverse populations. and then encourage primary care. frankly, i don't consider myself real expert in all if details. generally speaking, we think that earlier intervention effort holds a lot of promise. and, would urge the careful evaluation of those programs, p.h.s. to see how we can build on them and make them as attractive as possible. >> thank you very much. i yield back the balance of my time. >> thank you. we about have about seven or eight minutes left so we're going to conclude with mr. engal. when i say that, i mean they're voting. i don't know if the members realize we have three votes.

>> well, thank you mr. chairman. i won't take the seven or eight minutes. i just want to pile on about the i.m.e. in direct medical education. a major concern to my area of new york, new york city. and i echo everything that mr. weiner said. we are very, very concerned. there are many teaching hospitals in new york city. they've been devastated by cuts on the federal and state level. whether it's dish payments, or in the health care bill that we passed. we had a whole fight over do gooder states provisions, things like that. they've been decimated back and forth. new york has 15% of the teaching hospitals. we train 15% of the doctors across the country. it's a really big thing for us. i kkow you said that it wasn't a $3.5 billion cut per say.

and these teaching hospitals would still receive funding if they showed their further erg goals. but the yet to be established goals by the secretary of h.h.s. and the new york city teaching hospitals are very worried they would lose up to $450 million annually. and you know, that's just really untannable. i understand that, but what you said before about you want to make sure there's quality. of course you want to make sure, but at some point you can't get blood from a stone. i think these hospitals are just about at that point. and they are some of the best hospitals in the country. and every time we look for money or every time we look to so-called reform something we hit them again and again and again. at some point it obviously is going to affect the quality or care or what tchay can provide

or how many -- or what they can provide or how many nurses they can hire. i just want to echo what so many of my colleagues have said. i really wish you would look again at that point because our teaching hospital just cannot afford even the whisper of cut. it can have a very negative and debilitating thing that could happen to them. >> i certainly understand the anxiety about it mr. engal. but, that uncertainty often accompanyity teaching hospital. as mr. weiner suggested. the vote on this recommendation, was unanimous. two of the members of the

commission are deeply involved in medical education and graduate medical education training. i've referred a couple of times now to my group in boston. our principle hospital, women's hospital and children's hospital have no antipathy towards teaching institutions. but we do think that the taxpayers, the health care system, the medicare beneficiaries deserve some accountability in the use of resources. >> but you see, i'm not going to argue with that statement. but i question whether the way you've proposed to go about it is the best way in going about it. obviously we need to train tomorrow's doctors to have appropriate skills to provide care among health care system. but i just think slashing funds,

to teaching hospitals that there's no guarantee they can recoup, i think that causes a lot of angst. and i think it's negative. reports that we have, i think that med pack reports that teaching hospitals now have medicare margins which obviously means medicare is not covering the cost of medicare patients, you know, what could be the justification or even a whiff of cutting funding from teaching hospitals so that medicare pays even less. it makes no sense to me. >> i certainly do understand your perspective on it. and take it really seriously, i do. at the same time, i hear from a lot of colleagues involved in academic medicine. who believe the system need to be reformed. believe that teaching hospitals can do a better job of training

physicians for the future. that medicare is their last hope. there's too much inertia in the system. they do too well with the status quo. they need somebody to boost the process of medical reforration. these are people engaged in system that say we need medicare, that move the lever. >> we're out of time. i apologize, i think we only have a minute and a half before we finish votes on the floor. let me thank you all. as you heard, mr. members want to submit written questions. we ask them to submit them within 10 days and have you respond to them as quickly as you can. thank you so much for all that you do. without objection, the meeting of the subcommittee is adjourned.

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