from the -- millions. i have been an attorney for 22 years ago and never seen a program like this. usually, everybody is pretty territorialized. people work together. they believe in what we read doing. it is pretty inspiring ftc have the collaboration goes on. . .

those of the actual educational of events, and we had 139 media outrage -- out reached events. and that is after we called down the cases that were brought -- culled down the cases that or fraud. our message and mission is simple but very powerful. we teach the beneficiary that they need to protect, detect, and report, the aromatic card is

their health insurance credit card -- there will listen to that message. do not give that number out to anyone. know who you are giving it to. and protect that medicare system and euros safety and identity by doing that. i need to spend a moment on our volunteers. you will hear from diane in just a moment. but i wanted to mention how this comes together. we have an amazing volunteer that is not able to be here today. he had a story where he was sitting in his dialysis chair -- he has dallas's three times -- -- dialysis three times a week -- and a woman approached him wanting to give him a lot of test strips. he picked -- she picked the wrong person to approach. [laughter] he started asking all of these questions and she turned and left. we thought that that was it. it turns out that two weeks

later, he got a box with a clue costs -- at glucose monitor and tester is. he was offended. his identity had been compromised in medicare had been. those shipments were stopped and an investigation is still in selling. i hope i have captured the spirit and the passing of the program. people do care and what to do the right thing. we help them understand what that is. [applause] >> thank you for sharing your experience with us. diane? >> thank you and thank you all for coming. i want to tell you about my journey of how i came to be a volunteer. in my professional career, i started off as an elementary school teacher. after a couple of years, i went on that 30 years of government

service, in social security and this agency. the height of my professional career was working with singers, educating them on what benefits they were entitled to, or helping them to resolve an issue with social security or medicare. during my years with this agency, i also worked in many activities that are classified as anti-fraud activities. once i was hired and looking for something to do was a volunteer, i found that the work of the senior medicare patrol would allow me to continue that which i enjoyed the most -- working with singers and fighting fraud in health care. seniors are concerned about what happens in health care. it is one of the most critical aspects in their lives. it is their main social activity when they go to the doctor. they listen to all the advice

that they are responsible for the health care and the problems in health care. the difficulty with that is that health care has become very complicated. when i joined in 1976, seniors had one decision to make -- did they want part see or not? that was about it. benefits were more limited. the mechanisms were simpler. medicare was there to treat injury or illness. today a senior is faced with a, b, c, and indeed. benefits to treat elena's, supplemental insurance programs, do they take it now, do they wait later. if the complexity of this problem can be overwhelming for some of our seniors to know whether they should or should not accept, or what should happen. seniors want to do what is right. they want to fight health care fraud and protect medicare. they want to protect the trust

fund. the complexity of the health care process today makes it very difficult for them to do that. the smp volunteers are able to do vital functions for our seniors -- educate and advocate. as a former teacher, i find there is nothing better than to be able to educate a senior on the way -- on the waste and fraud and abuse. i had a training session and there was a poster on the wall that caught i i -- learn to teach, teach to empower. and that is one of my goals as volunteered, helping them understand what they can expect from the health-care system and fight what is wrong. i did this when i meet with a senior one on one and discuss their case or one i am able to speak to large groups of seniors. as a former government employee, being able to advocate for the senior is also one of my goals.

many times a senior might not report suspected fraud because they are either afraid of the process, afraid of the perpetrator, or just unsure of how to do it. as a volunteer, i have the tools and the knowledge on how to put their case in the hands of the proper investigator. why has all this fraud grown? today's our seniors are living much longer. i just attended a relative's 100th birthday and she is still going strong. in our mobile society, we find more seniors are very isolated. they live in other states, other countries, and on limited incomes. these facts make seniors a target group for health care fraud. in california especially, which confer with the fact that many seniors also had been less as a second language.

this can add to their isolation. we know that health care fraud is a large moneymaker. i went to the web site and found that cases, many referenced earlier, and they are multimillion-dollar fraud, not a small dollars. the key to this is the senior -- or more importantly, the seniors medicare number. promises or intimidation have worked for them to secure this precious number. some of the cases that you heard thet we've also heard about ones that make the news,, "60 minutes," they'd pick people up and take them to their doctors' offices or labs, with promises of money and other gifts. sometimes that gift is as small

as a case of ensure, which tells us how needy our seniors have become. the medicare number is now called and is sold to other groups to send in hundreds of fraudulent claims to medicare. part of the educational process by the smp volunteer is to tell the senior that if it sounds -- it is too good to be true, it probably is. legitimate health care providers do not by your loyalty. they do not give you money or goods for your time or your care. for isolated elderly seniors, this promise of something for their time and their medicare number can be a strong pull. that is why we must reach out to all of the seniors. the promise is another fraud that we see over and over. we've all been bombarded with the ads for certain types of equipment.

a fancy wheelchair at no cost to you. it to know that it is wrong? the salesperson was so nice and it was paid for by medicare. medicare and sometimes be billed for something more expensive. if our health care system has become more complex, the volunteer looks at what makes it easier for the singer. we tell them they need to review each and every bill they receive. they should check it against their own personal log up doctor visits and other health-care encounters. anything that does not match up or look strange should be questioned. we would never think twice about questioning of credit card bill, but a senior may be reluctant to question something they see on

this. we tell them they must be vigilant with these bills as they are with their own credit- card statements. all legitimate health care provider has nothing to hide, and understands that if you question something you do not understand, that is perfectly all right. sometimes it is a simple billing error, or you may not even understand how the particular health care encounter was categorized. other times it may be the beginning of the house and out fraud. on reporting these cases early, a simple billing error is corrected and the potential fraud can be stopped early. we tell them they must protect their medicare number as well as the provider credit card. a stranger ask for their credit card number -- they would not think of giving it to them. the same with their number. never give it to anyone.

ideally, never take it out of the house unless perhaps go into a provider and you know you absolutely needed. -- you need it. a strong component is to educate seniors to be vigilant and protect that number. all kinds of scams exists either in person or by phone that are used to obtain that number. just before i retired, i moved in with my mother who is now a widow. we both had separate telephone numbers. luckily my mother would hand me the telephone any time someone calls about marketing calls. i'm appalled at the number of phone calls that she receives trying to sell her something or ask for something. yes, she is on the do not call registry. i do not get those types of calls on my own phone so i know somehow they are able to target my mother as an elderly senior. since i am present in the home,

i am able to prevent her from being taken advantage of. i keep thinking of that isolated lonely senior who is easily swayed by the collar. when the caller is trying to get information that they can bill medicare, and we can see how easily fraud can grow and why the educators and advocates for the seniors are so necessary. that is what we do in the senior medicare patrol -- educate an advocate, and that is why i am proud to be an smp volunteer. [applause] >> thank you. we now have time for questions from the audience. i believe the microphone --

>> seven years back, medicare tested a program where they send a notice of forward if you reported fraud. they had an avalanche of calls and great results. why don't we suggest to medicare that they are for a reward -- they offer our report -- forward for reports of fraud or suspected fraud and to mark >> yesterday the doctor came to our office and that came up in discussion with our volunteers. there is one on the books but it is going to be revised. it is very encouraging to hear them discuss it. >> i impact stirred event from the office of enforcement. , i also had an

elderly mother who got the same kind of calls. it is appalling what kind of misrepresentations are made to the elderly, including i am from cal, and medicare requires you to switch your enrollment. we're talking about the sec that sales and marketing practices of any medicare hmo over which the department has jurisdiction, which includes health net, united, and others who were at the top of the list of entities that people complain about. we can issue cease and desist orders against deceptive practices. we can issue order suspending the broker or agent. in california, because we have a unique situation of dual jurisdiction, we do not have the power to license or take

licenses, but the department of insurance does and we work closely with them on that. i wonder if we could get together at 3:00 -- i have a sample cease and desist order and others -- and i would like to talk with you about how we can work collaborative with. >> that's wonderful. chile is one of the investigators from that office. i conceive why they get a lot done. -- i can see why they get a lot done. >> any other questions from the audience? with that, then, i am going to close this panel and i want to again thank david, julie, and diane for their experience and passion on the issue of consumer education and reporting. we will now move to our next panel. how will bring out david.

-- i will bring out david. >> and now for our panel on providers. you've already met me. i'm from manage medicare and medicaid services. the rest of our panel, the senior counsel for the apartment and health and human services' office of inspector general, the university of california professor, the medical director for medical management-blue shield of

california, the senior vice president of integrity and compliance officer, and the assistant vice president of healthcare compliance from the university of southern california. if you will join me in welcoming our provider panel -- [applause] giveoing to start off and you a few minutes of what we're doing at the center for medicare and medicaid services in an hour new center for program integrity that i have the privilege of having been appointed to run by secretary sebelius. you heard her talk this morning about our shifting emphasis, we want to move away from the historical way of trying to deal with fraud by chasing after people after they had committed fraud and after they had received payment. we want to move from that to a posture where we are in a

position to prevent fraud from happening in the first place. to do that, we need to do several things. unfortunately as the secretary mentioned, the health reform legislation, the affordable care act, does give us very strong new authorities to move in that direction, and those authorities will help us keep people from enrolling in the first place as providers when they are not legitimate providers and should not be in the program and they're just dam artists who want to get into the program and start billing. if it will give us the authority to stop payment before we make them. medicare has a long history of wanting to pay claims on a timely basis. when there is a credible allegation of fraud, we will have the authority to withhold payment. and then we want to revisit people in the system, check on over time and ths

make sure they are still up to snuff. one of the things i want to touch upon that the secretary mentioned this morning is how we are moving in the direction of using new, advanced technology. the idea that we're in the 21st century, we have lots of tools that our disposal. we should be using them effectively and properly. we are right now conducting a number of pilots to use technologies, analytic systems, that are developed and our employees and to apply them to the medicare context. if one of the places where we're using -- exploring using these has to do with the screening of people who want to come into the program. we all hear very big numbers, medicare over $400 billion, medicaid $300 billion. we get 4 million claims a day.

the number that impresses me the most is that we get 19,000 new applications to be a medicare provider every month. we have to screen for 19,000 new application to find the very few who are not legitimate people, not legitimate corporations, and do not belong in the system. in doing that for some time, we have been conducting background checks, traditional ways, name and social security numbers and licenses and certifications, looking at list of excluded providers and so forth. that has been reasonably effective. but it has not gotten us as far as we need to go. one of the new technologies that we are looking at will allow us to go and do far more in-depth analysis of the person who is

applying, to look at mapping data, where the address is that they are submitting, to look it court records to see if they have been convicted of fraudulent activity, to look at a variety of other kinds of data, all at the same time in order to screen out people who simply just do not belong in the program. we're also exploring technology that will help us scream out claims. we get a claim in and we do a lot of screaming. we look to make sure that the identity of the provider is an active provider, not someone who is dead, for example. we look to make sure that he acted beneficiary in our system, making sure that the service being billed is covered by medicare, and so forth. this new technology will also allow us to look at other things. we're setting up lists of

beneficiaries whose medical identity has been stolen. beacon check it against those lists. ofre looking at lists suspicious billing patterns, where things do not match against each other. we're looking at list of medical conditions that do not fit with each other. we're moving in a very strategic and cautious way. we are committed to doing this and to keeping the bad guys out that you heard about this morning while making sure that we have the legitimate, honest providers in the system. we want to make sure that we hold back on payments when they should not be made and that we continue to make payments when they should be made. the biggest task ahead of us, a flavor of what we're doing at the centers for medicare and medicaid agencies, to move florida and use modern technology is -- to move

forward and use modern technology to prevent fraud in the first place. with that, i like to turn it over to our panel. we will start with spencer. >> good afternoon. as he mentioned, i represent the office of inspector general. oig has 1500 men and women across the country to protect the medicare and medicaid programs and its beneficiaries. as is evident, every time i s task force test down suspected criminals, we dedicate a lot of our resources to going after those who prey on our programs. we are also committed to sending a proactive medicine -- message of complies because we believe the vast majority of providers are committed to the best interest of our beneficiaries. it is a particular pressure to speak with you today. you're here because you get it. you share our concern to root

out fraud and protect our beneficiaries. i want to share with you a three-pronged message about how you can prevent fraud. first, understand the laws and their consequences. second, had a plan in place for your organization that cultivates the culture of compliance. third, know what to do when a compliance issue is identified. the first-ever, understanding and complying with the law. whether you are a provider of health-care services or someone who works with providers, you should be aware of the many laws to prevent health-care fraud. their criminal laws that make it illegal to tell for medicare and unnecessary services, to seek payment for services not provide, to take kickbacks for referrals, and to defraud private insurers. there civil laws such as this civil laws claims that which makes it illegal for anyone to knowingly presented a false claim to the united states.

and there are administrative flaws, such as the ability to exclude providers from every federal health-care program, disallowing payments for services rendered. an administrative monetary penalties that -- everything from kickbacks the false claims. while i do not have time on this panel to go into detail about all this authorities, i can give you the simple rule that can serve as at the check to ensure you are doing the right thing. the newspaper test. do not do anything that you would not want printed on the front page of the "los angeles times." if your organization is engaged in a practice that you would not want your patience to read about, that is a clue that the practices create a risk. create a culture of compliance. this helps everyone in a provider organization improve their understanding of program rules and help identify overpayments and underpayments, resolve potential problems

quickly, and minimize your risk as whistleblowers. soon compliance programs will be required of all medicare providers. you probably already have compliance programs in place. i encourage you to think beyond the basics of a compliance program and ask yourself -- is your organization sending a message directly from the top that compliance is taken seriously and treat it as a priority? do meetings focus on compliance or on the bottom line? if you work in a practice, is the managing partner present and engaged in compliance training? for those of you affiliated with larger providers, does your compliance officer have direct access to your board of directors or are they at a lower level of management? th oig devotes substantial resources to this and it is available at our website.

the third step -- become a partner in fighting health-care fraud by disclosing problems to the government. if you have not placed -- if you have in place are robust compliance program, you're going to find billing problems and potentially even fraud. the law requires that you return to the government bonds to which you are not entitled. ethics requires that you address the problem honestly. hiding the problem will not work and only create of breeding ground -- a breeding ground for whistle-blowers. we offer a soft disclosure protocol to encourage providers who have identified programs to come forward and work with us to get the problems resolved quickly. we're developing a similar program specifically for soft disclosure of violations of the physicians' self referral of.

you may be aware of fraud outside your agency and we encourage you to report those silly at -- illegalities to our tip line. there are laws and consequences, having in place a culture of compliance, and by knowing what to do when you uncover a health care compliance issue, if you can help become a partner in combating health care fraud. thank you for your time. >> thank you very much. [applause] dr. resnik. >> 94 assembling this summit and in fighting practicing doctors to participate in this panel. a serving the council of legislation. i want to start with something that i hope is stating the obvious but i want to stated anyway. doctors as a group are also concerned about health care fraud. it is the right thing to do, an

extension of our code of ethics, and also because health care resources are limited and are in some ways becoming more so. and their consequences of diverting those critical resources away from our patients who need care. those consequences are borne by the taxpayers who fund the programs, by the doctors who need to treat the patients, and by the patients as well. we heard today that we're concerned that is getting easy in this era of the internet and electronic claims for the criminal elements to undertake fraud, and that concerns us as well. dramaticve heard examples are about the extreme things that they run into. the reality is that for most doctors we do not interact very often.

our interaction with the program is more on the regular program integrity rules that we all live with. for the vast majority of doctors who are honest peter wehner -- physicians, to reduced honest mistakes, there are things that we need and would be helpful. first of all, we need extremely clear policies concerning payment, reimbursement, coverage, and program integrity. those policies need to be communicated effectively and there needs to be an it infrastructure in place to make sure that the vast majority of physicians, who operate in small groups, can get the information and make use of it. we also need and a continued effective partnership between organized medicine, the contractors, the agency personnel, to maximize communications strategies, to

identify problems together and work together to come up with practical solutions. unfortunately, real ingenuous fraud does exist. it is committed by people who should never have been enrolled as a provider in the first place. we certainly do agree that we need a program and a system implies that can find an target a rare providers who abuse the medical ethic and the trust of their patients. we heard this morning about data mining. using that data for screening is an effective tool but screening hasted move beyond volume of utliers. if you are a dermatologist like me in a high-altitude area, you will do a lot of skin cancer

than others. it is not necessarily that you are abusing the system. we need to account for a justified outliers. can you find disease when it exist? and does your test have false positives? many had experienced problems with program integrity on both fronts. many of us have seen colleagues who were honest caught up in an audit that did not go well or was not handled appropriately and were tortured by the process. on the other hand, some of us have actually tried to turn in fraud when we have seen it and have faced a system that sometimes presents all lot of challenges for us to do that as well. we're hoping for continued improvements and sensitivities, because there are risks and arms that can be done if the new funds being put toward this use of deployed poorly. it can increase administrative

burdens and delayed payments, problems for providers do not deserve them, patients access problems, and it is a lost opportunity because honest physicians can be allies in rooting out fraud. i do hope that we will be able to build trust in the years to come under the leadership that we have now, because i think over time, if we see egregious audits, it arose that trust. the most important thing is communication with the physician community. a lot of these are private contractors who did not directly worked in government but are contract to do the audit. and if they think we like to see

our new metrics. there are exciting cases, and counting the number prosecutions, the numbers of dollars recovered and that is important. it is also important to account for the harm is done if you have contractors out in the country doing inappropriate audits. in terms of appendectomies, they say that a surgeon who is doing think rights is going have some surgery is that the joint appendectomies that turn out not to be appendectomies. but you do not want to measure the number of appendectomies to be done, because you my reward someone who is doing too many. we welcome opportunities to partner together with a government to prevent fraud and to prevent the diversion of critical health care resources from our patients who desperately need those resources and our care. there's several things we need to do in order make that happen.

we need to help reduce opportunities for identity theft. we need and effective communications infrastructure. participate in developing tools , and mitigating harmful impact on honest doctors and their patients that will help build trust with the community. >> thank you very much, dr. resneck. i appreciate your remarks greatly. they reflect what i brought to this job and now have to deliver to it. dr. baldwin. >> thank you for having us here today. i appreciate the opportunity. i am a medical director with blue shield. i was in private practice for 23 years as an intern is, so i have a good insight on both sides of the field. what i wanted to do was give you a quick overview of our to fraud and abuse at lucille.

-- at blue shield. i oversee the provider review department. have two branches in our companies, a special branch. the report to the legal department and under that we have investigators that have been in the business for a long time. they're focusing on truly fraudulent behavior and billing practices. billing for services not rendered, falsifying diagnosis to justify a test, significant and it is a fine line between fraudulent and just -- billing. and that can be difficult and we interpret what the doctor is really doing. other arm of our company of fraud and abuse is the provider compliance review which i oversee. we report to health care

services. it is really the educational arm of the insurance company, blue shield. we're looking at things -- oding,mes similar, but cuttin procedures outside of specialty, we see that a lot now. frequency of visits, quality of care issues in general is what we look at. we have programs much like cms progress. we used our sentinel which can be set to -- we use star sentinel. examples would be higher than average medical tests per patient, an enormous amount of revenue, frequency of visits, and again this is usually what

we're looking for and what is outside the. . . that is how we have to start. for the outside the peer group -- that is what we're looking for, something outside the peer group. we can ask for medical records from the provider. we will do an audit of five or 10 medical records. once i look at these or the team looks at these, we will always send it to a specialty outside adviser not part of blue shield. that this does look significant or of the findings are significant, we will send a corrective action letter to the provider. the physician a chance

read our letter, request that he sent a letter back explaining what the findings are and if he has in the reasons for this, and he is always welcome to call me or one of my partners. assuming we get a corrective action plan and everything looks appropriate, we will as the us review records in three to six months. good, that is the a. back with no improvement, there still egregious billing outside of expected, possible actions would be pre-payment review which most providers have send and medical records with each claim to be about a wooded. there is always the possibility of termination. if there are quality issues, these doctors may be turned to credential in. it looks truly fraudulent, we to the special

investigations unit. there are issues here for appropriate practice patterns. an orthopedic doctor who only does ankles, it shows he has a lot of procedures above the average. those of the things we leave out quickly. we're now looking for those issues. we're not looking for those issues. with the corrective action explanations. probably 70% of things we look like -- look at do not come to anything. most doctors are very honest. they take the corrective action plan seriously. they're sometimes indignant that someone does not trust them. and that is about as far as it goes. i think there areas where health

savings right now, only looking at the traditional fee- for-service population. half of our patients are capitated patients. we're not looking at those. in general they do not have the sophistication of the resources to look for fraud. there is a big area there and not being identified. it is going to be essential that medical groups, health plans, the government of payers are going to need to work together to better identify duplication of services. we have all the separate entities doing this at the same time. and we are only identifying office-based providers. also, a hospital claims from doctors and ambulatory surgery centers and hospitals.

in summary, for us documentation is the key. even in this time of electronic medical records, you would not believe how many progress notes are illegible. there is no documentation for the need of the visit, the time the decision making process. that would help us a lot. that is said. >> and thank you very much. >> margaret hamilton. >> thank you, a pleasure to be with you this afternoon and be part of such a distinguished panel. i want to start with my premise. as a compliance officer, will put all of you in law enforcement out of business. i hope every compliance officer really looks at their work with that goal in mind. how can we do that as compliance

officers? first, we want to establish a culture of ethical behavior, we want to make sure that our compliance programs are effective, we want to understand how organizations risks and vulnerabilities, we want to make sure that we are auditing and monitoring particularly those things to which we are most vulnerable, and we want to make sure that we're taking effective corrective action which includes refund overpayments that are identified and potential self disclosure when necessary. just a little bit about me. i came into compliance in the late 1990's with this "tag, you are it" method. i have had broad experience in health care, starting on the paper side, over to the provider citing human resources, and then to risk- management and into compliance.

having that broad understanding of health care, it was quite valuable as i began my compliance career. back in the late 1990's, just after oig published his program guide for hospitals, one program was the establishment of the hotline, some billing audits, and that may have been about it. we have come a long way since then. at st. joseph's health system, it is at catholic ministry, with 24,000 employees, 12 acute-care facilities as well as other entities along the continuum of care such as hospice, home care, and other models. mr. about 138,000 in patients each year, 2 million adult patient, and the number of other patients as well each year. the st. joseph system has

received the gallup great work plus award. i'm going to start and ask for my compliance charter. this piece of the charter is not my original work. as a member of the health-care complies association, i had the opportunity to network with a number compliance professionals to establish best practices, to share and really figure out the wonderful things folks across the country are doing in terms of compliance. this was borrowed from one of those compliance professionals. it serves us, and this was approved by our board, and it is integrated into the fabric of our organization. first, health care meets the needs of our claims program when it is delivered with the highest quality care, documented, coded, and build in a manner consistent with the services ordered an provided, provided to

meet the best interest of our patients and their families, free of undue influence, that respects the rights and dignities of patients and their families, it is provided by appropriate and competent providers and staff, and properly reimbursed by the government and other payers, and it furthers the mission of sages of health system in its tax- exempt purpose. an effective compliance program regard both structural elements as well as substantive elements. our focus on the structural elements include focus on the seven elements of effective compliance program such as insuring that we have an effective standard of conduct, policies, high level oversight, auditing, monitoring, educational programs, training, and the other things as well as insuring that we have their rigorous risk assessment process.

that helps us to evaluate the adequacy of our controls, our auditing program ensures that within test those controls, and we established metrics to measure the effectiveness of programs. along with a structural element, we have substantive elements, addressing those risks to which we are most vulnerable. the search for the risk assessment which includes an analysis of risk both internal and looking externally what is going on a law enforcement, looking at the cia, looking at guidance from the government. from a risk assessment, we developed our work plan addressing those things to which we are most vulnerable, developed an audit during and monitoring plan as well as our education plan. as a compliance officer, and i am not possible for compliance and might organization. that comes from a collaboration with our board, management, and

every employee in the organization. my job is to establish the framework to ensure that collaboration and effective programs can take place. i think we can work together really effectively. our goals are very reliant. things like. -sharing project, compassionate -- compared a billing reports and pepper reports are incredibly important. that allows us to -- we cannot compare as effectively as you can, it really allows us to establish, recognize where we may need to focus effort. round-table discussions and ultimately what we want to do as compliance officers is to replace your actions on the enforcement side with our actions. we want to earn your trust.

we've talked a lot about education here. at -- it is important to remember that education imparts knowledge but does not always change behavior. changing behavior really requires a change in culture in some organizations. culture is what drives behavior. it can help drive organizational culture by requiring things like scorecards, metrics which are tied to management incentives, having a compliance officer on board, make sure that metrics are reported regularly, standards for evaluation programs, mandatory board education, and making sure that the agenda is always on there. i think that my time is done. >> thank you so much.

and in the university of california health-care system. >> and thank you for having me. let me introduce the university of southern california health care components to you. we recently acquired to hospitals. we have had a very robust medical group consisting of over 500 call physicians with every specialty you can think of. when we came into private practice in this big way that we did in the early 1990's, it was about that time the word compliance and compliance programs were being introduced. one of the first thing that the university of southern california said is that we will build a compliance program. they actually executed that. they looked at other guiding

documents and was under their guidance and they're finding that our current program evolved. let me just -- margaret mentioned that it is an essential element. this is important when we branched into private practice and plot hospitals is that this would not be a shell document. if it would be living, breathing program that was integrated into every aspect of the organization. a compliance program is a risk management program. it is just the department, sitting at the end of the hallway, it will not be affected. education as far as we as concerned is the cornerstone of an effective program. education is not about online education programs.

it may be that bud is a running dialogue with your provider to help them understand the complex rules that we face every day and try to comply with them. to help us do that, we have to have politics and procedures that are specific, risk-based monitoring. we also look at things like our error rates, and what do we feel we have not done well in terms of documentation, and other types of risks that come into compliance area. auditing means that we led to an outside organization to come in and look at the integrity of our program. it is one thing that think that you're doing well but it is another thing to have someone validate that what you're doing, what you are studying and the monitoring -- and monitoring is

affected, and we engage outside experts to do that. governance -- jennifer mentioned that. when we purchased our hospital a year ago, the first board meeting, the first action item was what is the compliance plan going to be for this year and you will be back here in six months to tell us how you're doing. with that kind of support from the board, it can be very effective. our university is governed by a board of trustees and our board of trustees received a regular report directly from the chief compliance officer has to our self monitoring and our activities and our findings. patients -- i want to describe something we established early on with sanctions.

if you do not apply sanctions, it will be an ineffective program. i am proud to say that it is the health side of that are in big is the most frequent calls. we get reports that are sent to us research interests and, i have no clue. have someone who is an expert at this teaches have to do this. or new proposals and complex rules that are coming out. those phone calls come in and we work with our constituency to make sure they feel well- informed. compliance agitation needs to begin -- compliance educationese oding andwith cutt documentation. the most effective way to deliver it is one-on-one. we have the findings of the monarch inactivity to help

bridge of the monitoring activity to help coach them. i think that think the most providers need coaching on are the evaluation and management issues. we do a lot of education around privacy and the importance of protecting our patients' privacy. attics -- margaret mentioned ethics. we have a code of ethics, but how you bring that alive and make sure that it is a guiding your business decisions? and how are you supporting what you say your code of ethics would respond to? quality -- this is a new area that i think the inspector general opened up in his remarks here. quality is a part of compliance. how're we integrating our activities with those activities that determined the quality you parted delivering and your institution or to market and in conflict of interest. research universities have for a

long time have a lot of concentrated area her critique effort in the area of conflict of interest in the research. a new dialogue is around our relationship with the industry. what is appropriate, inappropriate, and i will speak about that and it is high on our radar screen. i like to call a connecting the dots. we were too often in silos. we often stopped an integrated provincial and program. -- credentialing program. we do that when people are seeking privileges in our environment. we're doing primary source verification, checking references, and we're saying that you have to be a member in good standing with the compliance program. before you start, you sign

invested in the door. to stay with this, you do this every two years. you have to show the ability to understand how to document your records and that the results of your monitoring indicates -- and we have standardized test patterns to determine that someone understands how to properly document or record, which eventually will end up with a bill to the medicare program. looking at quality now and how we integrate and feel like we really accomplish that relationship between compliance and credentialing, how you embrace quality at the same time into a compliance program? those of us in health care,

those of us in california are vigilant about looking for things that need to be reported and recorded in a timely fashion. wrong side surgery, the wrong patient, things that should never happen to a patient under your care, had a we reported and how do we respond in terms of taking care of them? that we'reit time looking at closely -- worth less care. what does that mean? we certainly understand never events, but in terms of worthless care, what is the difference between a bad end can predict the outcome that could been expected to something that was a low standard of care? in terms of quality improvement, how has compliance

integrated into the equality committee said that they can be a part of that? >> we're going have to leave it at that. 90 very much. -- and thank you very much. we had used up all of our time. i do want to thank -- take a couple of questions. there might be some strong interest but i want to move on to introduce the inspector general. .

>> i have to say the message is

received. we have to have our policies and procedures. this is for the real provider community. >> my question goes to the position on the panel. what can we do about the science program? this puts aside the one size does not fit all.

is there more specificity about what a program does? >> having been in the organization and running the program, we have had the opportunity to see what works and what doesn't work. before i would look to the government to give me metrics, i would prefer that we open that as a robust discussion. >> i would agree with that. having an opportunity to develop a program which is consistent with our values, is important to

see a program. >> i think that they know a problem when they see it and that is were the reasons why we want to partner. there is a huge opportunity for us to sit down and talk about the things that we think would make sense. i hope that we can really sit down together to talk about within different specialties and different size offices. >> we don't want to create too big of a problem. join me in thanking our panel.

[applause] now it is my a honor to introduce our special guest, the inspector general for health and human services. he serves as the chief audits and law-enforcement executive for the entire department. he leads an office of more than 1500 professionals dedicated to fighting fraud, waste, and abuse. he is a close colleague and partner of ours in terms of developing and implementing our health-related legislation.

please join me in welcoming him. >> thank you, peter. good afternoon, everyone. i know that we have heard a lot of useful information about it. thank you for being here today. this is an incredibly important summit and having this kind of turnout is remarkable. why have we been asked to close the session? there will be a breakout session right there.

>as most of you, our office as its core mission fighting health-care fraud, waste, abuse, that this what we are about. we are in charge of releasing very nice programs. we have programs that depend upon the health care insurance and assistance programs. this is nearly one in three. we have a program to try to avoid and eliminate fraudulent claims, illegal kickbacks and referral. it was a very large program. we are a precious few in charge of doing that.

unfortunately, we have very important partners. they are a very significant part of this effort and they are well represented. who are our partners? in our own audience, we have representatives from every one of the offices here in california. this is an l.a. county, in san francisco, one county, san diego county. all of our components are here today. iog is an important office of services, counsel,

investigation, inspections evaluations. each one of these plays an important part in ensuring the integrity of medicare and medicaid. we realize the importance of collaboration. we take that sense of collaboration and externally. who are those partners? they include our partners within the department itself. this centers on the services. the administration on aging, the general counsel's office, or all of our very important partners with us. across the mall, the department of justice, the criminal

division, the civil division. the fbi, nationwide. the attorneys' offices across the nation. these are all very important partners. our sister inspector general offices, the department of defense, the office of personnel management, the social security administration, the u.s. postal service, all are important law enforcement officials. at the state county level, these are state and local partners who are integral in the effort to keep these very important programs clean. beyond that, the gao at the

federal level. i don't want to exclude to the federal accountability office in making sure that this is done as comprehensively as possible for the benefit of executive-branch policy makers and 40 congress. certainly, our health care suppliers. all of these people are important partners. perhaps the most important partner is the beneficiary. this is a very important source of critical leads.

there's a lot of money that flows through these programs and that money needs to be focused and targeted for a quality of goods and services and maintaining professional standards of care. from the text their perspective, the cannot afford substandard care or no care. certainly our seniors and disadvantaged deserve better. we have more reasons to work together. we have our core mission and then know that for many of you, that is not necessarily your

mission. you presumably have other responsibilities and duties as well. it is important that you have come out and shared this day and we have been able to continue to figure out how we can get what we need done as best we can so that the great majority of health care suppliers can actually do the important work on behalf of the nation's pinfish year is that they do every day. i really cannot add too much in terms of the substance at least for today's session. what i do want to try to capture as a final note is how we try to capture what this is

all about. we do this through an acronym that we name epcor. this is an easy acronym for me and i love it. let me give you a brief explanation of what this means. none of this should come as a surprise. e stands for enrollment standards. it is too relaxed. we need to filter of those who are masquerading as health-care providers. we need to get rid of a lot of fraud that should not have occurred. the enrollment standards are very important.

p, payment methodologies. we need to align pricing to reflect as much as practicable market prices. these programs are big and expensive ebony to make sure that the government gets its money's worth and beneficiaries are well served and the nation cannot afford to overcome any way. c, compliance. that is an important part of our programs. there are complexities and issues that need to be understood and work through by you and your colleagues. we have a world-class website, if i do say so myself.

this includes a wealth of valuable material on how to work the compliance programs effectively. we need to make sure that use -- that these are in compliance. o is for oversight to get quality data quickly. we need to do a better job when it comes better -- time to understand that data. with increased resources, we are in a much better position to do the kind a quality work that is really important to do.

r is for response. i think all of our law enforcement partners for showing how response can be quick and can be reserved to $1 billion returns to the treasury. this is serious money. this is because we have such an effective collaboration and i think that that is the word that is always important to leave with you these programs require the kind of partnership that from our perspective that we are working hard to encourage and relief flower in all parts of

what we do because that is really the key to being able to get a better handle on eliminating health care fraud, waste, and abuse. the challenges are great going forward. [applause] >> thank you for an interesting session. for those of you who are participating in the provider panel, that is just outside of these doors to the left.

we will meet there and go for about an hour. bernanke very much for attending. we appreciate your -- thank you very much for attending. we appreciate your attendance. thank you. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010] >> in a few moments, a town hall meeting with senator ben cardin.

then senator coburn from oklahoma. after that, a discussion on the upcoming plan the burning of the car run. then a discussion on the amending of the constitution. several live events to tell you about tomorrow. secretary of state clinton is that the council on foreign relations to talk about u.s. leadership in the world. the british foreign affairs secretary testifies about foreign relations and the budget says the formation of the coalition government. that is at 10:00 a.m. eastern. president obama will announce plans for new business tax breaks.

more now on the new health-care law from the town hall meeting in maryland with benjamin cardin. this is a little more than an hour. >> good afternoon, everyone. i would like to introduce to you our council member. please welcome her. [applause]

>> thank you, cathy. i'm old enough to be her mother. that keeps us apprised. good afternoon, everyone. this morning, or this afternoon, i want to introduce the people who are here with us. we have senator peters from district 23. we have delegate jim hubbard. delegate more of in holmes, district 23 b. can glover, the chairman and ceo of -- we have a representative from the prince george's county health offices.

we also have our councilwoman from district 4. karen sylvester, the director on aging for the county. patricia morris, the director family services. my colleague from the city council, district 3. melanie griffith, district 25 to.

welcome, everyone. for those of you are not from our area, glad to have you. when the best things is that if you have questions, we are going to find the best and most qualified people to answer them for you. i know we're all concerned about the health care reform law. we have invited one of the legislative reporters -- supporters and headed the agency that will be carried out a lot in maryland. the maryland department of aging pretax the right of the older people in maryland. to meet the needs of senior citizens, the department administers programs primarily for local area agencies on aging. the area agencies it minister the state and federal funds for the programs. -- at the ministeadminister stal

funds for the program. the secretary evaluate services needed by the elderly person and sets a priority for meeting these needs. the secretary chairs the interagency committee and the oversight committee on quality of care and nursing homes and assisted living facilities have and serves as advocate for the elderly at all levels. it gives me great pleasure to introduce my friend and his secretary for the department of

>> good afternoon.

soft our guest has been on many powerful committees. osteoporosis screening. has continued it is a commitment to strengthening medicare. senato-- senator cardin has cond his commitment to strengthening medicare. there is a plan to allow people between the ages of 55 and 64 to buy into medicare. the senator supported the newly enacted patient protection and

affordable care act. why? law will benefit all provide our families with affordable quality health deficit and we thank him for that. [applause] the senator will brief you on a number of other provisions in this new law which benefits seen years. that is us, me, you. this includes expanded coverage for preventive care to help seniors remain healthy and vital for as long as possible. it is very interesting that he is doing is here because i was telling the person that runs the

center that whenever i come to prince george's and people start talking about services and programs for seniors, they always talk about the center that buoy -- bowie. [applause] my mother is a great bridge center, i wanted her to go to a center that had good bridge. they said, i will have to take her to bowie. i company did the senator on many meetings on this topic and he has convened these meetings to give this vital information to our seniors and our families. i have heard of appreciation. many people have contacted the

department and have told us that they appreciate the senator coming out to talk about this new bill. without further ado, let's bring up your friend and mine, the senator from maryland, ben cardin. [applause] >> thank you so much for your service to the people of maryland. the o'malley administration has put a real priority of service to our seniors. it is nice to be back. i was here a year-ago for some town hall meetings concerning health care. we had an interesting debate. it was more noisy but i thought it was a constructive discussion and the city council.

we have worked together as a team to figure out what we can do to provide a more effective health care to the people of our nation and i'm honored to be joined in the federal delegation by senator mikulski. the majority leader of the house of our present is played an important role in the enactment of health reform and guided it to make sure that we stayed true to our purpose of universal coverage and cost containment.

we have many people love worked on this. there are many things i could say about the bill that i want to start with one because i think that this is a fundamental issue. at long last, the nine states of america joins every other industrial nation in the world is says that health care is a right and not a privilege. [applause] this is important because three years ago, a 12-year-old had a problem with his teeth and his mother tried to get into a dentist and he had no insurance. finally, the tooth became abscessed and went into his brain and he was rushed to the mercosur minute performed two

surgeries and i costs about a quarter of a million dollars and still lost his life. -- she was rushed to the emergency room and they performed two surgeries and it cost about a quarter of a million dollars. we believe that every person in america should be entitled for affordable quality health care. we're the richest nation in the world, we can do better. there are many things that we can argue about this bill whether it is good, bad, indifferent. this is a work in progress. i start with the fundamental principle that many of us were seeking which is universal health care. everyone in america should be in the system. when this bill is fully implemented, over 98% of this people will be covered by about insurance. that is a pretty good record. [applause] the point was to reduce the rate

of health care costs. health care is too expensive. we're not getting what we should for the dollars we're spending and we think we can get better value. the democrats and republicans have not agree on much this year but one thing that they agree on is that they both believe that the cbo is a pretty objective scorekeeper. it is agreed that we use those numbers and trying to evaluate whether the bill does what it says it will do. the numbers are generally pretty conservative. the cbo tells us that the taxpayers of this country will save over $100 billion in health-care expenditures as results of this bill and over the next 10 years, we will save over a trillion dollars. we have made a good start in trying to bring down the cost of health care to the taxpayers of this country. how did we do that?

this bill spends money. we provide subsidies to small business owners said they could purchase insurance for their employees. we invest more in community health centers because we know that people need to have primary health care in their communities. we invest in primary care because we don't have enough health care providers and primary care and subsidies for low income people they can afford health insurance we're using preventive health care to deal with diseases. this saves money. we know this. safeway supermarkets has a plan.

however, they monitor what you do. they make sure that you're actually on the treadmill and a couple of times a week. they make sure that you take your medicine for high blood pressure or cholesterol or you manage your diabetes. they hold you accountable and make sure that if you're smoking, you stop. if you do all of that, you save money for yourself and you get more benefits for less cost. this system is trying to use preventive health care to bring down the overall growth rate of health care costs. we believe that this bill will do that. let's talk about the specifics and then i will open up for your questions. there is a lot in this bill, there are some things that i would have liked added to this bill that are not in it. i would like to see us do more

. let's talk about medicare. we just celebrated the 40th anniversary and i'm proud of the. i was not in congress and we passed medicare. but i was there when we improve some of the benefits and we strengthened the system. i am committed to making sure that we preserve and strengthen medicare for future generations. this is one of the great programs in america that has lifted seniors out of poverty. we will do everything in our power to maintain these programs. how does this affect your life? well, first of all, you get more

benefits. there is a provision in this bill that guarantees who that your benefits that are in the law for medicare must be continued. there are no reductions in the required benefits. that is now by law. that was not in the law before, that is now the law. the second thing is that expand some of those benefits. the medicare prescription program and the tone of whole are many things that we thought were wrong from the beginning. we opposed that whole. we will do something about it. this bill starts to closed the whole. this year, about 40,000 people

in the state of maryland will be vulnerable to fall into this whole. if they do, they get a check from the medicare system to help fill in the doughnut hole.

>> have your premiums will cover the overall expensive. there are no government subsidies and this is for voluntary. this is to help you in the event that you need her lawn care services. this is a new program. i have heard that there are cuts in the medicare system, that is what people tell me. you are saying that it expands the benefits, we heard that it

was cut in this bill. what's right? let me give you the whole story. the congressional budget office tells us that what we did will extend the solvency of the trust fund for a least nine years and perhaps for as long as 12. we have protected the system for another decade. that is what the scorekeeper is telling us. we also cut several hundred million dollars out of reimbursement. well, and know that there are different opinions but currently we go to a hospital and the hospital pays the bills, that bill that the insurance company pays to the hospital includes the cost for uncompensated care. almost 15% are not paid for

because people don't have health insurance. we are changing that. by 2014, 90% of the people in this country will have health insurance. we have reduced the payments to hospitals to reflect the fact that there will be less care that is uncompensated. today in maryland, every family that has health insurance is paying about $1,100 more than they should to cover the people that don't pay health insurance. once the system is implemented, we have the savings therefore we don't have to pay for those that already have health insurance. there is another place that we have reduced payments to medicare and medicare advantage. i think maryland is somewhere around 8% of our seniors. that is where the private

company will pay or benefits and perhaps charge you fees and they give you more benefits than the required benefits under medicare. we are pained the private insurance companies much more than we do for those who are not in the plan. the government is subsidizing these plans. to make it worse, those of you who are not in medicare advantage are paying a higher premium than you sure it because you are subsidizing the private insurance plan. we are starting to change that in this bill by reducing the subsidies we're giving private insurance plans. that is the fact about what is going on in medicare. we strengthen it, we increase it. we do what is right in terms of providing for people. there is one area that you need to mention is that the medicare

reimbursement rates are scary and the congress needs to fix this or they will not able to see you anymore. that has nothing to do with what we are talking about. we changed the payment structure for physicians and it does not work well. we have been extending a fix for a long time and we have missed the dates in different occasions. i introduced legislation to permanently fix this. in need to do this. this is unrelated to the debate on the health care reform bill because this was not really dealt with. i want to cover one or two points. as i said, there is more in this bill than just medicare, this deals with the full health care system. you should be particularly

supportive of this. the only way that we can deal with the budget deficit on health care is to deal with the health-care system collectively. if we are dealing with medicare and trying to reduce the budget, all we do is shift more costs on to our seniors. that is not the way to fix this, we have to fix the entire system. that is what we are trying to do. we went after a couple of groups that we thought really needed help such as small businesses. small business owners pay about 20% more than the same insurance than big ones do. -- small businesses pay 20% more than big businesses. very few private companies have plans made for them. and we have changed that. that has been changed

immediately. small-business owners this year get a credit for purchasing health insurance for their employees. by 2014, we provide for the exchanges where the small companies can get the same premiums as large companies saving them a considerable amount of2 money. [applause] if you have more than 50 employees, you have to provide health care. that is his accountability. if you have under 50, there's not irresponsibility. we think small companies have enough challenges. if you try to purchase as an individual, this is very difficult. we have fixed that by setting up these exchanges in the state. the state of maryland will be

involved. we set up a plan so everyone can get affordable coverage of choice and a plan that is best for you but we also provide subsidies for low income families. it could be as low as 2% of your income we make it affordable for every person in this country. you no longer can use our health care system and not pay for it. we want everyone to be responsible and use the system in the most or procure rate. lastly, we take on a private insurance companies. the abuses have been well documented. we have families' right in this community that cannot purchase private insurance without restrictions that were ridiculous. we had a family that had high cholesterol. they took medicines and the

cholesterol was under control. the insurance companies want to give them a pre-existing existing exclusion in regards to cardiac care. that is ridiculous. we had a family where there was spousal abuse. one woman was excluded from coverage because of pre-existing conditions. we had a family where the husband and wife had to purchase two separate plans because there children had pre-existing problems. they had to purchase two separate policies with separate deductibles and separate co- payments. we are finishing those abusive practices by eliminating pre- existing conditions. you buy insurance to protect you from those kinds of things. we now coverage to children up to the age of 26 on a press policy. that is important. i cannot tell you how many families i have talked to these

kids credit from college and the same day they find out they have no health insurance. now they have time to get on their feet. we require health insurance companies to let these to meet a minimum return to you on benefits. if they are a large company, 85 cents of every dollar they collect must go back to benefits. 15% is enough for their administrative costs. better value for the dollar, that is what we are trying to do. one of the areas that i wish we could address, i would have liked to of seen a public insurance option and we have more competition. we're not able to do that. i think that we should do more as far as primary care who is concerned. there are issues that we need to continue to pay attention to.

i am proud of this bill as a good frame work for america to say, look, we will provide affordable health care but we want responsibility and for everyone to be in the system and we will continue to work to achieve the goals we have set out. i think you all for your help and participation. there are many people that have helped me understand the health- care system and i think that our results have been better because of your participation. you will have to get in line because of the way this his is set up. i am more than happy to take your questions. i will take them as best they can. >> i would like to think the delegates for being here. i will support anything that will advocate for our seniors. there is one thing that is not

in the program that will need to be addressed and i'm wondering if you can talk about it. as of june 1st, 2010, there are new supplement programs that came out for anyone who turns 65 or becomes disabled. the old programs will stay the same. the medicare recipients can keep those programs. they may or may not be able to move to the new ones where the race will be less but this will be based on the health care questions on whether or not they can move. understanding their methodology, i see the old program becoming very stale with no new blood going into it. i see this is creating a problem in the future for our seniors not being able to form those old programs. i think that that will have to be addressed when and see if we can't get them out of their into the new ones which are probably

the peak the purpose of the new ones coming out in the first place. on the present of service which i totally agree with, i think that the preventive services, the brochures they have fun the medicare website, every single recipient being discharged from hospital should have that in their packet so they understand what preventative services are. thank you, sir. ahoy >> they need some other pins insurance. they have a -- they need another insurance plan. they will have to have these needs. president obama made a commitment to our health care debate.

if you're satisfied with your current insurance, you will be able to keep it. we will have some inconsistency between plants that are currently existent in new plants that are created. you have made some of them. the starthey will have to provif the conditions including the pre-existing conditions, the emergency care, a labor standards come on, on come on. the old plan has a new plan in which they can frame their benefit structure. we lost to wait until this comes together and then have some consistency. then we need follow-up care.

if you don't have the capacity or the knowledge of what you need to do one discharge, all that means that you will be a revolving door back to the hospital. there must be a sophisticated way to manage care for someone who was discharged from a hospital. that is built into the pilot programs and the demonstration programs where we will be providing grants to state and community groups that are working with us on ways to reduce emissions so there is an active plan to do exactly what you said on making sure that people have the facility to make sure that they are cared for

after hospitalization but also the knowledge. >> hello, senator. i am a registered nurse. more importantly, i am a patient advocate. i work at the senior health center. we have been around since 1974 and we were started by a group of seniors. i went through some of the affordable care at an we are talking about in gauging and in power in the communities. that is important to me. the reason that we exist today is because of the community involvement. we are probably one of the early models that is trying to be established under the new health care reform plan. i would like to see more community-based health centers.

we have not been charging patients since 1974. we have gotten rid of the copays. i would like to see more community-based health centers opened up and some specifically for seniors. the needs for seniors are not to be rushed through in five minutes. i want to seem more community- based health-care centers because we see people coming from brentwood, from southern maryland, this is a long drive. here is my concern and this is what i really want to stress, we have our medical doctor or director and when someone comes in without insurance with

diabetes or any complications, we don't have the specialty component in our health center or the tertiary care for an endocrinologist or a cardiologists so are really want to see more health centers, more funding for the senior health centers. a little bit over a 500,000 budget with hundreds of singers and we are saving a lot. i want to see some specialty care that we can send their patients to without costing them an arm and leg. >> thank you. dimensions is critically important for efficiency of care to get people into primary care facilities and emergency rooms. tivo families use the emergency

rooms as a clinic and a primary- care facility and that is the most expensive way. usually, they will wait too long. they don't get the services or tension that they need that you can get in a health center. immediately, there is support in this bill for dramatically increasing the support for public health centers. we're talking about a huge commitment of expanding. we have already started on this. several of our centers have seen significant increases in capacity as a result of investments in the recovery act. under this bill, we provide even more support for expansion of qualified centers. this means new centers and an expansion of existing centers. we want to see more dental

care, mental-health services, comprehensive and larger. we want to see them in areas where the greatest needs are. many of our qualified centers have a large demographic group within the senior population. we want to make sure we are meeting the needs. these health centers are needed everywhere. we want to make sure that we have a comprehensive plan. there also other avenues available that are not for profit where we can participate with the federal government on programs to deal with primary care needs. we want to set up our own demonstration program to show that you are managing health care. it is one thing to say that everyone has health insurance, another thing to say that there are services available for every community.

we know that that is not the case today. this will not change because of the bill. we know that there are many needs that are not getting met. we need time to expand the facilities and their resources. that is why most of the provisions kicking in 2014. . .

my question to you -- what is the likelihood that that will happen, and could you comment on the legislative theory of excluding hearing from medicare? >> thank you for that question. uni have chatted about this. -- you and i have chatted about this. if the rationale goes back to 1965 when the program was created. at that time, medicare was looked at mainly as a program to deal with illnesses and injuries. it did not deal with prevention or quality of life.

that is not how it originally started. it was what private insurance did in the 1960's. you needed insurance if you ended up in the hospital or if you broke your arm or if you became sick. that was the main reason for insurance in the 1960's. the other services were not terribly expensive. in 1960's, prescription drugs were not an expensive part of the health care system. hearing aids were just darling. they were not sophisticated back in the 1960's. we have a much more effective way to improve quality of life through the hearing system. most of the private insurance companies have modernized their programs. medicare did not. as a result, we of supplemental insurance in addition to medicare. many of us want to see expansion of medicare to cover basic

medical needs. hearing aids should be part of medicaid, i agree with you. it should be included in the system. i think we have a better chance of getting it in now. we're not trying to bring down the rate of health care. then we can look at the expansion of basic medicare. it is on a sound financial footing. but it will require us to have the resources to do it. we have to manage diseases more effectively. one of the rewards of doing that is to expand the basic medicare program to include your basic needs including hearing aids. >> hello, senator carden. my name is diane james and i'm a senior health coordinator for prince george's county.

what i'd do is educate individuals on health care reform. one of the questions that i always get whenever i am out with the individuals is questions on doc fix. what do we say? this is been kicked down the road for quite a bit. what are we to tell our residence when they want to know about doc fix? >> excellent question. first, it did this woman of round of applause. she is doing a great job for us. they've been answering questions for our seniors, they are always available, and i thank you for the time you put in to try to help our seniors understand the complexities of health care. it is not easy. that is the debate over the last two years selling. we're very much interested in trying to provide the type of support that you need. your question dealt with doc

fix. the problem we have -- you look at it from two points of view. you can let it get scoring or a government expenditure. in view. it could be difficult to fix. no one expects the system to kick in. it is part of the base budget. why not week in cement in the base budget rather than find the offset to pay for something that is already agreed would never happen? if you look at it as an all said, it is a lot of money to fix it. we do not know where the money is going to come from. the one thing i can tell you, congress will not allow the cuts to go into effect. we will make sure that doctors are reimbursed fairly, and it is my hope that we can find a way

to avoid some of the partisan bickering and come to an agreement and put this behind us. it really is not right. we should fix it. >> thank you very much. >> hello, how are you? equal time, equal time. >> actually not because i came up. i am can glover, the ceo of dimension. i want to and knowledge that this health care reform is really more important than i think people think. [unintelligible] now i have to fix it. anybody? >> you have to talk into it. >> the microphone is not on? should i just yell it? ok.

is this better now? i think -- >> and there you go. >> carlton is my guy. [laughter] [applause] what i was saying was is that for my people's time, i would be in support of everything that has been done. i think you and our team in washington ought to be celebrated. it is change the whole dialogue, particularly as it occurs here in prince george's county. your leadership in washington, yet the secretary's leadership on and leadership side, you have jim hubbard and others. you have this very data -- very different discussion.

with all of these new paradigms', what would be the role of the wishes constantly played to continue the floor of motion that started this legislation and this reform? >> thank you for your question. let me just tell you the challenges the dimension has had. they have operated households in areas that have a large number of people that did not have insurance. the prince george's hospital was located in an area where many people in the district of columbia came into it without charge of the use of the telesis -- of the facilities, did not pay for it, and that created a huge problem. that will help in hospital care in prince george's county. everyone will be covered. you will have a much higher reimbursement rate. secondly, we're going to build infrastructure that will provide the type of health centers

needed so that hospital is used when it is needed and not for care that can be provided at a different facility. and then you can reimbursed on a fair amount of the hospital because you are not paying. for all those reasons, we think it is when they come together. hospitals are critically important to our communities. we know that they're incredible things done every day. i've been your prenatal facilities and to your preemies, and it is incredible. we want to make sure that that facility is available here in prince george's county. we also won a major that allegis facilities to deal with the challenges that should not be in your emergency rooms. that is where we need to work together. >> good afternoon.

bananas dion brown, and i am the community brown -- my name is dionne brown, and what is in the package that will allow seniors to remain in their homes without having to leave the transition to assisted living or nursing homes? many of the seniors idea would have an issue with leaving their own private home because there is not anything in the package that relates in there. >> thank you for that question. there things that i would like to of seen in the bill that are not there. this bill does not deal in any extensive web with long-term care needs. in it is not. i think we need to deal with long-term care needs. it is a huge issue for america. [applause] this bill did not really deal with long-term care needs. yes, it has of voluntary insurance program where you can

buy an insurance policy that will pay you a certain amount of money if you need home health services for institutional care or assisted care. if you need that type of care, there is an insurance plan that you can buy. that is an improvement but it does not deal with the underlying problem of how we deal with long-term health care needs. to many families have reached a very difficult decision, whether they can continue to keep a loved one in their home or whether they put the person into an institution. in many cases, it is a financial issue. if they could qualify for medicaid, the government would pay the cost of the institutional care, and adding to the cost of the taxpayers, which is not what you want to do. you would much rather -- much rather have stronger home health-care services, but we do not provide help for assisted living. it is not as strong as nursing homes. we have to get the fix the long

term care issue, and it will save us -- save the taxpayers of this country significant tax dollars and provide better services in the community where people really wanted. i got -- i went to the situation where my father was sick and we were able to keep him in a home environment. we were able to do that. it cost of lost less money than putting them into a nursing home and that is where my father wanted to be. many families that they do not have that choice and we have to figure out a way that the person receives the right level of care and we will save all this money and be much better for people. [applause] >> i'm a senior citizen. health reform is such a painful process, and one reason is the senate's own rules were simple majority means nothing.

we need 60 votes to get anything done, and 60 votes seemed to be hard to come by less to give away the store. what in the senate to to change the situation? >> thank you for that question. i agree with you and that is why many of us had been working on the procedural problems. we have rights to protect the minorities in the senate for a legitimate reason. i can understand on fundamental issues why the party that is in the minority may want more time in order to make their point. you can in the united states senate. the difficulty is that of alaska after years, the party in the minority has used the filibuster. tingley on every bill, on the district court judge, on a minor bill dealing with certain land use. we have not been able to build

bridges bring these builds up because of two reasons -- the 60-vote threshold can it takes too much time to go through the filibuster rules. it could take a week. we cannot spend a week on a relatively minor bill. it is been terribly abused. the answer is what can i do? the best thing to do is to change the procedures in the senate to eliminate these abuses of the powers. on routine issues, they are up and down budgets. senators to try to use dilatory practices, that there is accountability on what they're doing. we can make it look like what is going on. i think the filibuster should be a filibuster. but the public see what is going on private and saying you cannot bring up an issue. and i would hope that we could find democrats and republicans working together to change the rules of the united states

senate. and that is a fundamental issue. i know many of you here, you know that i believe that the elections are part of that, but then you were together, democrats and republicans, to get things done. i work closely with republicans to get things done. that is how you got things done. that is how you need to work. democrats and republicans need to work together. isan division is just wrong. if we could talk to each other, the abuse of the filibuster something they ought to agree is wrong. we should fix it and make sure there is accountability and do the people's work and keep the election period as short as possible. when they robert, let's come together and work together. -- when they are over, let's come to get rid work together.

>> my name is lisa ransom. my question is simple. are there any provisions in the legislation that address training for health care workers? >> thank you for your help. you have been one of the individuals who has been very great help to me in understanding the health care issues, understanding the community. the answer is yes, a significant resource on training. you do not have enough primary- care therapists, nurses, doctors, people in the community. we do not have enough. we have to train more. it takes time to train. we are starting now to put a significant investment into the training. you put money in here to help with training costs for those committed to going into the underserved areas. we're trying to deal with this in several ways. directing resources to increase capacity. i think the community colleges are one of the most effective ways that we can expand training in the allied health

fields. that is true here in prince george's county and in many other areas of our state. the of already made some adjustments to increase the numbers and we're going to try to encourage that more. one difficulty is nurses to want to be teachers. they can make more money doing other things than teaching. we have to invest to increase the capacity on the primary care front. we're committed to dealing with it. we're starting today. we know we have at this fully implemented by 2014. >> hello. i'm a member of the senior center. i have problems -- i have cataracts removed and i let in some outpatients, and y'all want me to pay up front. and then submit the charges to

medicare. well, i cannot do that. i do not have the money. i wondered what can be done about that. >> thank you for that question. my understanding is that there are ophthalmologists they will not take medicare as their primary, and therefore they will not get insurance, therefore require you to pay the bills up front and assist you in getting reimbursed. i think that is the minority of ophthalmologists. most work directly with the system.e cent an talk to the shift representatives and see whether we can i pick you a broader list of doctors. >> my name is pearl boyd, and

i'm up president of the center here. my question is similar to the other ladies. so many of us seniors, my neighbors and so many of us like to know what can be done about affordable dental work? it is so expensive. [applause] >> thank you for the question. dental care is so important. again, the mounting driver is the continuous reminder to us improves george's county. oral health care is very important for your general health care needs. it is the number one disease among our children. it is preventable. particularly for young people, there think that could be done today they can keep them a lot healthier.

but they have to go to a dentist. they have to get the care. we started with the young people, and in the children's health insurance program, the s chip program, i am very proud of the amendment that i offered that gave it mandatory dental care for children. they will be covered under this bill. we've also expanded dental care in this bill. there is been an expansion of dental care that will provide more comprehensive care but not enough. the come back to the same question basically on the hearing aid. this is an area that i find needs to be included in medicare more comprehensively. i agree. >> i understand about that. my grandchildren, they think the to some of these places they have now and get carefree. but now that we're the age that we are, are there any dentists

or any programs where we can be covered at a reasonable cost? >> the answer is yes, and i will refer you again to the people who are here. there are opportunities but it needs to be expanded. we do not have enough yet. but there are opportunities. i have been informed that your the last two to ask your questions. >> last but not least. thank you very much. i'm sally leonard, and i want to thank you for your work on health reform legislation, which i believe is that critically necessary and for your support of community health centers. i would be remiss if i did not point out that the health center program is designed for rural areas and urban areas, but we live in a suburban area with incredible need. i was wondering if you could briefly talk about the revamping of the criteria for medically underserved areas and populations.

>> we've had a conversation about this. we support very much the expansion of the definitions. these are basically waited. areas as to get funds. -- weighted point areas as to who gets funds. we have to change the standards of that a suburban area that has a unmet needs can get services underqualified health centers. that will be critically important of meeting the goals of the new health-care bill. congratulations on what you are doing. you're doing great work. >> good afternoon, senator. i'm reverend bob henry. you know about the project that we built where we opened at 270- unit senior center, the largest senior living center built in

the state of maryland with low- income housing tax credits. as a part of our vision when we started this process some eight years ago, but one that our seniors to age gracefully in place. moving from an independent living into assisted living and then they would have to transfer off if they needed 24 hour care. we're running into insurmountable odds in getting the same types of funding that we did to develop the independent living, for our assisted living facilities. i know you mentioned the need for more assisted living facilities, but is there anything on the horizon that helps? in the second part is, we built within the facility a health- care portion -- week dedicated some space, and other words, for health care of our seniors on the property. here again, we cannot get any assistance for staffing that because the position -- that

doctors we were working with, their complaint is the primary care reimbursement. now that we have this new facility to care for our seniors, we cannot get the doctors to come in because of the reimbursement. >> that is a great question to conclude on. the bottom line is that the bill was passed and signed by the president deals with health care. expanding health care insurance to every family in america to try to put the brakes on the growth of health-care costs, take on the private insurance industry, and say, we believe in competition but we need to make sure that it is fair competition and these abusive practices no longer take effect. we need to manage the centers to deal with primary care to reap the benefits of prevention. that is the main thrust of the health care bill. you have to look at this from a

holistic point of view. that difficulty with assisted living, today there is no real federal definition of assisted living -- something we need to do. secondly, we do not know how to characterize this. is this health care, is a housing, is a social services? therefore that finding clothes come from different agencies. there are hide funds available -- there housing funds available to help low-income and moderate- income families with assisted living. it is not enough and does not deal with a holistic issue, the continuum of care. not many of the assisted living have certain standards to get to certain levels. what of that facility can handle a person who needs additional care later on is not always consistent. there's a lot that needs to be done. the state of maryland has been very aggressive in this area. i think we can learn from the state of maryland. i do congratulate this

administration. they've got a handle to get more information to seniors in this area and to use all the tools at their disposal so that more families can take advantage of assisted living. you need to continue month care. those people who need to be in nursing home, and their people that just need some help in their homes. there are different types of care needed. we need to make sure that we have a national policy as a relates to all of these issues. i am hopeful -- let me just conclude on this note. i think your questions today showed that americans are really interested in resolving these issues. they know their problems. they know they have had problems with private insurance companies. why is and my hearing aid covered or why can i get dental? these are questions that we need to we do have the framework and

now a commitment to make sure that we answer those questions. i do believe we will figure out how to get this health care system the way that it should be said that you would get that type of care that you need, so that families can also get the level of long-term care that they will need in order deal with the demographic changes. this is happening. we cannot afford to pay -- to put people into nursing homes that do not need to be there. we have to figure out a better way to deal with these cost issues. and i'm optimistic that we will be able to do this. i want to thank you all for being here today. it is a beautiful day and you took time to talk about health care. i want to a knowledge one more time the team. i want to mitchell is a warren, and senator mikulski said that we're going to take care of this. it was not in the bill that came out of the committee but she

added the amendment that put the women's health care issues front and center and prevention in the bill. congressman hoyer make sure that this was affordable. it was he did said that we're going to make sure that at the end of the day we're not spending more taxpayer money. there were a lot of people in the house to fight him on that. at the end of the day, we get that accomplished. our team is working together on your behalf and these types of meetings are very helpful to me in trying to understand how we need to proceed. i always appreciate the time off they give us from the senate being in session to get out and talk to the people of the state of maryland. you were close by so it is nice to come by. thank you very much for having me here. [applause] [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

>> health care is the right, not a privilege. >> senators and congressmen have been holding town hall meetings in their states and districts and we have been covering i them. it is all searchable and free on your computer any time. >> our coverage of town hall meetings around the country continues with oklahoma senator tom coburn. this is an hour.

>> we will spend as much time as we can answering questions. i will get in your full and i will learn from it. i will tell you at a time that i'm good about reading the e- mails that i get. if you get a letter back from me, and almost everyone does thomas we have lost it, you can count that i have read the letter that you have sent me or those e-mails that you have sent me. you can also count that it is my word coming back to you, not somebody else's. i'm about 5000 behind right now.

[laughter] i spend about 2.5 hours on it. if you have not got an answer, it is my fault. it has been longer than that, you may question whether we have actually gotten it. the average about 2000-3000 letters a month. it is important to me to hear from you because that is how i learned what oklahoma thinks. i'll spend a few minutes talking about where we are. i think we have three real problems in front of us. but me differentiate between the problem and the symptoms of the problem. part of our problem is that we do not talk about the real problem, we talk about the symptoms. the first problem is that we've ignored the u.s. constitution. if you go and look at the enumerated powers, will have

done is we have expanded it far beyond what it was ever intended to be expanded by our founders. and we have done it in the name of doing good things, but as we send -- spend $1.4 billion a day that we do not have been charged to our kids, it is time for us to reconsider that. we also have $13.5 trillion in real debt that will have to be repaid, going to $20 trillion in 2020. what that does is that that steals opportunity and future from our children and grandchildren. that is not a heritage. we ought to reject that and make the hard choices about what the priorities and what are not. i've tried to do that over 5.5 years. i've offered more minutes than anyone else up there. the third thing that we have

that is a problem is that we lack visionary leadership. doldrums right now economically and in a lot of other ways. and that because we have not had a voice to vocalize that we need to get back to embracing the very characteristics that made this country the greatest country in the world. it has provided more and greater standards of living than any other country ever provided, greater freedom, and greater advancement. and it did not because of us but a system in which we have limited government and individual will and freedom ends up trapping the best thing of bureaucracy can never did. by far. the hope is that we will recognize this and that we will move. we do not have one problem in front of us as a nation that is not solvable. but if we talk about the

symptoms and not the real problem, we delayed the time in which we have to get to and work on the real problems, and it is just like practicing medicine. if if you come to mean you got fever and cough and chest pain, and i say, i can take care of your call. i give your narcotic. i could take care of your fever, and i can also give you something to help the chest pain. but i never diagnosed the fact that you have pneumonia entreats the real disease, you will feel better and then you will get a lot worse. that is what we have done. we need to get rid of the politically correct dialogue to say you cannot talk about something. if europe that something? we have a lot of problems in front of us and we need to discover what they are, talk about the real problems, and make hard choices that says what is number one, what is number two, and what is number three, knowing that we cannot do everything we were elected to

come off nor should we get the federal level. to voice ao get you question. i'll get you to repeat it so that everyone can hear it. yes, sir. [inaudible] larry roberts is in a hospital in st. francis. i have two questions. illegal immigrants -- i'm so sick and tired of hearing about illegal immigrants, and the fact that nobody is doing anything about it. obama debt token thing in august were supposedly said some troops down there to help the border.

as a band-aid on the situation. legal immigrants i've got no problem with. but drug lords and criminals coming in to request -- country illegally, and the government is not doing anything about it, bush did not do anything about it, obama is not doing anything about it. why in heaven's name don't we stop that? >> what was wrong with our encouragement in 2006 we created a change on the border that said -- spent $8 billion of your money. we made a significant change on the border. increasing border patrol and a significant amount of money on fencing. that was not completed under this administration for some reason. but the number of illegal immigrants coming into the country is about one-third of

what it was during that time. they're still way too many. no republican has ever survived that cannot control its borders. we will not survive. if someone tells you we cannot do it, then they are either ignorance, deceitful, or have no knowledge of history. the fact is that we can. there are a lot of problems associated with it. getting a consensus to do just that -- you may be interested to know that 40% of people here illegally came legally. they came under a visa that our government granted to them. the congress has been incompetent in creating a system and forcing the executive branch to enforce that system that manages a legal basis. that is something we can solve but it has to be a priority and that has not been for this administration and in east to be fixed.

if we -- why have a visa system if you do not enforce it? the second problem has to do with bureaucratic mess. yet the department of interior that will not allow the border patrol to come on to their land because they are afraid it might tear it up. but the very same place where they might tear it up is where the vast majority of illegals are coming across the land, tearing up the land. never do what is best when it is safe for the bureaucracy. that is because we haven't controlled bureaucracy. it is not a simple problem, you are right. there is a move to fix that. we could not get it fixed completely when president bush was in there. we ought to seal our borders and control. anyone who says we cannot do that is inherently wrong.

it requires the leadership to do it. you the questions about the 14th amendment. we do not need to address the 14th amendment. that is one of the symptoms of the problem, not the problem. if you control the border, you don't have any problem with the 14th amendment in terms of children coming here in gaining citizenship because they were born here. if you control the border, they would not be an issue. it's important to get back in control of the issue. [applause] who is next? >> why are you using your senatorial powers to sequester my records? i have people that witness you asking me three times if you could take my medical records home. have asked the same doctors that you referred me to and i have

their correspondence back to you thanking you for the referral. i also have records from the u.s. marshals file showing you were faxed my records. >> we have communicated with you add in an item -- let me finish. we have tried in every way possible, we have searched my former medical office upside- down and out, we cannot find them. that will not satisfy you and other than the fact that you're welcome to carry this through. no one is a question in your records. your records are lost. -- no one has sequestered your records. your records are lost. >> they were sequestered at your request. >> that is not true. you're welcome to talk to john in my office. we cannot solve a problem that

is not an accurate description of the problem. >> we have your correspondence. i didn't print screen in your office when your nurse went to the back. i should from your computer my records are archived. >> you are in the area and i was spending more time on this. we do not have electronic medical records in my office. >> there was a screen that shows what records you have. >> no, we do not and you are in error. >> in the wall street journal this week in, in an interview , there wasmint success in getting conservative candidates elected senate. they were derogatory. there was not in the naming of additional person. they named you and senator demint that had a voice in

trying to do a thing like tamp down earmarks, bringing attention to the national debt, talking in a market-based conservative fashion. do you see any hope that there was discussion about getting pushed back from the national park issue, and another vilification that you have taken from both sides because of the stance that you have often taken in the senate -- is there any hope that you see a bus pulling some true conservative -- including true conservatives to get you some help in pushing for some of these needed reforms that you have discussed with the margin it i liked the word that you use because you did not use the word republican. labels are cheap. not very accurate. having been in the senate for 5.5 years, i've been labeled a lot of things, most inaccurate.

our country has problems. how do we solve them? we certainly do not use the absence of common sense to get to the solution to our problems. that is one of the biggest problems that i see in washington. there are a lot of great people, democrats, republicans, liberals, conservatives, in washington. the frame of reference is the critical factor that is missing. a large number of people who serve in washington love our country, but they have absolutely no real world practical experience on almost anything because they have spent their entire career in "public service." when it comes to making critical decisions, they do not have a machine that they worked on that broke down that thomas certain lesson. -- that taught them a certain lesson.

you wonder how many flat tires they have changed in their light. going to the practical aspects of living life, where you are taught and learned something about living life. they do not have a malicious motives. but we need is people with real- world experience to, applied that experienced the problems that are facing our nation, much like our founders did. instead, we have a career class of almost elites the become arrogant in their position. -- throwingclaiming anything on anyone that might not be applied to me. we need clear thinking and we need to recognize -- what was the country built on? that country was built on a heritage of sacrifice. one generation works hard, sacrifices hard, a decree opportunity for those that follow. it was built in the fact that we had certain constitutional

principles that we followed to a great degree and from the late 1940's. and then we started abandoning a, the true meaning of the constitution by expanding the commerce clause, expanding the general welfare costs, and now you say anything, you do not care about these people. the fact that -- there's not anyone in this room that would not sacrifice to help someone who was not truly in need. but there is a big difference in that and in creating a system designed to be defrauded and abused. that is truly where we find ourselves. one in 19 people in this country today are on disability. that does not count our veterans. you really think one in 19 people in this country are disabled? have we designed the system to be abused? yes, and in the recent past, 600,000 had been given

commercial driver's licenses. if you know anything about medicine or commercial driver's licenses, and disability, if you're truly disabled, that means by definition under the law there is not a job in the economy that you can perform, but you can pass a commercial driver's license and meet the physical exam for that? that is one small example but it cost us $14 billion. and you have $114 billion, what you have? present, it adds up. when we have done oversight hearings where we can identify $350 billion of waste, fraud, abuse, or duplication, and you cannot the body electric in the senate or the house to go after that, it is time to send different people there.

what senator demint has concentrated on is sending him some help. the real answer is you. holding us accountable. holding us accountable for our vote. all the way over there. [inaudible] >> his questions about the health care bill, and a large amount of savings came by eliminated the options for people who are on medicare advantage. the political right way for doing that is that interest month project insurance companies were making too much money of that. the thing that people do not count on rural and poor

oklahomans who cannot afford a supplemental medical policy. they're in much better taken care if of a coordinated care of medicare advantage then it would be on straight medicare. they're being penny wise and pound foolish. if you think insurance companies are making too much money, cut their money but do not take away benefits from a of medicare patients. what we will see is millions of americans lose critical coverage under medicare advantage. it is not critical if you're sitting in washington talking about that gentleman. but if you talk about his health care in his ability, it is a critical problem. if in fact you want the decisions and your health care made by bureaucrats, then we need to address what this administration is done on health care. but we passed up a golden opportunity to fix the real problems in health care. you know what they are? it costs too much.

health care in america costs too much. why does it cost too much? one of $3 that we spend today helps nobody in health care. $1 out of $3 does not help anybody who is sick get well. what would happen to the health care tomorrow if in fact we get rid of that $1 and a $3 that did not help anybody? your interest freeman the cost of your health care would go down a 33%. that would be beneficial, wouldn't or to mark why wouldn't we designed assistant to get rid of the excess cost in the system rather than put the government into rationing -- which they will deny -- and into a new payment panel which is a massive shortage of primary-care doctors in this country a?

why don't we fix the real problem? we did punishment for the insurance industry, and then paying for the people who are medicare advantage. some will not miss a beat. but for 89,000 oklahomans on medicare advantage, they will see a significant reduction in their benefits. what we're doing, if you like the health care you have got, you can keep it? i do not think so on medicare advantage. you cannot keep it. healthcare is a big issue. it is not that we could not have fixed it. we missed that. we did not do anything about $250 billion in tests are ordered that nobody needs. half of that is because of the court system, and because of the system where we underpay primary-care because they did not spend time with you. they walk out the door and ordered tests that you may or may not need but they're

covering themselves because they are not paid adequately to spend time with you that they should be. we're all taught the same thing in medical school. if you listen to the patient, they will tell you what is wrong with them. by having a great differential diagnosis and spending time with your patient, you can come to a diagnosis of all the time without the first test. we will not pay for that because we have a price control called medicare and medicaid. have you ever ask yourself why the best doctor is paid the same as the worst? what? i would think that we would want to reward excellence and punished incompetents. but medicare sees them all the same. i want the best -- if i have to have heart surgery sunday, i want the best one doing it, not the worst. yet we have a system that does not differentiate between the

qualities. what can we not had a chance. market? like to see potential outcomes before you buy instead of after you have got it? the allocate almost everything on the basis of the market is except health care. we do not let consumers make a value judgment about it. and the other problem, while we're talking about health care, is we always assume someone else is paying for it. that is why the inflation is in there. the real wages in oklahoma would be 11% higher of the last three years if we truly had market forces driving health care. 11% more in real wages, and instead they went to health care costs, because they are out of control and more -- and no market forces are disciplining the price or the outcome. [inaudible]

>> i am not going to learn to live with it. this is being filmed by c-span so i'm going to get into lots of trouble but i am used to it. [laughter] i believe the plan is for this plan to fail. as a matter of fact, i know that this plan will fail. health insurance will be too high, a jewel create adverse selection. anyone young that is healthy, you'll pay the fine in 2014 rather than spend $9,000 on health insurance. it is part because if you get sick, then we have to cover you. it does not rise to $795 until 2014. what is going to happen? the healthy young people are not one to be in the insurance pool. what is. happened to the people over 40

who are sick? will happen to the cost of their insurers? that is why i think it is designed to fail. ultimately they want their revert back, we need a government-run, government- mandated, single payer health care system. this country has the best health care in the world. the outcomes -- i'm a three-time cancer survivor. colon cancer, metastatic, and melanoma. why am i alive? the health-care system in this country. it works 30% better on average than anywhere else in the world on cancer. yet we will destroy the system that created that outcome. it is time that we change it. can we? yes, and what is going to happen and a lot depends on what happens in the election. you're not going to get it repealed until you have enough

votes to override a veto. and that is not likely. you either have to change the president in 2012 or you be ready for a big fight that says we're not going to spend $1 to the government agencies implementing this. when that happens, there is going to be a fight and the american people have to decide. will everyone get wobbly need when we play hardball on whether we allow this administration to implement it? that's why they are rushing so fast. they are afraid the election will change things and there's just 34 months -- 3400 new pages of new regulations and that is 5% of what is coming. what did think the cost of complying with that is going to be, let alone the system not working financially? and it take $540 billion out of

medicare to create two new entitlements, where we subsidize everyone else is health insurance? and we create the long term care that will not be financially sound? medicare is already broke. $37 trillion liability. we will have to fix medicare and fix the real problems in health care. it will be a hard battle. it will be a big battle. and the presses. you is that the republicans are shutting down the government over health care. do you want this bill or not? do you want the money? because of the president will veto any bill that does not have the money to implement it. america needs to decide -- do we want a socialist-leaning health care system, or do we won a market-driven system with more

responsibility on you did you have to date, but will markedly lower the cost to you in your kids in your grandkids? that is the choice. i'd vote for the american-style intervention rather than the socialist-style of intervention. [applause] >> [inaudible] [laughter] >> i look on you as a potential president of the united states. [applause] >> let me stop you there. i want to give you a story. i've been married 42 years. i liked the why i've got. [laughter] if i ever thought about that, i

would lose her. and i'll have to go through training with another wife. i'm not doing that. [laughter] >> i do not think that what happened. >> you do not know my wife. >> i understand that there are five states not providing ballots for our soldiers overseas. >> his question is about -- in the 2008 election, most of our troops, their votes did not count because the states to not fill the responsibility of getting those ballots to them. senator cornyn has been working on this. it is based on timing. we will have a tough time holding those states accountable. here's what should happen. if the state does not make the

ballot available to the troops, there ought to be a financial consequence on what goes to the states in terms of government programs that are legitimate. [applause] and they ought to know it at that time that we will work to make sure that if you are taking away the person -- the person who deserves the right to vote more than any of us -- then there's going to be a consequence. yes, sir. speak real loud because i am hard of hearing. >> thank you for what you have done for us. when we go to the polls in november, do our duty, following that up, what source of information can we go to that will allow us to keep your feet under the fire? under the fire?