[House Hearing, 110 Congress] [From the U.S. Government Publishing Office] SUBCOMMITTEE HEARING ON ENSURING PROMPT PAYMENT FOR SMALL HEALTH CARE PROVIDERS ======================================================================= SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE COMMITTEE ON SMALL BUSINESS UNITED STATES HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS FIRST SESSION __________ AUGUST 1, 2007 __________ Serial Number 110-39 __________ Printed for the use of the Committee on Small Business Available via the World Wide Web: http://www.access.gpo.gov/congress/ house U.S. GOVERNMENT PRINTING OFFICE 36-114 PDF WASHINGTON DC: 2007 --------------------------------------------------------------------- For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866)512-1800 DC area (202)512-1800 Fax: (202) 512-2250 Mail Stop SSOP, Washington, DC 20402-0001 HOUSE COMMITTEE ON SMALL BUSINESS NYDIA M. VELAZQUEZ, New York, Chairwoman HEATH SHULER, North Carolina STEVE CHABOT, Ohio, Ranking Member CHARLIE GONZALEZ, Texas ROSCOE BARTLETT, Maryland RICK LARSEN, Washington SAM GRAVES, Missouri RAUL GRIJALVA, Arizona TODD AKIN, Missouri MICHAEL MICHAUD, Maine BILL SHUSTER, Pennsylvania MELISSA BEAN, Illinois MARILYN MUSGRAVE, Colorado HENRY CUELLAR, Texas STEVE KING, Iowa DAN LIPINSKI, Illinois JEFF FORTENBERRY, Nebraska GWEN MOORE, Wisconsin LYNN WESTMORELAND, Georgia JASON ALTMIRE, Pennsylvania LOUIE GOHMERT, Texas BRUCE BRALEY, Iowa DEAN HELLER, Nevada YVETTE CLARKE, New York DAVID DAVIS, Tennessee BRAD ELLSWORTH, Indiana MARY FALLIN, Oklahoma HANK JOHNSON, Georgia VERN BUCHANAN, Florida JOE SESTAK, Pennsylvania JIM JORDAN, Ohio Michael Day, Majority Staff Director Adam Minehardt, Deputy Staff Director Tim Slattery, Chief Counsel Kevin Fitzpatrick, Minority Staff Director SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE CHARLES GONZALEZ, Texas, Chairman RICK LARSEN, Washington LYNN WESTMORELAND, Georgia, DAN LIPINSKI, Illinois Ranking MELISSA BEAN, Illinois BILL SHUSTER, Pennsylvania GWEN MOORE, Wisconsin STEVE KING, Iowa JASON ALTMIRE, Pennsylvania MARILYN MUSGRAVE, Colorado JOE SESTAK, Pennsylvania MARY FALLIN, Oklahoma VERN BUCHANAN, Florida JIM JORDAN, Ohio ......................................................... ______ ......................................................... (ii) C O N T E N T S ---------- OPENING STATEMENTS Page Gonzalez, Hon. Charles........................................... 1 Westmoreland, Hon. Lynn.......................................... 3 WITNESSES Wilson, Dr. Cecil B., American Medical Association............... 4 Merrill, Dr. Robert, D.D.S., American Association of Orthodontists.................................................. 5 Henkes, Dr. David, Pathology Associates of San Antonio........... 8 Austin, Dr. Gordon T., D.M.D., Northwest District of the Georgia Dental Association............................................. 10 Kelly, Dr. Frank B., American Academy of Orthopaedic Surgeons.... 11 APPENDIX Prepared Statements: Gonzalez, Hon. Charles........................................... 21 Westmoreland, Hon. Lynn.......................................... 23 Wilson, Dr. Cecil B., American Medical Association............... 24 Merrill, Dr. Robert, D.D.S., American Association of Orthodontists.................................................. 32 Henkes, Dr. David, Pathology Associates of San Antonio........... 36 Attachments to Dr. Henkes Testimony.............................. 48 Austin, Dr. Gordon T., D.M.D., Northwest District of the Georgia Dental Association............................................. 65 Kelly, Dr. Frank B., American Academy of Orthopaedic Surgeons.... 67 (iii) SUBCOMMITTEE HEARING ON ENSURING PROMPT PAYMENT FOR SMALL HEALTH CARE PROVIDERS ---------- Wednesday, August 1, 2007 U.S. House of Representatives, Committee on Small Business, Subcommittee on Regulations, Health Care & Trade Washington, DC. The subcommittee met, pursuant to call, at 10:00 a.m., in Room 2360 Rayburn House Office Building, Hon. Charles Gonzalez [Chairman of the Subcommittee] presiding. Present: Representatives Gonzalez, Larsen, Altmire, Shuler, and Westmoreland. OPENING STATEMENT OF CHAIRMAN GONZALEZ Chairman Gonzalez. The Subcommittee on Regulation, Health Care and Trade on Small Business will come to order. Today's hearing is on ensuring prompt payment for small health care providers. I am going to begin with an opening statement, but I do want to preface my remarks as well as the remarks by the ranking member, thanking each and every one of the witnesses. Please understand this is probably the busiest time of the session for Members of Congress because we are supposed to go on the August recess and we are trying to do a few things before we leave either Saturday or Sunday or it could be Monday or Tuesday. We are not sure. But we are hoping certain Members will come through. Also understand you have submitted written testimony and that testimony is actually reference material for us. And the questions that we will be posing today will again inform us, enlighten us and guide us. And staff is here, of course, and we count on them to take a lot of notes but we do that ourselves. Again, thank you very much. And I am hoping we will have members--as a matter of fact, we have been joined by Congressman Shuler at this time. Members may come in and out, and that is just the nature of the beast around here because there are so many demands being made on Members. And the Chair will recognize himself for an opening statement. Small physician groups face many challenges today. Unfortunately, many of these have nothing to do with practicing medicine. Whether it be the increase in bureaucracy of managed care or the prospect of reduced Medicare reimbursements, it can be extremely difficult to make these businesses profitable. Today's hearing will look at one of the biggest financial challenges facing the industry. Payments from insurance companies to health care providers have long been a concern of health care providers and their member organizations. Providers have shown that some insurers delay payments for a significant portion of the insurance claims. This often leads to cash-flow problems and increases the cost of care for the patients that they serve. Such conditions are particularly problematic for small health care providers. As small businesses, they just cannot afford to be exposed to the sort of instability that an unpredictable revenue stream creates. Payment delays are nothing more than an unfair business practice that let insurance companies earn interest on money owed. Cash flow is an important issue for the small practice and late payments hinder their ability to run and expand their businesses. The insurance community argues that the prompt payment of claims is not a problem, that the market in concert with State laws will address any lingering problems. This subcommittee is interested in our witnesses' responses to that particular assertion. Small providers lack the financial resources to hold insurance companies accountable for their failure to make timely claim payments. If an insurer is unwilling to make a payment or wants to delay payment, what remedy do small practices have at hand to compel payment unless we provide them with one? Only prompt payment laws that are enforced make it possible for small providers to be paid in a timely and fair manner. Efforts to enact prompt State payment laws have been successful. To date, all 50 States and the District of Columbia have prompt payment rules that apply to insurers. These laws were designed to help small providers who lack the ability to negotiate payment schedules with insurers or to compel payment. As such, small business health providers can rely on State efforts as opposed to hiring their own attorneys to enforce these requirements. But there is a problem. States do not seem to be effectively cracking down on insurers who are not complying with State prompt pay laws. In part, the focus of today's hearing is to understand why prompt pay laws fail to be as successful as providers once hoped. Ultimately, health care providers need prompt payment laws that are meaningful in practice, not just on paper. I believe this means promoting stricter enforcement of existing laws, strengthening prompt payment requirements and holding more health plans accountable. Though prompt payment laws can be found throughout the country, providers seem to uniformly agree that they are far from effective. This is a significant source of frustration for State insurance commissioners who have directed considerable resources to enforcing compliance and providers who are challenged by the problem daily. Without a solution, small practices will continue to struggle. I would like to thank again each witness. We look forward to your testimony. And at this time I am going to go and yield and recognize the ranking member, Congressman Westmoreland, for an opening statement. OPENING STATEMENT OF MR. WESTMORELAND Mr. Westmoreland. Thank you, Mr. Chairman , for holding this hearing today. This is a very important hearing, especially for the medical profession. I would also like to thank all the witnesses for your participation. And I am sure that today's testimony will prove to be very helpful to this committee and to our Congress. Payment for service is the core of our economic system. No industry would survive if those who bought a product only paid a fraction of what it cost. But that is exactly what is happening to physicians in our health care industry. And not only are physicians often paid less than what their services cost, they are also being paid well after the bill comes due. So not only do you not get all your money, you don't get it in a timely fashion. The ironically named prompt payment issue is one that is affecting physicians and patients all over the country. Surveys have shown that it is at the forefront of physicians' concerns and I know that from listening to many physicians that come into our office every day to complain about the system. And their payment schedule is one of the things that they complain the most about. I don't know about any of you, but when I visit my doctor, I want his full attention to be on what he is doing and not wondering if he is going to get paid for seeing me. Almost every State has enacted some form of prompt payment law in an effort to address this very real issue. Unfortunately, these laws usually have very little enforcement and therefore allow the problem to persist. I am proud that my home State of Georgia has one of the most comprehensive laws governing payment for medical services. Our law requires that insurers pay claims within 15 working days of receipt. While this law has helped, it has by no means eliminated the insurance companies' desire to withhold payment. This Congress faces a great challenge as it tries to lower the overall cost of health care, while also providing access to those who need it. I hope that we can all agree that shortchanging our physicians is counterintuitive to having an effective health care system. I know that today's hearings will be helpful in addressing this challenge. And again I want to thank the Chairman for having the hearing. And I welcome this distinguished panel, and thank all of you for your willingness to testify today. Thank you. Chairman Gonzalez. Thank you very much. Is there anyone else who wishes to make an opening statement? I want to welcome Dr. Rob Merrill. It says on our agenda that he is representing the orthodontists which are based in St. Louis, Missouri. But I want the record to be very clear that Rob is a citizen-resident of the great State of Washington with Nancy Washington. I have known him and his family for a long time, 10 to 15 years I guess it must be by now. So I really appreciate the hearing, but I wanted to especially welcome Dr. Merrill to the hearing. Thank you very much. We will proceed with the testimony. I would advise the witnesses that you have 5 minutes, and I know that may not be sufficient time, but we will try to hold you to the 5 minutes. But also understand we will have follow-up questions. And since we don't have as many members present, we are going to have a little bit more time and you will be able to again probably supplement some of the comments you wish you had covered during your testimony. The first witness will be the testimony of Dr. Cecil B. Wilson. He is the immediate past chair for the Board of Trustees for the American Medical Association and has been on the Board of Delegates since 1992. The AMA is the largest medical association in the United States. Dr. Wilson has been in private practice of internal medicine in central Florida for 30 years. Dr. Wilson. STATEMENT OF DR. CECIL B. WILSON, M.D., BOARD CERTIFIED INTERNIST, IMMEDIATE PAST CHAIR, BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION Dr. Wilson. Thank you, Chairman Gonzalez, Ranking Member Westmoreland, and members of the subcommittee for the opportunity to testify today. My name is Cecil Wilson. I am the immediate past Chair of the Board of Trustees for the American Medical Association. I am also an internist from Winter Park, Florida. The focus of today's hearing is of great importance to the medical community given that 52 percent of physician practices in this country have three or less physicians and account for 80 percent of outpatient visits. Small physician practices have limited leverage relative to large insurance companies since antitrust laws prevent physicians as a group from addressing payment and other contract terms on a level playing field. The ability of physicians to address unfair payment practices continues to diminish with the increasing consolidation of health insurers. In the majority of metropolitan statistical areas, a single health insurer dominates the market. The growing disparity in negotiating positions has created an environment where insurers are able to evade prompt payment laws with little, if any, adverse consequence. This has a financially debilitating effect on small physician practices and could limit patient access. When one side has all the market power, more efficient market mechanisms are hampered. A common problem confronted by many physicians is insurers paying claims late. Even if a claim includes all the appropriate information, insurance companies often find reasons to delay or deny payment. This is tantamount to small physician practices extending interest free loans to large insurance companies. In addition, this seemingly intentional behavior by the insurer creates an onerous administrative burden. Physicians and their staff must spend hours on the phone pursuing payment of unpaid claims. In fact, growing numbers of physician practices have been forced to hire office staff dedicated solely to collecting late payments. Because of this, some have had to eliminate services and clinical staff positions as well as forego equipment upgrades and the adoption of health information technology. Fundamental fairness warrants timely payment. As the Chair has stated, in 50 States and the District of Columbia, legislation and regulations have been passed tied to the prompt payment of claims. Despite this, physicians still experience problems with receiving payments from health plans in a timely manner. Evidence of the continuing problem is that State regulators have imposed more than $76 million, including fines, interest, restitution and statutory penalty fees against third- party payors for late payments to physicians and other health care providers. And it is not just State regulators who have understood the problem. In 2000, a number of individual and class action lawsuits were consolidated and eventually certified to cover more than 600,000 physicians. The suits were brought to address violations of prompt pay laws as well as other payment violations by some of the Nation's largest for-profit health plans. Settlements were reached with most of the insurers. However, these short-term solutions will begin to sunset this year. The AMA urges Congress to pass legislation that will establish a strong Federal prompt pay standard, protect more robust prompt pay State laws by ensuring the Federal standard is the floor, establish concurrent jurisdiction over enforcement between the State and Federal Government, clarify that State prompt payment laws apply to all ERISA-covered health plans, strengthen penalties to prevent plans from considering fines and other associated financial sanctions as merely the cost of doing business, protect physicians from retaliation by insurers if they pursue their remedies under the prompt pay laws and expand protections to address other tactics utilized by health insurers to delay or decrease payments. The AMA looks forward to working with the committee to achieve our shared goals of strengthening and safeguarding the viability of small physician practices and providing quality care to patients. Thank you for the opportunity to be here today. [The prepared statement of Dr. Wilson may be found in the Appendix on page 24.] Chairman Gonzalez. Dr. Wilson, thank you very much for your testimony. The next witness is Dr. Rob Merrill. Dr. Merrill is Chairman of the American Association Orthodontist Committee on Governmental Affairs. He is a board certified orthodontist and has been in practice since 1990. The AAO comprises 15,000 members in the United States, Canada and abroad. Dr. Merrill. STATEMENT OF DR. ROBERT MERRILL, D.D.S., M.S., BOARD CERTIFIED ORTHODONTIST, CHAIRMAN, COMMITTEE ON GOVERNMENT AFFAIRS, AMERICAN ASSOCIATION OF ORTHODONTISTS, ST. LOUIS, MISSOURI Dr. Merrill. Chairman Gonzalez, Ranking Member Westmoreland, and distinguished members of the subcommittee, on behalf of the American Association of Orthodontists, I thank you for your leadership in holding this important hearing to address issues related to late payment and benefits by insurers. As the current Chairman of the Association's Counsel on Government Affairs, it is my honor to have the opportunity to share the experiences and perspectives of its member orthodontists as the committee considers ways to alleviate the problems caused by the late payment of benefits. Orthodontists are uniquely qualified and educated dental specialists who correct improperly aligned teeth and jaws. There are currently 9,200 actively practicing U.S. members of the AAO. Orthodontics is one of America's finest examples of a thriving small business community. The Nation's orthodontists, over 75 percent of whom are solo practitioners that employ an average of seven dental service professionals, currently provide care to an estimated 4.4 million adolescents and 1 million adults. Just over 60 percent of patients nationwide have insurance coverage that includes an orthodontic benefit to one degree or another. In my own office, approximately 55 percent of our patients have orthodontic insurance benefits. The best insurance companies pay claims within 30 days, not unlike the best patients who are also prompt in paying their bills, so we don't have to send out multiple statements requesting payment. The average orthodontic practice is often hard hit by economic downturns as families often defer what may be perceived as elective orthodontic treatment. Often underscoring these financial difficulties is the practice of insurance companies that delay payments to orthodontic practices and thus cause additional hardship for the practice and its patients. As health care providers, orthodontists care about the quality of treatment of their patients and have a personal interest in the success of treatment. Since there are a relatively small number of orthodontists nationwide, we believe it is likely that insurance companies view the practices as lightweights that can be moved to the back of the line when it comes to payment of benefits. In short, this issue is about fairness as it involves large powerful insurance companies and their relationship to small community based health care providers and their patients. I would like to describe five ways in which late payment of benefits by insurers specifically harms the average orthodontic practice, a system used by one insurer that works well in my practice and outlines several areas where legislation could potentially help. One, cash flow problems. As small businesses, it is important to keep a steady and consistent cash flow in order to pay salaries of employers, the employees, vendors, and to upgrade equipment in order to provide the best, most technologically advanced care to patients. Late payments by insurers complicate cash flow, thus causing numerous accounting problems that require additional time, resources and staff to alleviate. Two, increased burden on patients. Many orthodontists in recent years have stopped processing insurance claims since the cost of hiring additional administrative staff to comply with insurance company red tape outweighs the benefit they receive in return. Regrettably, this causes additional strain for the patient, who is then burdened with the task of completing complicated reimbursement forms and communicating with the insurance companies. Three, administrative costs. Higher costs of insurance company compliance results in overall costs of patient care being increased. Many of the Nation's orthodontists who have longstanding practices report that insurance company benefits for orthodontic treatment have remained unchanged for over 20 years. This means even patients who are covered by insurance often bear the entire burden of increased health care costs. Four, non-duplication of benefits. A related issue that affects orthodontists is what is termed non-duplication of benefits. This means that patients are covered by more than one insurance policy, yet the second policy will refuse to make any payment on behalf of the patient. It may be that both parents or a parent and a step-parent are employed and have paid the premiums for insurance that includes orthodontic coverage, yet will be unable to receive the benefit because of a non- duplication clause in the insurance policy. This means that the employee who happens to have insurance coverage through a spouse cannot access their benefits equally to an employee working for the same company who is not covered by the insurance plan even though both are paying the same premium. This situation is unfair to those who are paying for a benefit and not receiving it. This needs to be remedied. Therefore, the AAL believes that consumers who pay for insurance coverage should get the full extent of the coverage they are paying for instead of getting caught in a tangled maze of paperwork that ends with a denial of payment by the second insurer. Congress should require that where families have multiple dental benefit plans, each plan will pay a portion of the dental care claim according to their contracted scope of benefits, not to exceed 100 percent of the amount of the claim. Five, coordination of benefits. The treatment fee is such that both plans will usually end up paying their maximum, but the secondary insurer will refuse payment until a primary estimate of benefits is received, causing additional payment delays and increased paperwork and expense for the office and insurance company alike. An effective repayment system that works best for my office from an insurance company are the ones that pay automatically once the initial billing is received. This cuts down on expense and increased work hours for both the orthodontic office and the insurance company. Manual monthly insurance billing is very time consuming and adds to the administrative expense for both the practice and the insurance company and this ultimately costs the patients more. The AAL appreciates the opportunity to share the experiences and perspectives of our member orthodontists as the committee considers ways to alleviate the problems caused by late payments of benefits. I hope that the testimony I have offered has been valuable for that end, and I hope that if the AAL can be of further assistance to this committee, you will not hesitate to call upon us. [The prepared statement of Dr. Merrill may be found in the Appendix on page 32.] Chairman Gonzalez. The next witness is from San Antonio, and he is Dr. David Henkes. I have known David--I know, Rick, you were saying you had known Dr. Merrill for a number of years. I hate to even tell you how long I have known David. He was starting his residency and I was already a seasoned 5-year lawyer, which is way, way back. And we share many things in common and that is a great passion for the University of Texas Longhorns. Dr. Henkes hails from San Antonio. He is a board certified pathologist and the immediate past President of the Bexar County Medical Society in San Antonio. He currently sits on the Board of Trustees for the San Antonio Medical Foundation and is on staff with Christus Santa Rosa Health Care, one of the top health care organizations in all of south Texas. Dr. Henkes is also a partner and practicing pathologist with Pathology Associates of San Antonio. Dr. Henkes. STATEMENT OF DR. DAVID HENKES, M.D., BOARD CERTIFIED PATHOLOGIST, PATHOLOGY ASSOCIATES OF SAN ANTONIO, PAST PRESIDENT, BEXAR COUNTY MEDICAL SOCIETY, SAN ANTONIO, TEXAS Dr. Henkes. Congressman Gonzalez and Ranking Member Westmoreland, and other members, I want to thank you very much. I would be nervous in giving this testimony except that I look at your friendly face. Overall in Texas the prompt pay laws we have passed have been helpful, but they haven't really gone far enough. There are still some bad actors out there. In December of 1995, UnitedHealthcare was fined $4 million for violations. There is also the problem where the insurance companies tend to say they are ERISA and so therefore these are not regulated by States. Since most of their claims are ERISA, that has been an issue. As you mentioned practicing in Christus Santa Rosa, it is a very--I am very honored and very happy to do that, but it is a very high Medicaid and Medicare and indigent population. So you can imagine how slow pay and no pay has a real impact on our practice, especially when we have specialized pediatric cardiac surgery, pediatric oncology, and we have to attract talent for their special pathology needs. I want to tell you about an example in our practice that we had that extends beyond just the typical, you know, the slow pay for a claim submitted. In 2004, UnitedHealthcare had sent out a notice saying they would no longer pay for clinical pathology services. Clinical pathology services are services that pathologists provide to hospital laboratories for oversight and direction and usually comprise 25 to 35 percent of the time that a hospital pathologist spends doing those type of services. They said they were going to follow the Medicare model and to pay the hospital, which is indeed what Medicare does. But that is not the model of private insurance companies in Texas, and every other one pays us on a separate component basis. They said the services were covered and we should look to the hospital for that reimbursement. We did and the hospital said we are not being paid. They gave us signed statements of that and we asked them if they had any increase for the nonpayment to pay through to us and they said no. We went back to United and they said, oh, well, okay, we will change that, what we are going to do is--they changed their position and said we are going to go ahead and pay you a little bit more for your anatomic services to cover for these clinical services. Well, that brings in an ethical consideration because a number of patients who don't have clinical services--they don't--they have anatomic services and may not have clinical services. So they are paying for those other patients. And so we challenge that. And then finally, after having this within the Department of Insurance for Texas for almost 2 years, we got a letter back from them just giving us a letter from United saying that they no longer recognize this service. And so we are not sure exactly what that means, whether it is covered or uncovered or what we need to do with that. In essence, what I recommend is that this committee not only look at the existing rules and regulations from the States that are out there, but look at more detail at some of the other practices like what I have just mentioned and help us in terms of addressing those particular practices. I would suggest some of the following recommendations. One, that insurance companies must state whether disputed services are covered or not covered, recognized or unrecognized. If a service is covered, it should be paid; there should be a payment for that service. Insurance companies should not be allowed to increase payment for one service to cover no payment or lesser payment for another unless it is specifically agreed to by both parties in a written contract. Payment to someone other than the provider or person who is authorized by that provider for reassignment should be prohibited. The committee should consider a single set of rules on claims processing by all insurance companies as clinically based so there is transparency in the claims processing system. In cases of dispute requiring arbitration, the insurance company should pay the majority of the arbitration costs and contracts should not have provisions to deter class action arbitration or litigation. And just on that last particular item, we are currently in a class action arbitration and they are throwing up a number of hurdles about that basically so that it has made it very difficult but it will go forward and it should go forward. I would be happy to answer any other questions. I appreciate your time and consideration. [The prepared statement of Dr. Henkes may be found in the Appendix on page 36.] Chairman Gonzalez. Thank you very much, Doctor. At this time the Chair is going to recognize the ranking member, Congressman Westmoreland, for the introduction of the next two witnesses. Mr. Westmoreland. Thank you, Mr. Chairman . I want to recognize Dr. Gordon Austin, a third generation dentist who graduated top of his class at the Medical College of Georgia. He completed his oral and maxillofacial surgery residency at the Naval Hospital in San Diego in 1993 and is board certified by the American Board of Oral and Maxillofacial Surgery and the National Dental Board, certified by anesthesiology. Dr. Austin served for 11 years on active duty in the U.S. Navy and continues to serve in the reserves with 30 years of continuous service. Captain Austin was mobilized to the National Naval Medical Center in Bethesda, Maryland for Operation Desert Storm in 1991 and again in 2003 for Operation Iraqi Freedom. Dr. Austin has been in private practice since 1987. He lives in Carrollton, Georgia, with his wife Meredith and daughter Courtney. And Lindsay lives up here in Washington, his other daughter. But Captain Austin served from 2002 until 2005 as the Reserve Officers Association National Dental Surgeon. He is currently the President of Northwest District of Georgia Dental Association. He is a friend of mine and a constituent. And welcome, Dr. Austin. STATEMENT OF DR. GORDON T. AUSTIN, D.M.D., P.C., BOARD CERTIFIED ORAL AND MAXILLOFACIAL SURGEON, PRESIDENT, NORTHWEST DISTRICT OF THE GEORGIA DENTAL ASSOCIATION, CARROLLTON, GEORGIA Dr. Austin. Thank you, Chairman Gonzalez. With the last name Austin, I certainly have a close kinship to the great State of Texas. Ranking Member Westmoreland, thank you for those comments, and members of the committee. I deeply appreciate this opportunity to testify before you on the issue of ensuring prompt payment for small health care providers. This is an issue of national interest and significant importance. There are currently at least 48 different State prompt pay laws, with to my calculation only South Carolina and Idaho not having such laws. In the complex environment of health care, any opportunity to decrease this complexity should be acted upon. Again, my name is Gordon Austin, DMD. I practice oral and maxillofacial surgery in rural Georgia. And as an oral and maxillofacial surgeon, I practice in both the hospital and the office setting. As a surgical specialty, oral surgery bridges the gap between medicine and dentistry. I file both medical and dental insurance claims. I am a Medicare provider and I am a Medicaid provider. I have submitted written testimony and other information, so I will keep my remarks brief to allow as much time as possible for questions. Although I am a proud member of the Georgia Dental Association, I come before you today not representing any organization but as a small businessman with a business issue. There are a couple of points I would like to emphasize. As a congressional committee with expertise on small business, it is certainly no surprise to you that as a small business it is vital that I be paid promptly for my services. Secondly, I believe action on this issue is a reasonable responsibility of the Federal Government because of the interstate commerce issues involved. Although I practice in Georgia, I file claims with insurance companies across the United States. A reasonable time frame for payment should be a consistent and national standard. ERISA plans are exempt from prompt payment laws, so Federal legislation would be necessary to fully establish the national standard. Thirdly, will it work? Is it doable? Currently under Georgia Dental Medicaid with the ACS and Avesis insurance companies, I can examine a patient on Tuesday, do their surgery on Thursday, and have the money directly deposited in my account on Monday. If some of the Georgia Medicaid insurance companies can do this, any third party payor can if they are so motivated. Yet I have submitted to you documentation of a recent far too common case of services which I provided in March that still has not been paid in August, along with a lot of the phone calls and documentation provided to the company. This demonstrates the unreasonable time and unnecessary expense to my office spent resolving many claims. Again, I thank you for this opportunity. I look forward to answering your questions. [The prepared statement of Dr. Austin may be found in the Appendix on page 65.] Mr. Westmoreland. Thank you, Dr. Austin. Now it is my pleasure to introduce Dr. Frank Kelly, who serves as Chair of the Communications Cabinet of the American Academy of Orthopedic Surgeons. Dr. Kelly also practices at the Forsyth Street Orthopedic Surgery and Rehabilitation Center in Macon, Georgia. A notable member of Georgia's medical community, Dr. Kelly has practiced in Macon for over 25 years. And he is a Phi Beta Kappa graduate of the University of North Carolina at Chapel Hill before completing his medical training at the Medical College of Georgia and his orthopedic residency at the University of Tennessee Campbell Clinic. Dr. Kelly is the past President of the Georgia Orthopedic Society and is currently serving as a member of the Board of Directors of the American Academy of Orthopedic Surgeons, representing over 24,000 orthopedic specialists worldwide. I want to thank Dr. Kelly for his willingness to come share his thoughts, and I look forward to hearing his testimony. Dr. Kelly, welcome. STATEMENT OF DR. FRANK B. KELLY, M.D., BOARD CERTIFIED ORTHOPAEDIC SURGEON, CHAIR, COMMUNICATIONS CABINET, AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS, MACON, GEORGIA Dr. Kelly. Thank you very much, Lynn. When I get back home, I don't know whether to tell my friends I went fifth or last. But perhaps fifth sounds better. Good morning once again, Chairman Gonzalez. And good morning again, Ranking Member Westmoreland. And good morning to other distinguished members of this subcommittee. As Lynn mentioned, my name is Frank Kelly. I am a practicing orthopedic surgeon in my hometown of Macon, Georgia. I also have the pleasure of serving as a member of the Board of Directors of the American Association of Orthopedic Surgeons. And I served as a Chair of our organization's Communications Cabinet. On behalf of my organization and behalf of my colleagues across the country, I sincerely thank you for asking me to testify this morning on this very significant issue of prompt payment for health care services. As a practicing physician and as administrator of a seven- person practice, I am deeply concerned that the Federal Government has simply not done enough to ensure that physicians in practices like mine are paid promptly by insurers. Having now been in practice for almost 30 years, I have witnessed firsthand how this delay in reimbursement has not only made it more difficult for us to run our practices, but it has already had the very real potential of adversely affecting the quality of care we deliver to our patients. Though we have tried to cooperate with insurance companies, unfortunately the vast majority of so-called clean claims, those claims submitted in accordance with the insurer's own guidelines, are not reimbursed in a timely manner. In fact, as has been mentioned several times this morning, these claims can average 3 to 6 months before payment and they can constitute a very major burden for those of us who depend upon this income for the day-to-day operation of our practices. In response to concerns from physicians nationwide in an attempt also to address this significant problem, as has been mentioned already, almost all States have enacted prompt payment laws mandating that third-party payors reimburse claims in a reasonable time period. My home State of Georgia, as has been mentioned this morning, is fortunate to have one of the most comprehensive and effective laws governing prompt payment for medical services. Under our State law, insurers must process payment within 15 working days after receiving these clean claims, otherwise pay a penalty of up to 18 percent of the benefit due. Our insurance commissioner, John Oxendine, has been unyielding in his enforcement of this law and in his commitment to our State's physicians, ensuring that big insurance companies don't take advantage of our small medical practices. Unfortunately, Commissioner Oxendine's reach extends only so far under the current Federal law. Approximately half of my patients and over 100 million patients across our country are covered by self-funded insurance plans which fall under ERISA, the Federal Employee Retirement Income Security Act. And according to the Supreme Court's decision in a 2004 case, these ERISA plans are exempt from State prompt payment regulations. As a result, thousands upon thousands of claims are slipping through the cracks in this system. While insurance companies may argue that the administrative burden of processing claims prohibits timely payment, I find this to be a hollow and very ineffective argument. Even Medicare, the Nation's largest health plan, adheres to a higher standard than do these ERISA plans. In fact, the Social Security Act requires that accurate Medicare claims be processed in 30 days or be subject to a significant interest penalty. Prior to the enactment of our State's prompt pay law, practices like mine relied heavily on Medicare for our monthly cash flow to meet the expenses of running our practices. Many of my colleagues and States with less aggressive prompt pay statutes still struggle with late payments from private insurance companies. They still depend upon Medicare reimbursements to cover their expenses. Though much work still needs to be done, I have seen the very positive impact of Georgia's prompt payment regulations on our State's health care system and on the many hard working physicians and small businesses within it. I am confident this problem of delayed reimbursements can be overcome throughout our country. This will require accommodation of at least three things. Number one, effective, extensive prompt payment legislation. Secondly, the accurate determination of what really constitutes a clean claim. And thirdly, and perhaps most importantly, appropriate enforcement mechanisms to ensure that insurance companies are adhering to these regulations. Our association supports prompt payment within a 30-day timeframe. Such timely reimbursement will allow us to spend more time doing what we were trained to do, and that is taking care of our patients. On behalf of my orthopedic colleagues, on behalf our association, I thank you very much for your time and for your interest and for the opportunity to express to you my concerns about this most important matter. Thank you very much. [The prepared statement of Dr. Kelly may be found in the Appendix on page 67.] Chairman Gonzalez. Thank you, Dr. Kelly. We have been advised we have got two procedural votes and I think we have the 10-minute bell. Around the 5-minute bell we will head out back to the floor, vote. Two procedural votes, that could mean anything. Congressman Westmoreland could probably give me some insight as to what the Republicans have in store for us. I don't think he will. As soon as we are through, we will come back. I will ask one question and get it started. Then we will probably have to excuse ourselves. Please stick around. Staff will tell you more or less the time frame once we get down there and start voting. But there are two votes and conceivably that could be 20 minutes or 30 minutes. But Dr. Wilson, there are certain things that kind of resonate. First of all, it appears everybody is in agreement that there is a role for the Federal Government and yet still leave room for State mechanisms to take effect, which I think is always the best thing we can do. But one thing that struck me in reading the testimony from all of you, but especially Dr. Wilson and I believe Dr. Kelly and some others, this thing about uniformity. It is surprising to me that at this point in time that there isn't some sort of uniformity on what a clean claim looks like, the minimum amount of information that has to be reflected on there that would be sufficient, though, for the insurer to go ahead and act on it, because it appears that there is a game that goes on obviously. And I think I will get to Dr. Henkes and he can explain what happened in his particular episode in San Antonio. But have there--obviously there have been efforts to try to come together on what some sort of uniform information would be required? Dr. Wilson. Yes. Thank you, Mr. Chair. And certainly there have been and certainly the AMA has been involved in a lot of those efforts, in getting uniformity in terms of the claim form as well as the requirements for a clean claim. The challenge, of course, is that each of the insurance companies is an independent business. They sometimes would claim that there is some antitrust provisions that would prevent them from cooperating in some ways. I don't think we buy that argument. But the reality is they have not been able to come up with something they all agree with that would mean a clean claim. The other thing that physicians face is what is called black box edits, and that is for any one insurance company they won't tell the physician what their requirements are. So you might have 10 companies you deal with and at a minimum if they would just let you know, what are the 10 things that ought to go into a clean claim, that would help the physician. Frequently those are considered proprietary and not available and not provided. So the physician finds out what is missing from a claim when he gets the claim back and says, well, you missed this. And unfortunately, sometimes you will correct that and then you get the claim back again and say by the way, here is something else we want you to correct as well. And each of those, of course, retolls the hours in terms of prompt pay which make that a challenge. The point is well made. We need some uniformity there. And there are times when the Federal Government can provide that uniformity and this is one of those. Chairman Gonzalez. Sir, we always hear here in Congress that many times whatever Medicare--what the United States Government through Medicare establishes, what would be a reimbursement rate for any procedure, a protocol and so on that generally insurers will then adopt that particular baseline reimbursement rate. Is that accurate? Dr. Wilson. The reality is more and more of the insurance companies are pegging their rates. They won't necessarily make that the same rate. But if as is anticipated--and we would hope Congress is going to block that. If we come January 1 and are faced with a 10 percent cut in Medicare payments, you can be sure that insurance companies will look at that and adjust their rates. Now, they won't all come down to Medicare levels, but they will use that as a model which then will obviously impact everyone adversely. Chairman Gonzalez. The reason I ask that, it seems that they are pretty willing to go ahead and adopt that which the Federal Government may establish if it works to their advantage but not necessarily other practices by the Federal Government when it comes to, say, Medicare. So I think we can maybe give them a little bit of guidance. At this time, the committee will stand in recess and we will reconvene as soon as that second vote or the last vote. Thank you for your patience and see you in a few minutes. [Recess.] Chairman Gonzalez. The subcommittee will reconvene at this time. I will yield to the ranking member for any questions he might have since I had the privilege of getting a few minutes in earlier. Mr. Westmoreland. Thank you, Mr. Chairman . And I want to thank all of you for coming. And I know a lot of people don't look at it as being--in the medical profession as being a small businessman. But coming from a small business background and knowing some of you personally, I know that it is a small business and that cash flow is critically important. And I am going to ask Dr. Austin this. Does a delay in provider reimbursement threaten to Dr. ve some of the small providers out of business? And if that happened because of this pay issue, what would the effect be on both the provider and the patients? Dr. Austin. Thanks for the question. I just wanted to say to the Chairman I really appreciated his comment about the Medicare rules. I believe you get it, that the insurance companies use what is to their advantage and this card was not to their advantage. It is really pretty simple in terms of running a business. The more hassles you have in a business, the more difficult it is to make a profit, the lower incentive there is to go into the business. So if the bottom-line continues to deteriorate, it is harder and harder to attract the best and the brightest to the professions. It is particularly problematic for small specialties like my own. The orthodontist as previously--the issue of being an orthodontist. When I was on the Medicare Carrier Advisory Committee, I was talking to the medical director about some issues that we had. And he said, you know, Gordon, we get 6,000 complaints from the cardiologists and we get six complaints from the oral surgeons and we just don't have time to get to your issues. And so that is really what happens to the small practitioners, is that we get pushed to the back of the line. And because we are small, it affects us more. If I do four surgeries in a day and one of those claims doesn't get paid, that is 25 percent of my income that doesn't happen. If you were in a large group, that is a smaller percentage and more easily absorbed. So it affects the smallest businesses, the smallest practitioners the most. Mr. Westmoreland. Just one follow-up if I could. And this would be to anybody because you may all have different circumstances. But what are some of the excuses or practices or dilatory things that these insurance companies do to prevent you from being paid promptly. Dr. Austin. It is pretty easy in my case. I do the same type of procedures over and over and over again and we face the same issues. A large part of my practice would be taking out wisdom teeth on a young person. We know that they are going to ask for an X-ray. We know that if we take out a little cyst, they will ask for a path report. And we know if they are a student, they will ask for proof of student status. We routinely send these in with the claim and yet we routinely get the claim back saying send us an X-ray. We call them and say you have the X-ray. They say, oh, yes, we do have the X-ray. They say send us the student status. We sent you a student status. Oh, well, maybe we didn't get it. So they know what stops the clock, and that is really what the issue is. The States have put a clock on them to pay the claim and they know if they can say it is not a clean claim, they are missing something, it stops the clock. So even when we send it, stamp on the claim that we sent it, they still when we call them or get the letter back, they ask for something we have already sent them. Dr. Kelly. If I might, I would like to echo Gordon's comments because I found the same situation in my orthopedic practice. One of the things I do, as you might imagine very commonly, is a knee injection. It is a very simple technique. It takes just a few moments. The same situation. We will submit the claim, they will send a letter back that always says--they send it back and they say we notified your patient 17 days ago. They always say 17 days ago that we received this bill and we need to have from you the patient's history and physical, any pertinent lab tests, pertinent X-rays, progress notes, anything to game the system. I think the Chair had it right earlier. I think it is almost like a game they are playing just to delay payment. So we have the same situation with knee injections in our procedures that Gordon does in his practice and it has just escalated. Dr. Merrill. Probably the most common thing with braces is when there is two insurance policies that cover--the average fee for braces is well in excess of what the lifetime maximum is. And secondary insurers will delay payment by saying, well, we are not going to issue our estimate of what we are going to pay until after the payment is received from the first insurer so we know what they'll pay and then we'll tell you what we are going to pay, even though both are going to pay that full amount. It is just a matter of being able to delay it an additional 3 to 4 months, which provides uncertainty to the patient. The patient is, like, do I have this or do I not, am I going to have to find another $1,000 or $1,500 to pay towards this or will my insurance pay for it? And my office staff have to explain that to the patients and they don't understand how the insurance companies work. And so it is very disconcerting to the patients when that happens, as well as being a problem for cash flow as you have alluded to. Dr. Wilson. One of the things that has happened along with the prompt pay laws in States is insurance companies now have a new category, which is called pending review. And so you get the report back--and I mentioned this in my written testimony-- that pending review doesn't tell you what it is they are looking at. It is like a concurrent audit and then that postpones the prompt payment and then ultimately they will say what it is that they want. Mr. Westmoreland. And just a little follow-up to that. Like Dr. Gordon and Dr. Austin and I am sure Dr. Merrill, you do the same thing over and over. So you know what they are going to ask for. Is there any type of checklist or something that you send in with a claim or is there requirements that they have given you that you routinely know? I mean, I understand how they are doing it, but I mean, it is really inexcusable if you do these things over and over and over and know what they are going to ask. Would one patient be different from another? Dr. Kelly. I will start that, Lynn. I think the incredible thing about this is we use the insurer's own guidelines. They ask us what to submit. We use their own guidelines for our claims. And even though we have followed their guidelines to the letter, they still come back requesting other information. I would request that sometime when you are in the Macon area, please stop by my office for 30 or 45 minutes. You will be just absolutely amazed at the type of requests that we get from the insurance companies. So they have guidelines, we go by them. It doesn't seem to matter. Dr. Austin. The claim itself--we have codes and the codes very clearly define as to what the procedure is that we are doing. So in theory, when we have submitted that claim with the code, we have told them exactly what we are doing, how we are doing it. And as I said, with Medicaid I can send it in on Thursday and have the money in the bank on Monday. It is not a matter that they can't do it. It is purely a matter of in their minds it is a business advantage to not pay in a timely manner. And they are much better at it than I am. And that is kind of where the issue comes in. The best people that are gaming the system are the insurance companies. The next people are the people that do regulations, Medicare, that set guidelines. But the person that is least able to really keep up with the changes is the small practitioner. So we are always a little behind the curve. The insurance company is always a little bit ahead of the curve and the regulations are somewhere in the middle. Dr. Henkes. Congressmen, as well, you have to realize too if you have four or five major players in one area, you are also playing with four or five different sets of rules. And that is why I believe that the more uniformity in the sets of rules would be better. Each one may have their own sets of rules, as Dr. Wilson had mentioned. Some of these are black box edits. They won't even tell you what the rules are. Dr. Wilson. I guess the other observation about, well, can they do it if they want to--well, someone said how does it happen with Medicare. And clearly there are rules for Medicare. And while if you look at prompt payment for Medicare across the board, it is about somewhere in the middle. However, for example, in my own personal example, which is solo medicine-- and I file electronically and I can tell you that the Medicare carrier meets the requirements, the 14-day requirement for a turnaround on electronic billing. And it seems to me that--and obviously those are the major health insurers who are contracted with Medicare. And that to me speaks to the issue that if the incentives are appropriate, if the cloud is there, in this case the Federal Government, then they will be able to meet some standards that are put in place. Chairman Gonzalez. The Chair is going to go and recognize Jason Altmire. And again, Congressman Altmire, thank you for joining us. Mr. Altmire. Thank you, Mr. Chairman and Mr. Ranking Member. I would just say very briefly it looks like we will have some disruption here to this hearing but that should not indicate that this committee doesn't understand the significance of health care as an issue to small businesses. And I just wanted to thank each and every one of you while we had you here together for your appearance here today and let you know we want to continue working with you as we move forward on this issue. There is no issue like this across the business world where small businesses are affected by health care every single day, every business in the country. And I really appreciate the fact, we appreciate the fact that you took the time out of your day to come help us with this hearing and walk us through your issues. And we look forward to continuing that discussion and just to apologize again for the disruptions that apparently we are going to be facing throughout the hearing. Thanks. Chairman Gonzalez. Thank you very much. Let me direct a question to Dr. Henkes. You pointed out an interesting case that you had with UnitedHealth and it is not for us to paint with a real broad brush. But nevertheless, the concern that we have, Republicans, Democrats, it doesn't matter, is that we have a business model that has been institutionalized by the insurance industry. The insurance industry is a very essential component to the way we do business in this country and we need a healthy insurance industry. But nevertheless, our fear now is that they have basically built into their business model a manner in which to delay payment for what very well could be obviously the business considerations of holding on to that money, the investments and so on that it brings. So, Dr. Henkes, you have pointed out the experience with UnitedHealth and how you had to go and address that obviously. The other thing that you pointed out in your written testimony was the concern--and some of the other witnesses also pointed out and I wanted to touch on this quickly--and that is some Federal clarification legislatively on the application of ERISA and how that plays a part in maybe complicating what can be done with insurers and the question of prompt payment. What is the position on ERISA and how do you see it? Dr. Henkes. Well, I don't think that the picture is entirely clear. From my understanding on this, there has been some discussions with the Department of Trade and that they have seen some ambiguity into whether this really has any kind of--they have jurisdiction over the prompt pay on this. We know at the Texas Department of Insurance there has been ambiguity by the researchers there as to whether the current laws apply, being State laws on to--for ERISA plans. I actually am on an advisory committee for an insurance company in Texas and they have taken the position that they do not. Of course I don't think this one has been actually totally played out. I think there may have been one court case in another State that may have given some credibility that maybe payment issues are not necessarily preempted by ERISA. But there still is a lot of ambiguity. So I guess at this point, I think the State agencies, as well as the Federal, are in ambiguity in how this affects on the ERISA plans. And I think that is why it is so critical to have you and this committee look at that to give that clarity and give that clarity that if it requires passing another law or if the compliance--that this is a part of State law. Chairman Gonzalez. I will advise you all--and I would need to do more research on this. I didn't have time to do it and check the status. H.R. 979 is the Bipartisan Consensus Managed Care Improvement Act of 2007, and it would amend ERISA. Among some of the provisions would be to impose prompt payment requirements on all employer-sponsored health plans. The act requires such plans to pay all clean claims consistent with existing requirements under the Medicare program. So obviously there are other committees that share jurisdiction. Much to our credit, the chairwoman of this committee, Chairwoman Velazquez, was able to expand the jurisdiction of this committee to share some of the jurisdiction with other committees. So we still have to work in unison. So it is obviously being addressed. We just need to see where we can try to coordinate this. Dr. Kelly, I think you were pointing out again, if we can come up with the proper role for the Federal Government and, of course, Dr. Wilson was also very specific as to what extent we could do that. Dr. Austin also touched on that and I think that is going to be our focus. What can we do to come in with a Federal standard? Again, that is establishing basically the floor, working with the States, which would be really more of the enforcement mechanism, and of course if they have higher standards, not to interfere and meddle with that. At least that is my perspective, and I think Congressman Westmoreland may have a different take on it. Also, I think we need to start looking at uniformity out there so that we don't have companies that basically say we don't have the information, you add on to it. If they choose to do that, there should be an additional burden placed on them with some consequences. And that is the only way you ever get accountability, is where there is consequences, which I don't think we have that at the present time. So there is much to be worked on. By the same token, I also wish to address many of the other items that you may have brought up in your written testimony addressing other trouble spots, not just the prompt payment. But I think that right now for the purpose of this hearing--and we will share the other recommendations and observations you made as to other, what I would say, difficult areas in practicing medicine. I also want to make another observation, and that is simply that this is the Small Business Committee. Most physician practices are small businesses, as has been pointed out. We recognize that you all are in a very unique position as physicians. You have to conduct yourselves as a business so you can open your doors in the morning and make sure that they are open every day. And that is a business. Nevertheless, I still consider you the last standing profession in the United States of America, and somehow you have to maintain that even in a business environment, and we are here to help you do that. We have another vote. We are going to be leaving in a few minutes, and I don't know how long it is going to take. So what we are going to be doing is basically adjourning and letting you all catch your flights and such. And I know some of you said you wanted to take some pictures. So I want to give them that opportunity. So at this time, I would yield to the ranking member for any comments he may have or any follow-up questions. Mr. Westmoreland. Thank you, Mr. Chairman . Mr. Westmoreland. Let me just thank you for having this hearing because I think this is a very important issue. I do agree the Federal Government does need to have a part in it. One quick question. How many private insurers handle Medicare in your States, do you know a number? Dr. Wilson. For Florida, it is just one. Mr. Westmoreland. For Florida it is only 1. Mr. Wilson. It is Blue Cross/Blue Shield. Dr. Henkes. In Texas we have the standard program, a Medicare program, but there are some replacement programs, HMO replacement programs. Mr. Westmoreland. Medicare Advantage type thing? Dr. Henkes. There are probably 5 or 6 of those, maybe 6 or 7. Mr. Westmoreland. In Florida it says there are 289 different plans for the Medicare Advantage; is that true? Dr. Wilson. The answer is I do not know that, and I responded to the wrong question. When you said Medicare, I tend to think of the Medicare carrier and not the Medicare Advantage plans, but there are a lot of them. Mr. Westmoreland. Okay. Dr. Henkes. We can get that information for Texas. Mr. Westmoreland. I was wondering, I know the Medicare Advantage is a little bit different program than Medicare itself, with a little different payment. I was noticing we happened to be talking about the Medicare Advantage program and I was just looking at the different providers, 289 of them in Florida. Do they all have to agree to the prompt pay or to the payment that Medicare prescribed to be able to offer that? Dr. Wilson. One would assume. Mr. Westmoreland. I would assume that, too. Thank you, Mr. Chairman , for having this, and again we are going through some procedural stuff right now, a little disagreement, but I thank all of you for coming. Chairman Gonzalez. I will tell you this right now; that we are conducting ourselves like insurers on prompt payment. Well, I think we're still going to make this vote, but I would like the opportunity to go out there and thank you personally. And Lynn, if you have a chance to also join me. I will do something a little different and instruct staff to get together. I want them to summarize some of the testimony regarding identifying everything that everyone agreed on, and what would be the remedy in order for us to share that with other members of this subcommittee as well as the full committee. And I ask unanimous consent at this time, the members have 5 days to enter statements into the record. And this hearing is now adjourned. [Whereupon, at 12:00 p.m. The subcommittee was adjourned.] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]