Thank you. Well, that bio must have been taken off the Internet because it focuses on some of the other work that I do, but I will talk about different things in today's session, not necessarily government contracting, but some things that cross over with it. So thank you for taking the time today to be in the session. We're going to talk a little bit about government affairs in general, kind of give you a temperature in the room on Capitol Hill of what's going on, and also how AAOE is advocating for you and your practice or your organization. So we'll talk about the temperature, what's going on, what the major issue areas are right now, and how AAOE is addressing them and engaging with lawmakers on Capitol Hill on your behalf. So with that being said, we'll go ahead and start. Just so you all are aware, I'm Lindsay Atherton. I work at a firm called Lobby It, and we are AAOE's contracted lobbyists on Capitol Hill. It's myself and my colleague, Jake, who is not here today. We work together to make sure that AAOE has access to lawmakers and their staff, as well as, if needed, administration officials, people like that, folks within the agency, you name it. We can kind of get access to folks and allow you to share problems that you may be experiencing, communicate potential solutions, and really just engage with folks at the federal level. So that's a little bit about Lobby It. We're a bit of an interesting firm when it comes to lobbying firms. We're definitely not what you see when it comes to a traditional firm. We operate kind of on a larger level with more clients, but we also represent a lot of the associations. So that's great for AAOE because we have a lot of experience in similar types of associations, where you have members that maybe have other full-time jobs or are doing other work outside of what they're doing for the association that they're either a member of or on the board of. So Lobby It is a bit unique in that sense, but we represent AAOE at the federal level, and we've been working together for a couple months now. It's been really great. Some of the folks in this room are part of the Advocacy Council, which I will touch on a little bit later in this presentation. But it's been great kind of getting AAOE's voice out there, and that's our primary goal. Number one above everything else is having folks on Capitol Hill hear directly from you as a manager, as folks that work in orthopedics. All righty. So just to set the stage, I'll talk to you a little bit about the 118th Congress that we've just entered, what it means, just so that you guys can have an understanding as I talk about some of the issues, what's kind of going on. So in the top left, you see split Congress. Obviously, the Republicans are in control of the House. Democrats are in control of the Senate. That is obviously different than what we've seen over the past two years. It means a couple things, right? So a split Congress means that there's not a ton that is going to get done this year when it comes to bipartisan legislation. There will be key pieces, and some of those will affect you and your practices. And we figure out what those key issues are as we engage with offices on Capitol Hill. But a split Congress basically means that standalone bills are much harder to pass. And the only things that really get through in a split Congress are bipartisan issues. So you may see things, you may see headlines about bills that pass out of the House or pass out of the Senate. That doesn't necessarily mean that they're going to pass or get the president's signature. When you're working with two partisan houses, they generally have an idea of what's going to be passed in the other house and what's not. What we're learning now, though, is the appetite with the new speaker under McCarthy, what his willingness is to bring things to the floor. Just as a little bit of historical background, Speaker Pelosi was a little bit different from what you see with him, in that when she brought something to the floor, she knew it would pass. He's a little different, at least from what we can see so far, in terms of having an understanding of what his appetite for bringing things to the floor is. So as you start to see the House pass more bills, we will have an understanding of the likelihood of a bill that has been introduced that it will get to the House floor and ultimately out of the House. So I said, like I said, standalone bills are harder to come by and harder to pass in a split Congress. What that means, though, for individual bills is not that they're not going to pass, but they are going to be wrapped into other pieces of larger legislation. So for the hundred and eighteenth Congress, there must pass pieces of legislation that exists. Those pieces of legislation are the farm bill, which is an every five year bill that's passed in Congress. There may be pieces in that bill that are related to rural health care and telehealth. So be expecting that potentially they basically create the farm bill to be a rural bill piece of legislation. So there may be things wrapped into that. There's also the FAA reauthorization, which happens. You have the omnibus appropriations package as well. So those are three of the main packages that will pass. And what happens at the very end of those negotiating processes is additional bills. They're called rider bills are tacked on to the end. And obviously everything's negotiated. But all that is to say is that in a split Congress, it is harder to pass individual pieces of legislation completely through. And they'll almost always be attached to one of the must pass pieces of legislation. There's also, like I said, new house leadership. So as we understand his appetite for bringing things to the floor, we'll have a better understanding of if a bill is introduced, what the likelihood that it is that it passes. The third one in the bottom left is an earmark makeover. Republicans have taken a really interesting approach to earmarks this year in the House. They have restricted two main accounts for earmarks. And just so everyone knows, an earmark is something that is directed from Congress specifically to a project in a state or local government. And it can also include funding to nonprofits. So the eligible entities for earmarks are state and local governments and nonprofits. The two accounts that Republicans restricted this year are health care and defense. So earmarks are not allowed currently in the House if it's related to health care or if it's related to defense. They're really trying to take a localized approach to earmarks this year, meaning that they really want to fund local projects only. So they've really restricted what, you know, nonprofits are eligible for in this process. The Senate is proceeding as normal with their earmark process. The one thing that I would also say with that is it's probably going to get negotiated out anyway. So even though the Senate is allowing it now, when they negotiate back with the House, it'll probably be pulled out. All those health and defense earmarks will probably be pulled out anyway. What that means, though, is that when it comes to specifically directed projects, they are very hard to come by when it comes to health care this year. That has caused problems with Republicans as well. So I don't know that that will be the case in the next Congress. But it's certainly something to look at when you look at the funding of specific projects, because it is much more difficult in an environment like this where they have restricted the earmark process to exclude health care this year. Last thing I'd say is this renewed focus on budget neutrality. Budget neutrality basically means that they want to match the budget from the year before. Republicans do. They don't want to see increased top line numbers. They don't want to see higher budgets. We'll talk a little bit about what that means for you and your practices. But ultimately, it's challenging for a number of reasons. It's challenging, really, ultimately, because some of the things that are priorities for organizations like yours have a high price tag. And we'll talk about what they are. But anything with a high price tag is going to be hard to pass. And we'll ultimately need to be met with an equal or higher offset. An offset is something that obviously you're taking out of the budget in order to include your own. But with Republicans, their number one priority right now, especially coming off of the last couple of years, is fiscal responsibility. So anything that has to do with spending money, they're not going to want to entertain unless there's a unique solution to it. So keep that in mind. We'll talk about some of the unique issues that we are addressing for you on Capitol Hill. And then we can ultimately talk a little bit about what those budget cuts are going to mean for you all. So here are four of the main issues that we talk with staffers about. I'll tell you a little bit about the Advocacy Council and kind of how we operate. We work together with the Advocacy Council to have meetings with staff of members and members. We talk about different issues. Now, these issues can rotate between what you see on the screen and something else that happens. So, for example, if a bill comes up that is really impactful, we'll certainly focus or highlight it. But these are four of the main issues that we're talking about this year on Capitol Hill. Long term solution to the physician fee schedule, prior authorization, health care staffing and access to rural and telehealth. Excuse me. Two of these. Well, two or three of these really are kind of budgetary red flags next to them. And by red flags, I don't mean bad. I just mean that these are going to be issues with congressional offices that they, especially in Republican offices, that they have challenges finding a solution to. I'll say this kind of in closing. The solution is there. The solution is just expensive. So that is a long term solution to the physician fee schedule. And then health care staffing obviously is going to take a significant investment from the federal government. So those two are ones that are particularly challenging. The Biden administration, though, in all of their requests for budgets is always including health care staffing in their request. But these are the four main issues that we are focusing on. It's open to shift and change as policies change, that sort of thing. But this is a good idea of kind of what we do. So the Advocacy Council is part of a that works together to deliver these engagements with members on the Hill. So basically how we operate is we determine what the applicable issues are. So let's say in the hundred and seventeen Congress, we got some issues addressed. We no longer need to put them on this list. Then we can determine what applicable issues, which is kind of what we're doing now. Right. Is determining what is applicable for the hundred and eighteen. We also determine what is position is on those issues. So if there's a bill that's been introduced or there's something else that has come up, we determine how is going to respond to that issue as an organization. We also engage with lawmakers and their staff. So we work directly with the lawmaker themselves and their staff on issues. And we have one on one meetings with them to kind of engage and tell your side of the story. We also you also work with lobby to coordinate all that legislative activity with us. Why advocacy is important. This is, I think, the really important part for you all to have an understanding of what the Advocacy Council is doing. Not only because you're having your voices heard, but you're also ultimately highlighting an issue and sharing a really unique perspective that a lot of time is not heard in Capitol Hill. I'll tell you, I was on the Hill yesterday or Thursday, and there was a lot of people in white coats. But a lot of those people in white coats probably have very different experiences than you do. So having an organization that represents exactly what you all do is really important. So, orthopedic executives have a unique experience to share on Capitol Hill. There's obviously a breadth of experiences that you all have from the role that you play in your organization to your clinical experience, et cetera. But your experience is valuable and one that we often hear new and unique to staffers. These are also unknown a lot of times to staffers. So when we have these meetings, they may not exactly understand what it looks like when you have an issue with prior authorization or when you have an issue with an insurer or you have an issue getting the medication that you have requested for your patient. So your in-person experiences are really a lot of times unknown. And our ultimate goal is to go to Hill staff, tell them your story and ultimately have them understand your problem so that when they find a solution, they've either one heard from you on what that solution might be, or they at least have a good enough understanding to realize, okay, here's maybe how we would fix this issue in the future. The third piece here is as an advocate, you're better informed of what issues may come up. The reason this is important is as we have these meetings, it's not really just us dumping our issues on staffers on Capitol Hill. It's really kind of a combined experience, meaning that a lot of times we're either gathering intelligence or we're hearing from offices about the priorities that they have. So we're hearing from an office what they may introduce, right? So they'll say, oh, we have a bill that we're dropping next week on this different measure. So you get a good idea of what may be coming from an individual bill perspective, but really generally you also can kind of get an idea of, oh, HHS is gonna drop this proposed rule tomorrow. You should know about it. So having that intelligence gathering aspect of our engagements is really important. And it's something that we really try to be front and center. One of the main things that I see with clients is they go to Capitol Hill and they talk a little bit about their experiences, but they don't listen to what staff have to say and they don't do any intelligence gathering. They almost always, if our meeting ends at 1.30, they're closing their mouths at 1.29. We really try to make sure that we're hearing from staffers to gather intelligence, hear from them on what issues may be coming up. The other point that I think is really important here is that there are other groups that have the opposite opinion of you, right? When you look at the most influential groups in Washington, they're oftentimes insurers or different types of systems that may have opposing viewpoints to you on your issues. And so making sure that your voice is heard as a part of the larger ecosystem is really, really important. Only because, like I said, there are folks that are talking about the same issues as you, but they're on the opposite side of things. And so having your voice be heard is really important. The last thing I would say is these meetings that we have as the Advocacy Council, you're highlighting the issue itself, right? You're saying we have these issues with prior authorization. Here are the problems that we have with it. Here's why it's really challenging for us as a practice. But you're also playing a really important role in determining what the solution for that is. So when you go to a Hill staff and they say, well, we've been hearing from physicians for the past year about the physician fee schedule. Do you guys have any ideas on how we could fix the issue? So you're playing a role, not only in highlighting the issue to the staff, but ultimately helping find a solution. So that's why advocacy is important. And that's kind of the role that AAOE's Advocacy Council plays in that process. So we'll talk a little bit about the budget next. Before we get started, does anyone have any questions on kind of the environment in Capitol Hill that I could help answer before we get into some of the more specific parts of this? Yeah, so this is part of it. So I think on the next slide, we'll talk a little bit about the budget for healthcare staffing. A lot of this is probably going to be challenging in this environment because as COVID has ended, you see a migration from the idea that there's a healthcare shortage. The reality is far from that, right? But as folks move away from COVID, that kind of goes to the back of their mind. Biden's healthcare budget, like I will talk a little bit about, which is largely just messaging at this point, but it includes lots of funding in here for healthcare staffing. So we'll talk a little bit about that next. But you can see there's $28 million to support innovative approaches to recruit and retrain new providers. And then it also has dual enrollment learning programs. The last thing I would say, they're doing a lot in training, especially when it comes to allied health professionals as well, making sure that folks have access to apprenticeship programs and training programs. So a lot when it comes to healthcare staffing is related specifically to the funding and delivery of new healthcare staff. Hopefully that's a helpful answer for you, but they're trying to fund as much of that as they can to expand access to new talent and to make sure that folks are hopefully going back into the field if they have left and making that a friendly environment to do so. So I'll talk a little bit. Anyone else have any questions? Go ahead. The residency program is a major issue on Capitol Hill. I know it's federal funding that determines those spots. Again, that just is gonna come down to the price negotiations this year on what they can get that price tag to. A lot of it has been less so on the expansion of the program of the spots available. It has been on the salary piece of that and the amount of money that residents can make. But we'll just see kind of how that plays out. There have been bills for a long time about the expansion of, at least from a financial aspect, that piece. But also there have been bills associated with the expansion of the program. It's just, it comes in with a high price tag. Alrighty, so I'll talk a little bit about the budget for this next year. Just as a little bit of background, for a presidential budget request, the administration basically makes a request to Congress every year in around January. What that means is they basically say to Congress, here's what we want as an administration. Before that budget even comes out, the agencies themselves have negotiated what they'd like to see in their own budgets. So you see HHS, they take an entire year to negotiate what they're gonna present to the president for the next year. The president then will cut up that budget, make his own decisions, and then present it to Congress. What happens is that bill then enters the congressional process. So that kind of voids everything that's already been done. And it goes through the House Senate and then ultimately is finally signed. So when I say Biden healthcare budget, this is what came out of the proposal that Biden put together for FY24. It is dropped in February, and then it is usually signed on December 24th, right before folks go home for Christmas, because they cannot seem to do it on time in a year. The last two years, maybe even three, have been very delayed as a result of COVID. The negotiations for COVID funding took a very long time and they pushed the budget cycle back about four months. When that happens, it actually pushes the future year budgets, again, another four months. So last year, we did get it relatively on time. This year, we're relatively on time. I would say the biggest threat to the budget this year, there are two things. One is the debt ceiling, which is supposed to be negotiated around the same time that the budget is negotiated. And budget is going to be second on the list for Congress. The second thing I would say is the negotiating between the houses. So you're gonna see, in the past years, you can see the House do their own budget, and then you'll also see the Senate do their own budget. And then they'll take those two and they'll conference them and remediate any issues. In the past couple of years, you have seen a different environment, which is where the House will do their budget and the Senate will just mark it up rather than creating their own. And that's only due to time constraints. So when the Senate is under time constraints, they won't build their own budgets. So all this is to say that Congress has not marked up this budget at all. This is just what Biden wants. It is gonna look very different, very, very different when it comes out. You can expect these numbers to not exist at all if they have a dollar sign next to them or be cut in half. So we're just giving you an idea of what the Biden administration would like to see in FY24. So you see, and also the last thing I would add is the budget request is not necessarily always funding related. There are some policy proposals included in the measure oftentimes. 80 to 90% of the policy related decisions that are attached to a budget resolution are added at the end, but there are a few. So you'll see, he wants to see negotiation of drug prices with manufacturers. He also wants to see $2 a month for prescription for generic drugs covered under Medicare Part D that treat chronic conditions like hypertension and cholesterol, excuse me. It also would require 12 months postpartum Medicaid coverage and a Medicaid-like insurance option for low-income adults. And it's also allocating $150 billion over 10 years to fund Medicaid homes. Like I said, this is just a messaging document. It will not look like this when it is passed, but it's good to get an idea of where the administration is at so that you can kind of see where those priorities lie. Last thing I would say is that they know that these numbers are gonna get cut in half so they often go with like astronomical numbers just to say, well, if the Republicans cut it in half then we're still in a good position. So keep that in mind. The last three here are on the issue that we talked about a little bit earlier. There's $32 million for nursing workforce, 28 million for innovative approaches to recruit and retain new providers and 200 million in expansion of dual enrollment work-based learning programs. The dual-based work-based learning programs are huge with the Biden administration. You're definitely seeing a shift to more training programs. I think these top ones though are going to be an area of bipartisanship in terms of the healthcare workforce. So we'll just kind of see how that plays out. The last two things are rural hospital assistance. So $30 million for rural hospitals. And then again, rural healthcare workforce development training programs and telehealth. And it has dedicated funding for rural health clinics to support behavioral health. It would also grow the health center programs reach and put it on track to double in size and would expand the teaching health center graduate medical education programs. So just for a little bit of context on this side, what will happen next is the budget will pass out of the house most likely in July through December, it will be mostly with the Senate and then they'll negotiate everything. So really what you'll have is a really kind of expansive budget request. Republicans are going to shrink that down. Senators are going to kind of expand that back out a bit and then they'll pass it. So you, go ahead. So in general, they do. It depends on how the language is written. So what you saw in COVID funding was a long period. So in a normal budget cycle, the budget is for one year. You can have laws that say that expand that time period to ten years, or depending on what the issue is, they can expand that. In general, if it's one-year funding and you do not use it, it goes away. But Republicans are, in addition to budget neutrality, going to take a look at what funds have not been appropriated. So these are in bills like the infrastructure bill, COVID-19 relief funding, other major spending bills, and they are looking at recalling the funding that has not been spent. So it depends on what specific example you're talking about and if that funding can be recalled. It ultimately can be recalled. Whether they'll be successful in doing that, I don't know yet. But they have certainly talked about recalling that funding. Republicans have certainly talked about wanting to recall all of the funding that has not been spent. But that requires bipartisan action. The Senate would have to agree about that. Yes, yes. I mean, it would require, yes. In their budget proposal, it's just going to be interesting to see kind of how they bridge those gaps. I think that what's going to end up happening is that recall piece is not going to be successful, but they will hone in the FY24 budget. I think that's probably where they will be successful. Ultimately, McCarthy can say budget neutrality. The reality is the budget will probably look very different in a high inflation time. Being budget neutral in a time with record inflation is really, really difficult. And so we'll start to see where that shift is. Because it's not, it's not, you know, there's going to have to be cuts somewhere if that is ultimately going to be achieved. But I think we'll get to, we'll see a little bit about. Markups should start here in, I would say probably right now, April, May. So we will start to see where Republicans are at. And that'll give us a good kind of idea of where negotiations will go, but everything will require bipartisanship. Hence the likelihood of delay. So, yeah. Oh, there we go. All right. Okay. Clicked way ahead. There we go. Okay. Okay, so there are two things you all are familiar with. One is bills and one is rulemakings. Rulemakings are done at the agency level and they're often just a reflection of the priorities of the administration. So that you all know what the process for rulemaking is. They all have different time periods associated with them, but in general, they're oftentimes driven down through the Office of Management and Budget or OMB in the White House. They're then given out by the agency itself. And then after that, they do in-agency comment periods. And those can be for different periods of time, but they're at least required 60 days. That provides stakeholders the opportunity to respond with comments, public comments. And then ultimately, once that comment period is over, it goes back to OMB where they do listening sessions. So they do listening sessions, which are live. You're talking with a real person. You're not leaving a comment. And that you're speaking directly with the White House on that. Rulemakings are one of the areas where if the administration has the ability to do so, they will do what they want when they want. And your comment sometimes doesn't mean anything. Sometimes it does. And so it's really important to engage on the comment periods, because if they get enough response in one direction, they are actually likely to change things. But sometimes it is just a reflection of priorities of the administration and changes that they want to make. So talk a little bit about a couple rulemakings. The end of the public health emergency as of right now is set for May 11th. We'll see kind of how that plays out. I expect that sometime, whether it be May 11th or sometime this summer, the public health emergency will come to a close. That will also take away the permissions of any piece of legislation or funding that is tied to that public health emergency. So keep that in mind if you're looking at a program that is currently existing or rules that are associated directly with the public health emergency. There's also prospective payment system and consolidated billing for skilled nursing facilities. This would update payment rates, including implementing the second phase of the patient-driven payment model, parity adjustment, recalibration. And it would propose updates to diagnostic code mappings under the PDPM, the SNF quality reporting program and the SNF value-based purchasing program. It also is proposing to eliminate the requirement for facilities to waive their right to health, to hearings in writing, instead treating the failure to submit a timely request for hearing as a constructive waiver. There's also Medicare advantage rates that'll see a 3.3% increase in 2024 under a final notice. That's final, so that's different from proposed rule. And that is $14 billion increases in Medicare advantage payments next year, according to CMS. The finalized rate increase is higher than what was proposed this year. So that is an example where that was heard and reflected in a final ruling. CMS is ensuring that the government is paying Medicare advantage plans more accurately amid claims from experts that the program overpays for care currently. Yeah, yes. Right. Yeah, we'll talk a little bit about physician fee schedule in a little bit. Thank you. There's also been drug negotiation processes that have been released in March. They propose an offer and counter offer that'll engage with manufacturers when setting a price for drugs. So that was released in March. The new prices will take effect in 2026. And it will also use criteria when determining a maximum price for drug prices. The next one, and I'm running through these very quickly, so I apologize. But this is a CMS proposed rule that came out in December that insurers for Medicare advantage plans would have 72 hours to respond to requests for urgent care and seven calendar days for non-urgent requests. It's their first kind of attempt at regulating prior auth, which insurers say cut down on the necessary care. But they've been increasingly frustrated with the delays that it's led to care. So the proposed rule would apply to Medicare Advantage, Medicaid, Children's Health Insurance, and healthcare.gov. To speak a little bit about the piece that just came up, when it comes to prior authorization right now, it's probably the number one thing that folks talk about on Capitol Hill when it comes to healthcare. I'm sorry, not prior authorization, physician fee schedule. It's probably the number one thing that comes up when we're talking about kind of the medical field in general on Capitol Hill. So there's not a single office that is not very well aware of physician fee schedule issues. The issue, unfortunately, right now is just the budget. And so that's the real challenge with Republicans right now. They know it's an issue. I think there will be something this year that's done about it. Whether that is an inflation adjusted change, I don't know, but I think there will be some sort of change associated with it this year. The first one I would say here, the non-compete proposed rule. This is from FTC. They're looking to ban non-competes entirely. Be interesting to see kind of where that plays out. This is related specifically to the medical field. Some of the concerns that we've heard from physicians are that it is concerning to them that folks could leave their practice with their entire book of business, et cetera. So there may be concerns that you have as a practice related to non-competes. The administration is very open to banning non-competes. The first thing I would say though, is that when it comes to your book of business, that is considered, excuse me, business secrets or trading insider secrets. So that does not mean that someone can just walk away with your entire book of business just because they feel like they wanna go start their own practice or they wanna get a job somewhere else or they wanna start getting clients for whatever they're doing. The non-compete clause would really just allow folks to move without punishment. There has been major, major pushback from industry on the proposed rule. So please keep that in mind. The likelihood I think that this one goes through are on the lower end of things that we see on a daily basis, but just keep that in mind that that could go through, making it just harder for you to have your employees on non-competes if you do have employees. The last thing that I would say when it comes to non-competes is that every state is different. So your state may be operating in a no non-compete environment already. So just keep that in mind. Each state is different. Last thing here on this page is the Medicare and Medicaid policy and technical changes to the Medicare prescription drug benefit. It's finalized a long rule to claw back overpayments to Medicare Advantage insurers and anticipating it'll, the agency, excuse me, is anticipating it'll recoup $4 billion over the next 10 years. So it has obviously drawn fire from the insurance industry, but it will bring some level of oversight and accountability to Medicare Advantage that has used fee-for-service costs. On overpaid claims, probably yes, but it's in the instance where there's overpayments, if that makes any sense. It's not just, yeah, it's really just on that overpaid piece. So, I think that's the primary challenge. Yeah, the implementation I think is going to be challenging. The, they're only going to be doing it right when there's been an overpayment. I don't know what this implementation is going to excuse me look like it was just in this effective date, April 3, so it's very new, the implementation of that is going to be. I don't know how the implementation is going to play out but. Yeah, I don't know. So, I mean, obviously the main kind of, I won't call them victim, but it's really the insurers that are not agreeing with this decision. The implementation though, it has not started. I mean, this is just effective from April 3rd. So how that implementation occurs over the next couple of months and years is gonna be interesting to say the least, but that's, you know, you said it well, but the issue is primarily with between the government and the insurers, but. Yeah, I mean, what I would say is this, the messaging when something like this comes out is obviously pretty inflammatory. I don't know how at the end of the day what they're going to recoup. Obviously this is their plan. I don't know how they're going to do that through audits or through, my guess would be that this is going to be in instances of systematic overpayment, not just you overpaid one time. I mean, this is like a systematic issue. So they are probably going to track insurers that are doing this on a regular basis and target those organizations rather than like a simple instance of overpayment. They probably have instances where insurers, I can kind of ascertain from what they're saying, they're probably very large insurers that are doing this on a regular basis. And this is to target those folks, not to target individual instances of overpayment, but rather the larger insurers that are doing this on a very regular basis. Yes. So you'll see that probably divided up a couple amongst two or three insurers that are doing this on a very regular basis. So, yes, the last couple of things that I will talk about are a couple of bills that we are tracking. And these bills are, I would say, largely bipartisan in nature. All the ones that we are highlighting here, the ones at least that we're tracking. Like I said, there's not a ton of appetite for individual bills right now on Capitol Hill. But these will likely, if they do go through, will be packaged into larger bills. The reason that's important is as you look through the news and see things like this, when there are bills like the Omnibus Appropriations Act, obviously, lobby it plays a primary role with the Advocacy Council in making sure that that process is reviewed for anything impacting kind of you and your organization. But please make sure that if you see large bills passing that either have a health care related title, really taking a look. It can be really important to make sure that little things are not included. So I'll give you an example. One of the more recent ones is the No Surprises Act, which was done in the FY22 budget. That was included in the Omnibus Appropriations Act. So it's buried on page 1,500. I mean, these are 2,000-page bills. But they're buried in there. So just make sure that you're at least asking, ask AOE leadership if they have kind of a write-up or anything for you. But we're certainly always looking through budgets and larger bills to see if there's anything applicable. I'll talk a little bit about a couple bills. So the Strengthening Medicare for Patient Providers Act, it would address payment uncertainty affecting Medicare participating physicians and avoid a possible physician shortage for Medicare beneficiaries by changing the physician payment rate above the current law by providing an annual Medicare physician payment update tied to inflation, as measured by the Medicare Economic Index. Last thing I'll say is when it comes to the physician fee schedule and physician payment in general, how this process, and even with the residency question, generally what happens is when a bill is decided that it is going to move, it goes to the House Rules Committee. And what happens when a bill goes to the House Rules Committee is that bill also goes to the Congressional Budget Office. And so when you have something like this that says Medicare beneficiaries, by changing the physician payment rate above the current law by providing a Medicare physician payment update tied to inflation, the Congressional Budget Office will take the piece of that bill that's included there and put a price tag on it and then say this bill is going to cost you $20 billion or whatever it is. That CBO score is really, really important when it comes to getting a bill passed. So if something has a much larger, it's called score, CBO score. If something has a much larger CBO score than expected, it can be challenging to get that through the process. CBO scores are really reserved for bills that are moving. So not every bill that's introduced gets a CBO score. It's really quite the opposite. But having a CBO score can be a blessing or a curse. It's necessary for bills to have a CBO score, but it can be challenging once that comes out to get it passed. So anything you see here with a non-number price tag associated with it will have a number price tag associated with it at some point after the CBO score. So this is the Save Rural Hospitals Act. It would just amend the Medicare Area Wage Index formula that harmed rural and low-income hospitals. As we know, some of those areas lack resources available than more populated areas. And it would establish a national minimum of .85 for Medicare Area Wage Index, which is used to adjust the overall payment for the Medicare program based on geographic differences in labor costs that overly affect some of the more rural areas. This is the Telehealth Expansion Act. And most of these bills have already been reintroduced. That can give you a little bit of an idea of kind of where the appetite is. What you're going to want to look for is bipartisanship. Obviously, more R's in the house. If you see that, that's a good sign. But an R and a D in both is really the key piece, and then also getting additional co-sponsors. So this would expand access to telehealth services, expand, make it permanent, excuse me. And then it will allow first-dollar coverage of virtual care under high-deductible plans, allowing Montanans and other Americans to access telehealth services without needing a first deductible. All righty, well, that is some of the bills that we're tracking. If you have any specific questions, my colleague Jake, who's not here today, he helps me a lot on AAOE, and he can answer more specific questions, and we can get together and do anything. If there's any questions related to just general kind of Capitol Hill environment issues, specific issues that I touched on in today's presentation, I'm happy to answer them if anyone has any. In Florida, we have to at least ensure that it's free for all of our occupants. So, I'll tell you a little bit about the formulation, so the Advocacy Council at AOE, you can reach out to AOE leadership if you're interested in engaging. You submit an application there, and then you're part of the Advocacy Council. That's where the lion's share of the work goes as an organization, so if you were to help draft a bill on behalf of AOE being on the Advocacy Council would be a key piece of that process. From the side of introducing a bill, generally how it works is lobbyists and organizations write most of the bills themselves. Sometimes you can work either directly with an office in the drafting of that bill, or you can present them with a bill that's already written, so my recommendation is generally to have a bill that's already written. How that looks is I usually take a bill that's already passed previously, relatively in recent time to what you're looking to pass, so you draft a bill, and then you have to shop it with offices, right? So, an office has to introduce that bill, and it has to be introduced, it doesn't have to be introduced in both, but it really should be if it's going to pass, so you have to find a champion after that process in the House and in the Senate. In an environment like this, you would want a Republican lead in the House and a Democratic lead in the Senate. You'd go to offices telling them what your idea is. They have internal legislative counsel as well as committee staff. Those committee staff are lawyers, and also they have internal lawyers in a lot of the offices that will help you draft the legislative language, meaning this is legally feasible, this is not legally feasible, that sort of thing. And then once you get a champion, that office will introduce the bill, and then you're kind of really ready to go. It will probably look very different from what you propose to what is introduced, just because there's legal issues associated with bills, and you have to kind of get approval from everyone and their mother on it. But once the bill is introduced, then you go through a process called co-sponsorship. Co-sponsorship is where other offices can sign on to that bill to kind of give a stamp of approval. The bills do not necessarily need to go through committee, but if they do, then you, if they don't, excuse me, if they don't go through committee, then you need a lot of co-sponsors, so I would say 50-plus in the House and 20-plus in the Senate. If it goes through committee, then you really need the support of the committee to get it through, so that would include committee leadership and folks like that to even get it through the markup process. So, the last thing I would say is you really need to kind of garner the support of either the speaker or the committee leadership, and healthcare is a really interesting kind of issue arena. It is, in my opinion, very inappropriately delegated in Congress, so you have the HELP Committee in the Senate that handles healthcare as a primary issue, health, education, labor, and pensions. And then in the House, it is covered under energy and commerce, so it's not equally divided like other issues where there is an equal, so you have health, education, labor, and pensions in the Senate, and then you have education and workforce in the House, and healthcare is not a part of that. So, long story short is to say that you really just have to work with an individual office and then ultimately garner the support of either the committees or leadership. Any other questions? I'm not sure in which context. Yeah, I can send the specifics over. I'm not quite sure exactly what the parameters of that piece are. There's probably a lot of different pieces, but I'm assuming that it probably has something to do with telehealth. Any other questions? All righty, thank you so much for your time everybody.

Lindsay Atherton

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