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House | March 11, 2015 | Press Room | Representative Avila Press Conference

Full MP3 Audio File

Said he’ll be here in a few minutes so if you wanna go in. [SPEAKER CHANGES] We’ll go ahead. First of all I wanna thank everyone for coming and delve into a subject that is confusing and convoluted and a lot of us in the General Assembly are just learning about in the last couple of sessions through some special study committees, myself included, as to what CON is, certificate of deed, and how it impacts our healthcare in the state of North Carolina. So first of all, like I said, welcome. I appreciate you taking the time to come. I will be making some brief remarks about what I saw as a need to get into this. I will introduce my co-sponsors and have them explain what their interests are and what their background has been in terms of driving their interest in CON and I have some people who live in the real world with it and I feel like we’ll learn quite a bit from talking to them and I guess I should explain first off that this is going to be the beginning I hope of a good conversation about CON. We had the legislation in a previous session and it did not make it through committee where a lot of the questions and concerns can get answered and discussed and resolved and I look forward to that with everybody because I feel like the best solution is on where everybody sits at the table, explains what their concerns are and how it’s going to impact them and the objective for everyone should be better, accessible, affordable healthcare for the citizens of North Carolina and have each of us with whatever our function is, as a provider, as a legislator, as a consumer, be at the table in determining what that is going to look like. In CON I’ve served on a couple of study committees, confused most of the time in the beginning because it is such a complicated issue, but however I understand the concept real well because I’ve actually been a patient in the ambulatory surgery centers which I’m sure looking at most of the age group in here, most of you’ve had your baseline colonoscopy so you know where of I speak, but that’s the sort of issue that we’re talking about because in 2005 the first adjustment I should say, or change to North Carolina CON laws were made for the very purpose of the gastrointestinal/endoscopy functions and has benefitted North Carolina and its citizens from healthcare, prevention and diagnosis and treatment of some severe issues, health issue quite well and the certificate of need that I’m proposing changes is an incremental. I’ve heard and there are indications that there are some more comprehensive changes being looked at, however with the cautious nature that I have as a scientist you know you only change one ingredient in your experiment at a time in order to be able to determine if it works or not, which is why I’m proposing and hope people recognize that a more deliberate and incremental change will help us see what works and then if things don’t work quite the way we want them to we don’t do a lot of damage before we can undo it and make some adjustments. So moving too far too fast can sometimes undermine the best intentions. And I’ve handed out quite a bit of material. I’m starting to look somewhat like Representative Stam who’s notorious for that, but I think it illustrates the driving force of why we need to look at CON in North Carolina and that’s cost. You have a handout that shows through the estimator here of several different treatments and the cost differential between an ambulatory surgery center and a hospital location and that points out I think more than anything else the need for us to seriously look at this because in anything that we’re looking at in the General Assembly in healthcare from Medicaid reform to anything else, the driving issue is cost and we have to understand where it is and where we can drive it out of the system and how best to do that. There’s examples. I won’t take your time because I wanna get

But you can see that in particular, you can see, there’s the bunionectomy prices go from $3,600 to over $13,000, from an ASC to a hospital, and you have to understand too, in the triangle area, 70% of that particular treatment are actually done in the hospital, high cost setting. So it’s not that we want to eliminate the hospital’s ability to do the procedures, we just feel like with the shift of some of the population, we can begin to get a handle on the expense of health care in North Carolina. Right now, certificate of need actually doesn’t make or break a hospital system, simply because there’s 24 states throughout the country that don’t require CON to open an ASC, and I think you can see from the very illustrative chart there, how North Carolina ranks in terms of just how restrictive we are through our certificate of need process. It touches on just about every aspect of health care provisions in the state, and we can begin in certain areas, just as we did in 2005 with endoscopy, moving into other areas, and make a gradual change and improve the landscape for the state. There are a couple things that have been – that have arisen as the biggest objections were the fact that, one, we would cherry-pick and these facilities would end up serving a clientele that was in my favorite terminology, on an unlevel playing field with hospitals, simply because of federal regulations which mandate hospitals serve anyone who comes to their facility. And I feel like we’ve done a good job in what we have laid out in this particular piece of legislation in addressing that concern, and that is we have a charity care limit that we have put in, for 7%, and that is well above the majority of charity care percentages which are illustrated on another sheet which I’ve passed out, which are the reported charity care levels of hospitals. So I feel like with that mandate, that they are to meet that charity care level, the argument that the hospitals are going to be stuck with unpaid, uninsured patients and things of that nature has been taken care of. The other concern, and rightly so, a lot of our rural hospitals, where the population may not be sufficient to support two facilities, a hospital and an ASC, and in order to overcome that, what we have put in place is a requirement that in counties of under 100,000 population, that there has to be an agreement between the hospital and this facility before one would be able to locate there. So I feel like we’ve been very cognizant of the concerns that the hospitals have. There are two main concerns, which I feel like are well warranted, and I believe we’ve taken care of those, and I know we’ll have discussions continuing on this, and any of the issues which come up legitimate, I feel like need to be given the time and energy consideration in any adjustments that we move forward on. But as I said, it should always be directed with the goal that each of us has as a legislator, as a provider, as a consumer, and that is accessible, affordable health care for the citizens of North Carolina. So this time I’m going to thank and recognize a couple of my sponsors. Representative Dan Bishop, who is also on the bill with us, was unable to join us, and if you have a chance, to get in touch with him and find out what was his motivation and why he is supportive of this. But I do have with me today as moral and physical backup and support here, are a couple of my sponsors, who I greatly appreciate in stepping forward with a controversial issue and being willing to help me fight a good fight. First of all I’d like to recognize Representative--

Joe from the Durham area. And Mickey has a history quite a long history with CON and I'm going to ask him if he would explain that. [SPEAKER CHANGES] My explanation thank you representative Brown is very simple. We want to bring down the cost of medical care and health care in this state and the way to do it is to put it on a competitive basis. CON's simply just knock out that competitive basis and that's where we are. About fifteen years I've been trying to do that and I know I'm gonna get a lot of flack from a big hospital I've got in my district but I think eventually as they come around to seeing how things are it will work. And then the other thing is that we've got to make sure that those areas not being served by those bigger units get some type of service. And if you've got to continuously apply for a certificate of need take for instance in Belmont where the hospital gone completely totally those people have to go forty five miles or more to get some kind of service. If there were competition really sitting there and you didn't have to have a certificate of need to set up like a ?? operation for instance or something like that then you wouldn't have the problems a lot of the problems that exist. So my thing has been making the thing more prevalent service and driving down the cost of health care in the state and I think by and again here again this is not a hatched approach this is a simple approach going across the board doing it slowly slow but sure basis. Where you don't just axe everything off and take it out but you move slowly but surely. And in the end I think prices will be brought down. That's my whole thing on that. [SPEAKER CHANGES] Also joining me is representative Jeff Collins. [SPEAKER CHANGES] Representative Avila obviously has done the yeoman's job as far as work on this bill so I'll try to keep my comments brief. I was fortunate enough to serve with her on the CON study committee we had I guess it's been three years ago now where we had public hearings around the state. Opened my eyes to a lot of things going on with CON. I guess the thing that saddened me the most was when I saw how large the body of legislation is. Made me think I was in Washington D.C. instead of Raleigh. I have a bumper sticker that's under the glass on my desk in the legislature in the house chamber that says limited government free markets fiscal responsibility. That pretty well sums up why I'm part of this drive. The more we can make medical decisions based on conversations between patients and doctors rather than legislative fiat by people like me and rulings from bureaucrats who are tasked with administering rules that we pass. And the less it can be about turf wars based on the rules that we've passed and lawsuits between medical practitioners based on the lawsuits we've passed the happier I'll be. That's basically why I'm part of this movement. As representative Avila has stated where going slow and trying to make sure we've put safeguards in place I don't want my hospital to suffer any more than I want any hospital in the state to suffer. Again I've tried personally to lower the cost to the state of health care I've never joined the state health plan I've had a health plan in place through my business it is a consumer based health plan so I have quite a large deductible so I'm sure when I go for my next colonoscopy I'll be taking close attention to where I have that done. But anyway this bill just follows very much in line with the education I got from the CON committee and with just my basic philosophy to start with. I'd like to thank representative Avila for all the hard work she's done on this. [SPEAKER CHANGES] There is one addition to this bill that I'd like to point out. Some may have noticed it in terms of areas we're going to remove the CON requirement. And that is our psychiatric beds. I don't think anybody in the state who has listened to any of our mental health meetings and discussions and committee presentations would not recognize the fact that we are currently at a very large shortage of those beds so we're hoping that because of the procedure which is so complex takes such a long time and is expensive that we might remove at least one obstacle to help encourage increasing the number of beds we'd have available for the people in the state. At this time I'm going to ask Dr. Matt

He’s an ophthalmologist and a retinal expert, and lives in the real world, and I think can probably illustrate much clearer what the practical ramifications of the direction we’re taking will mean. [SPEAKER CHANGES] First I wanted to thank Representative Avila for having the courage and dedication of the patients of North Carolina, to put forth this bill. A certificate of need law has historically been an attempt to control health care costs, and to ensure health access. What we have realized over time, is that it has simply failed in its efforts to do so. In fact, in 2004, the Department of Justice and the FTC released a consensus report stating, and I quote, “CON laws are not successful in controlling health care costs, and pose significant anti-competitive risks that usually outweigh their purported economic benefit.” So unfortunately, North Carolina has headed in the wrong direction in maintaining what you can clearly see is one of the most restrictive CON laws in the country. Since the CON requirements from the federal government was removed in the 1980s, we have 14 states in the United States, that have completely abandoned them, and we have an increasing number that are loosening them. So on a statewide basis, there are real world consequences involved by maintaining the status quo. One of them, looking from ten miles up, I would say, yes, many people say the real world, but my family looks are me in North Carolina and says you’re living in paradise, and I’d have to agree. But we see from ten miles up, that we see a tremendous cost leveed on the taxpayers of North Carolina for our Medicaid and Medicare costs. Then when we look down at the individual North Carolinian which is where I spend my days, in and out, sometimes in the middle of the night. What I see are patients who look at the costs involved with receiving their care that they need, and specifically I always think of one patient in particular, who presented to me with being legally blind in both eyes, and I needed to give the patient surgical care. That was the only way to correct the problem. And unfortunately the patient looked at the costs involved, and where I am, there is no ambulatory surgical center available that is providing care at ambulatory surgical center costs. So this patient was left with the potential for tremendous financial strain, and unfortunately was left with limited to no transportation that would get the patient to a nearby city that did have an ACS, or an ambulatory surgical center operating at those costs. In the time that it took fighting aggressively to get the help needed, the patient is now doing better, but may very well have been left with vision that is not where any of us wanted it to be. It’s impossible to know, but I can’t help but think it. So I do not believe anyone in the health care community—whether it be hospital, ambulatory surgical centers, or the providers themselves, such as myself—want that type of outcome. And so that is why I’m in support of this bill, in order to try and bring our health care facility access, bring the costs down, increase our access, and allow the patients to get the care they need in a more timely manner, and in a more cost-effective manner, especially as we all see what is happening in the health care community nationwide. This becomes incredibly important to all of us. Thank you. [SPEAKER CHANGES] At this time I’d like to recognize Donald Bryson, who is the North Carolina state director for Americans for Prosperity. [SPEAKER CHANGES] Thank you very much. I think this is a very important issue for North Carolina, as well as just a national discussion. I don’t have a lot to add that hasn’t already been said. I thought the three bill sponsors really knocked it out of the park, but I think this is an issue that spans across traditional political divides, from the far left to the far right. Basically people in the political left, middle, and right, want health care reform, and we basically want three things, it’s just a matter of debate of how we get there. We want widely accessible, low-cost, high-quality care. And certificate of need, these laws restrict--

two of those three things that restricts access and it probably keeps cost overlay inflated. North Carolina remains among 36 states, along with the District of Columbia, that continue to limit entry and expansion of their respective healthcare markets through certificates of need. On average, states with certificate of need programs, or CON programs, regulate 14 different services. You can see this chart from the Mercatus Center at George Mason University has North Carolina with 25, which is well above the national average. Throughout the United States there are approximately 362 beds for 100,000. However, in states such as North Carolina that regulate hospital beds through CON programs, the Mercatus Center study found 131 fewer beds per 100,000 persons. With North Carolina's population at 9.85 million, we can assume that there are about 12,900 fewer hospital beds throughout the state as a result of CON. I bring that up not because, I bring up the hospital beds not necessarily because this legislation addresses that but as Representative Avila put forth, this is the beginning of an incremental conversation about North Carolina's certificate of need laws and in a state where we are almost 13,000 beds short of what we probably need, we need to have this discussion about what this law necessarily does to us. With the special interests that consistently lobby to keep these laws in place, the certificate of need laws in North Carolina are approaching a state of regulatory capture, which is very dangerous. I think that Representative Michaux's statements earlier pretty much illustrate what we need to do is that we need to make this marketplace more competitive, we need to drive down costs, and we need to provide more access to people throughout the state. Thank you for your time. [SPEAKER CHANGES] Thank you, Donald, thank you very much. Now I'd like to recognize Alex Johnson with Generation Opportunity for some comments. [SPEAKER CHANGES] Thank you. We're going to represent a different perspective here today. Generation Opportunity advocates on behalf of millenials throughout the state of North Carolina and we the certificate need laws, three problems with them, the main one being cost. Due to some federal laws that have been passed regarding our healthcare system, millennials are now paying the brunt of health insurance costs. Our premiums have skyrocketed throughout the country, especially here in North Carolina. You have millennials now at a 14% unemployment rate in North Carolina, their living in their parent's basements and their unable to afford healthcare. Now they're required to afford healthcare we think that his reform package is a great way to bring down costs and allow young people throughout the state to have more access to affordable healthcare and just more access in general. The other point that I'd like to bring up is we have a record number of college graduates going to medical school currently in North Carolina. The problem is they're going to graduate from medical school and they're going to be continuing down the same path they've gone on. We at Generation Opportunity like to, we believe our generation is one of the most innovative generations this country has ever seen and certificate of need laws stifle that innovation. They prevent those students that we have now in medical school from graduating and creating new ways to improve healthcare and improve treatments and just the general daily life for patients. We believe these laws are very restrictive of those medical students' ability and future doctor's ability to provide better, more affordable care for individuals. The main point is we have a lot of, like Donald's point, we have a lack of hospital beds in the state of North Carolina and with certificate of need reform laws it will provide more access to beds. We're trying to lead the way in innovation and lead the way in providing great care for individuals, not just young people but older generations as well. So that's why we're behind this bill 100% and we believe that it should be passed as soon as possible. Thank you. [SPEAKER CHANGES] Thank you, Alex. Now I'd like to recognize Kathy Erickson, she is the Practice Manager with Eye Associates of Wilmington. [SPEAKER CHANGES] Thank you. I'm going to try not to be terribly redundant. I just want to say some things from the physician's perspective. CON reform is a very necessary step. Of course the issues, cost, access to care, and then also, in ophthalmology we have a huge demand for increased productivity. I'm glad to hear that there are more

people going into medical school because we need them to become ophthalmologists. I'm from south eastern North Carolina and my doctors, I have five surgeons serve both the elderly and pediatric populations. We have an enlarging population of retirees along the coast and growing families serving their country in the Camp Lejeune area. Right now seventy percent of our ophthalmic surgeries are patients of Medicare age. Our practice has the only pediatric ophthalmologist in eastern North Carolina and his practice is thirty nine percent Medicaid. There are significant cost savings anywhere from seven hundred to fifteen hundred dollars based on data from two years ago. Per procedure from Medicaid and Medicare and out patients if they have the option of obtaining the ophthalmic in a licences ambulatory surgery center. I also want to address the charitable care issue. Private practice does provide charitable care we currently work with prevent blindness in North Carolina as well as local organizations to provide ophthalmic care to low income families. We will continue the charitable efforts with the CON reform. Right now our ophthalmologists in the Willmington area currently have limited access to hospital based operating rooms and the request for additional block time or operating room time for established surgeons and new surgeons goes unanswered or even denied. Right now I have a surgeon who is booking out cases surgery procedures three months. I don't think it's right for our Medicare population or any population to wait three months to have a needed surgery. Cataract patients they have their first eye done and then their second eye they may have to wait four to six weeks for the surgeon to have access. The time to schedule that patient. Cataract surgery is the second most out patient surgery in the U.S. Their is a shortfall in the number of ophthalmologists compared to the demand for services due retiring ophthalmologists fewer trainees and the increased demand for services. To meet the needs of this ageing population our ophthalmologists need to increase their productivity and without the CON reform law we will be unable to do that. Thank you. [SPEAKER CHANGES] Well I think we've heard from several different perspectives. Why we want to proceed with this even though at times it may get uncomfortable and we're going to make enemies as well as friends but I think in all good things that's the case. So at this time I'd like to open up for questions from the press or anyone that has any issues and direct them to whomever you would like of the presenters this morning and who, Rose. [SPEAKER CHANGES] I'm just curious you said that loosening things up for ambulatory surgical centers would result in more psychiatric beds how does that happen? [SPEAKER CHANGES] In the bill where we've stricken the need for getting a certificate of need in order to provide services in addition to providing for ambulatory surgery centers and diagnostic centers we've also added psychiatric beds. They would no longer have to go through the CON procedure. Do you have a follow up? [SPEAKER CHANGES] Yes sir. [SPEAKER CHANGES] Jason ?? Business Journal. So can you be a little more specific on the seven percent charity care is that something that's required for each one of these new ASC's to provide? [SPEAKER CHANGES] Yes. [SPEAKER CHANGES] Who regulates that? [SPEAKER CHANGES] It would now our getting into the specifics of the bill and I can get you a copy of that too. But there's actually a definition of how you would calculate that and that's something that's interesting too when you see this list I gave charity care there's not a standard procedure or formula people use it's calculated different ways but we've specifically laid out in the legislation how you would determine and we're basing it on Medicare in terms of dollars. But it's pretty much you would subtract from your revenue the percentage that you gave to charity care and it needs to equal seven percent. [SPEAKER CHANGES] And so along those lines let's say someone reaches only five percent you know a practice only reaches five percent in a fiscal year what do they owe the remaining two percent to some sort of a fund that then let me ask what happens to that fund. [SPEAKER CHANGES] And that's a good question because a lot of these types of issues are going to happen because I'm sure that in some areas you would not meet that full requirement and we need to make sure that you know we've got all the procedures in place to accomplish what it is we're trying to accomplish but at the same time not be unrealistic in terms of expectations. An I'll, I can get

get a little bit more specific. [SPEAKER CHANGES] And would that include bad debt put into the charity care calculation? [SPEAKER CHANGES] That's a good question. I was going back to section seven, it's calculated to provide access to Medicaid and self-pay patients at 7% of the total revenue and there are not any particular breakdowns in terms of bad debt and things of that nature. There again, those are the sorts of issues that will get into the nitty-gritty when particular questions such as this come up and we'll work through those, because that's a legitimate question. Bad debt can be an inability to pay or a straight out unwillingness to pay, so do you punish a facility because of people's inability or resistance to payment? We'll work those out. We don't have 100% of the answers to 100% of the questions. That's why, when I work on legislation, I like having all of the people in the room, rather than talk to this group over here and this group over here and then come back and try to make a decision. I like everybody to explain what their concern is and what their issue is and what they face. Those very sorts of issues are the types of things taht will be on the table when we sit down with the people, as [??] talked about, the real world or where we live in conducting our business. I'm going to go to Dan. [SPEAKER CHANGES] How big of an impact do you see this having on state expenditures for Medicare and Medicaid because of a higher cost differential? [SPEAKER CHANGES] We will be asking for a fiscal note and whether or not that's going to be something that can be actuarily determined. We have a lot of data on what's happened in other areas where they have made this change but that's something that's going to come out of a fiscal evaluation of what we see happening when we put the law in to place. It will affect state funding and therefore warrants a state fiscal note. Yes, Jason? [SPEAKER CHANGES] This might be along the same lines there, but do you have any kind of an estimate on how much this would reduce overall healthcare spending in total? And again, that might be answered in the fiscal- [SPEAKER CHANGES] Not in total, but I can give you an example, just simply because of the way the rules are written, if you open an ASC, and I'm pulling numbers off the top of my head but I feel like they're fairly accurate, when you open an ASC you can do it under Medicaid number for a hospital or Medicaid number as an ASC. The price differential there is just a straight out almost 40%, So just because of the type of facility you are and the requirements for the pricing that's allowed under federal regulations. I'll double check those to be sure but I know in some of our committee work, if anybody else has a, say Amen to that or has a correction, please let me know. Yes, Rose? [SPEAKER CHANGES] And so then the bill would require ambulatory surgical centers to have relationships with hospitals so that if there's a negative outcome and folks need to be admitted, how would that end up working? [SPEAKER CHANGES] At no time, I don't think, a doctor would want to be in any position where he would not have privileges at a hospital. So there would definitely be agreements. I know locally we've actually, Wake Med is in partnership with an ASC here locally where they work with doctors. So this does not preclude hospitals joining these organizations with providers and setting up an ASC. It doesn't limit who can do it and how they can do it, that sort of thing. We're just basically saying in order to set them up, you're not going to have to go through this months-long, thousands and thousands of dollar process in order to get started. Yes, Jason? [SPEAKER CHANGES] Just a point of clarification, so this bill would remove from the [??] requirements, the ASC's as well as the psych beds, so I guess we would, on the big board they would go from 25 to 23? [SPEAKER CHANGES] Actually, diagnostic centers, we're taking three off of the list. [SPEAKER CHANGES] Along the same lines, real quick, the ASC's, that's across the board, I know at some point there had been discussion that this bill, or a bill, would include surgery centers that focus only on single specialties. [SPEAKER CHANGES] Right. [SPEAKER CHANGES] But that's not the case here, this would be for- [SPEAKER CHANGES] The initial bill that was put out

Previously did a special carve-out set aside for single, and it was a lot of language and manipulation, and in further discussion and looking at the benefits and everything, it was decided to make it a clean elimination and allow a multi-specialty. [SPEAKER CHANGES] A surgical team would be multi-specialty or-- [SPEAKER CHANGES] The state can choose. Right, yeah. Originally it would have been single-specialty only, but we’ve decided not to put that restriction in. [SPEAKER CHANGES] Dan had a really good question a minute ago about the cost of Medicaid, and I think that legislators, as well as the general public, should view CON reform as an integral supplement to Medicaid reform as we go forward with that discussion here. Because if we’re going to try to control costs with Medicaid, and we have to control costs with Medicaid, we can’t continue to have 300 or 400 million dollar cost overruns. We have to find a way to, at a macro level, control costs about health care overall, and that will in turn, help control Medicaid costs at the state level. So keep that in mind as we go forward with this, but I think that is a very exciting thing to help with the state budget as we go forward with Medicaid reform. [SPEAKER CHANGES] So you’re saying you want to get everyone to the table. Have you had everyone at the table, or do you want to get everyone at the table? Considering his point, have you had the hospital association at the table, and in terms of Medicaid reform, I mean, what, a third of the states’ hospital are running in the red, so I would guess that they would have some objections to this, and is there a bargaining chip around Medicaid reform? [SPEAKER CHANGES] I haven’t really looked at it from that standpoint. It’s highly likely. But as far as sitting down and beginning to iron out issues that’ll start with our committee process, and when I’ve worked on bills in the past, we’ve gotten to the point where I wanted to present something to a committee, that I felt was going to be—any legislator wants to go to committee or on the floor of the House and say, “This group, this group, this group, this group is supportive of my bill,” and everybody goes, “yay!” and they don’t have to think about whether or not they’re going to vote or do any of this kind of agonizing. So the objective with what I hope, with the framework that we’ve got stated here, is to bring everybody to the table, and say, “what are your legitimate arguments? Where can we help?” and is this something unfortunately some people are just going to have to swallow what may be a bitter pill, and take the next step. I’m not quite sure how that going to work out, but that’s where I see it going in terms of conversation. There’s a point that hasn’t been brought up, and I wanted to, the concern for a lot of people is, “oh my goodness, you’re eliminating all the control and oversight” and all this kind of stuff. That’s not the case with this, because there’s still licensing procedures, and oversight that’s going to be regulated through the accreditation standards, through Medicare conditions, participation. Those type of regulations and strings attached, will still apply in terms of the quality we’re required without this entry-level applications, so to speak. You had another question? [SPEAKER CHANGES] Yeah. Sort of shifting here. At one point there was some discussion about making sure that we define a procedure room, what’s allowed to be done in a procedure room versus an operating room. Does this bill address any of that? [SPEAKER CHANGES] It doesn’t because that’s being undertaken in a separate figure that would just kind of cloud the issue. It is a significant issue and we felt like it was probably a stand-alone, and it will be addressed in another piece of legislation or committee. [SPEAKER CHANGES] Some of the questions have been fine-tuning definitions of things. Charity care, and whatnot, and others have been as far as getting everyone to the table. I just wanted to mention, that if I was listening correctly this morning, our bill got referred to three committees, which I think, I don’t listen that well to all the bill referrals, frankly, because that’s time when we could get other things done in the House. I think that’s as many as any have been referred to in this session. Certainly not a record, I was one of the primary sponsors on the bill that got referred to six committees last term, but I don’t think this is, I don’t is a statement by the Speaker like that. I think was a statement by the Speaker. But we’ll have plenty of time and plenty of committee hearings to vet this out, make sure that all our definitions are tight as they need to be. Make sure that we have time to discuss it with everybody who has an opinion on this. So I just wanted to make that clear, we did get referred to three committees today, so we will have very good--

vett this with everyone. [SPEAKER CHANGES] Yeah and Jeff brings up a really good point cause there's a lot of areas that impact legislation. And primarily of course we're going to help where we're going to look at what this is going to do for people and how we're going to guarantee the safety and quality that we want to maintain for our citizens. But we're also going to judiciary and that goes to the point of being to make sure that when we put a word and a comma that it means what we want it to. And to clarify if there are any questions about what a particular procedure is or like you said a procedure room or operating room those types of things. So the judiciary part of it will take care of that and of course we'll go into appropriations because as Dan made reference to we're going to have an impact on the states budget. And we'll be able to present and bring that out as well. So I think we've go pretty much all the points covered in terms of the committees where people will be and more than likely because we've done this in committees in the past we will allow at some point in time in one of the other of the committees in time to comment. So that's where I want to open it up, have it out there have everybody know what's going on and be a part of it. Yes. [SPEAKER CHANGES] Why does this bill stand a better chance of passing than the one you previously introduced? [SPEAKER CHANGES] I think it's just like it is with a lot of legislation down here, circumstances and time. Health care is becoming something actually I think everybody is a little more aware of. It's been easy in the past to buy an insurance policy. Go to the doctor make your payment go home and the insurance company pays their part then they send you a bill in the end of it and I think patients now are beginning to realize this is a commodity. Similar to any purchase that we make and we have the ability through the information line like with the estimator to look at where we can get the same quality because everybody all of us in here have to make our dollars go further. And this is just giving us an opportunity to allow that to happen and give people the opportunity to have choices. Which currently they don't have. Any other questions or any of the presenters like to make any closing comments? Okay, if not thank you all again so much for coming and I'm available any time you have a question pop up.