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tv   Politics and Public Policy Today  CSPAN  May 27, 2016 1:00pm-3:01pm EDT

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meaningful use to aci, or whatever we're going to call it, we've got a 365-day rule. in the past it's always been a 90-day rule, which means that practices have to demonstrate that they comply for a 90-day continuous period within a 365-day period. it only makes sense. nobody is perfect every day. and if they're going to get dinged because they're not able to comply one day or two days or three days, then we've simply got to move to a 90-day, and i hope that you're able to work in that direction. >> so, it's one of the key areas we're inviting comment right now during the comment period. >> good. so, i invite comment as well from folks from whom i have heard. >> okay. >> on the alternative payment models, you've got a lot of folks out there, a lot of docs, guys and gals who have already modified what they're doing. the bundled payments, the bbci programs, the future cjr program. and yet, it appears that those programs that cms has pushed on docs and encouraged docs,
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incentivized docs to do don't even qualify for apms. that doesn't make any sense at all. so i hope you're looking at just grandfathering those or moving them in or allowing them to qualify as apms. >> so, congressman, one of the things that i think we have to do now that the law is being implemented is to go back and look at all of our models and see where we can make changes to them so that the participants in them can qualify. and i know that dr. conway is very much directing the team to look for ways to do that where possible. that has to meet -- there are certain requirements that have to be met. an example would be what percentage of the patients i'm seeing are part of this bundled payment. and so, because that's in the statute in the law, we have to look at how we can modify with these programs or work with you on what our flexibility is to be able to -- >> i agree. if you expand the ability for them to use their entire practice instead of just
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medicare, that oftentimes gets them to that point. >> right. >> so i would urge you to look at that. >> okay. >> docs are really frustrated for things which they are held accountable which they have no control over. one is on the meaningful use aci issue, this data-blocking that's occurring by the vendors. docs don't have any control over what the vendors do at all. so how we can have a system that actually punishes docs or potentially punishes docs because of something somebody else does that they don't have any control over, again, that doesn't make any sense at all, and they're pulling their hair out trying to comply with this. so if you can look at that, that would be appreciated as well. >> will do. >> i want to touch on the nominal risk that you talked about. >> okay. >> the nominal risk, as i understand it, is 4% -- minimum of 4% of total spending to be qualified under an apm? >> that's correct. >> and as you know, the physicians control, i don't know, pick your number, 14%, 15%, 16% of total spending. so, 4% of total spending is
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really 25%, 30% hit for the docs. so how can we have a system that punishes the people that are -- where the rubber hits the road, trying to care for these patients, and again for which they have little control over? shouldn't that be 4% of the physician total reimbursement? >> so, one of the areas where we're looking for feedback in the comment period is both what is nominal risk, quantitatively. we chose a number that was consistent across the mips program, but that's just in the proposal, so -- >> doesn't that presume that the physician controls every dollar of spending? >> and that's the second area that we seek feedback, which is under what universe total cost of care, which of course, the benefit of a total cost of care is a primary care physician has the opportunity to get rewarded for being able to keep their patient out of the hospital when they don't belong there and so forth. of course, as you point out, the challenge with that as well --
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so, it is an area where we're looking for feedback and very much -- >> a lot of those things are out of their control. >> sure. >> we'd like to believe that they control them, but in an ideal world, that might be nice, but a lot of those things are out of their control. i have a few seconds left and i want to point out the table you identified, table 64, which by your own data stipulates that solo practitioners are going to -- 87% of solo practitioners are going to see a negative adjustment. this is your own data. granted, it's two years old, but it's going to be two-year-old data that's going to reward them in '19 based on what happens in '17, so i urge you to relook at how you're adjusting that and in realtime providing an update. >> right. and we'll look at the final rule and having the most updated and accurate information in that table. again, while that table would not be good news if it were reality, i don't believe it is reality. however, i will say that the silver lining is i think drawing attention to the impact of this regulation on small and solo practices is a good thing.
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and so, i think it's where we need to have dialogue. and so, despite the fact that i don't think that table represents the reality, i do think that the reality of how difficult it is to practice medicine in a small or solo practice is very real. so we're looking for ways to make sure we make it better. >> great. thank you very much. thank you, mr. chairman. >> thank you. i think you might be sensing a theme up here. mr. blumenauer, you're recognized for five minutes. >> thank you, mr. chairman. i appreciate the opportunity to have the conversation today. mr. administrator, i appreciate the approach that you folks have taken to help us turn the corner. i personally have found the charade we went through for some 17 years embarrassing, dancing away from an event we know nobody had any expectation should happen. we're dealing with a budget fiction. i think the agreement that was struck is reasonable. there is still much value to be
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squeezed out of the system, but i appreciate the fact and some of the references from my friend, dr. price. we've got people who are in the middle of practice patterns, limitations on data, and just a whole host of other changes taking place. and i appreciate the commitment to do so in a thoughtful and deliberate fashion. you have also heard another theme emerge that people are keenly interested in making sure that we make this transition to rewarding value over volume and that we've had problems in the past with some things theoretically. i mean, i have strongly supported medicare advantage. but at the same time, the parts of the affordable care act to try to coax more value out of it, because theoretically, it should enable us to deliver care more efficiently. >> more efficient. >> and we continue to have a
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pretty significant premium. the compromise that was struck and one that i thought was healthy was to provide bonuses based on performance and try and deal with some of the areas where there is some decidedly -- i don't know if one wants to call them outliers, but there's some real performance problems, being overcompensated, coming from one of those regions that we like to think that if everybody practiced medicine like they do in my congressional district, we wouldn't have the funding problems that we have. i'm looking at charts like this that kind of display how it's supposed to work over time. i wonder if you can just give us a sense of where you think the pinch points are, where will be some of the things that we need to be prepared to be able to work with you, if there's further adjustments
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legislatively, if there are things that we need to do a better job of just being able to understand ourselves, to explain to our community at home. where are the pinch points that you think we need to zero in on? >> thank you, congressman blumenauer. i think i point to a couple of areas that i think are really critical focus areas for us. one is the education and communication process, particularly with smaller practices and individuals, solo physicians. it's vital that we hear their feedback and understand what the impact of the decisions that we're making here today will be on their practices several years from now. so that education process i think means a couple of things. one is that we talk in plain english instead of acronyms, which we are quite guilty of here, i know, but we're trying very hard to do a better job at that.
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we've created simple fact sheets and training sessions and powerpoints and as many options as possible to do that. and to the extent that you can help us do that and tell us what you're hearing, that's going to be critical. the second thing that i think we will need to continue to hear from you all on, and i think the conversation with congressman price is apropos to this, is where there are places where you think there should be flexibility and how we should be exercising flexibility, whether it's with smaller practices or whether it's in how we define the models that are the qualifier for the 5% bonus. in all of those areas, your feedback on our interpretations are critical because we really do want to get to the best answer. and i will tell you that we don't have a monopoly on that. we want to do that through the dialogue and the debate that
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congressman roskam referred to. and we also are going to have to make this an ongoing commitment, because we'll have to look at this program at the end of its first year and understand what worked well and what didn't and what could work better, and we can't be afraid to call out the things that didn't work as well and sit down together and try to figure out how to make those things better, whether it's with technical improvements or whether it's simply in how we're implementing things. >> mr. chairman, i do appreciate the opportunity to get into something which i hope we're able to periodically update, review. i appreciate part of this is process and part of it is performance and being able to strike that balance in a way that's protective of the people who depend on the service but also for the taxpayer i think is going to be a challenge for our friends at cms and for the committee. and i hope we can continue sort of zeroing in in that fashion. thank you. >> thank you. well said. mr. smith of nebraska's recognized for five minutes.
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>> thank you, mr. chairman. thank you, administrator slavitt, for being here today. i represent a very rural district, in some parts more rural than others, in fact. 75 counties touching 6 states. obviously, we're very spread out. number one agriculture district in the nation. very productive. of the nearly 60 hospitals in my district, about 54 are designated as critical access. and that might be a single designation, but that's about 54 different types of expertise and providers, and i'm actually inspired by the work that they do serving communities from smaller than 1,000 up to about 12,000-plus. nonetheless, they've got a very large task, and i guess so do you. can you discuss the feedback you received from rural providers in response to the initial rfi and how you address that in producing the rule, and then what rural providers and critical access hospitals can
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expect from this rule? >> yeah. thank you, congressman. in your district, and i think throughout the country, we face the challenge of not having enough physicians in many cases, enough specialties, and there are many districts around the country where there are only one or two providers in certain specialties. so we cannot allow the sideshow that goes along with the practice of medicine to make the practice of medicine less fulfilling and less rewarding. so as it relates to the small physician practices, the medical home models that many of them are participating in, we've had really terrific feedback from. and i think what i hear from small physicians is give us the opportunity, find ways for us to have the opportunity to participate and some of these
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same opportunities and models that people do in urban settings, and make them work for us. so, can you make changes to them that can work for us? so, that's i think one of the things. and then on critical access hospitals, obviously for us, so many of our medicare beneficiaries get taken care of and get treated and rely on those critical access hospitals. and the economics of health care in rural america is different than it is in other places, and that is both a short-term issue that we have regulations, as you know, to set up to deal with, but it's also a longer-term question around how those hospitals are structured, what they provide and how we support them in the appropriate way. >> okay. in your response to the chairman, you had mentioned a reporting exemption for small providers. at the same time, i've heard questions from those who fall below the reporting threshold who would like to be able to report data. will they have that opportunity? >> it's interesting you say that. i had that feedback last night
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in talking to a speciality society who said we want our speciality to be more engaged in the practice of medicine with seniors. and so, even our physicians who are only seeing small amounts, we want to do that. so, i will tell you, i have heard feedback in both directions, and i think our job will be over the comment period to take all of that in and figure out how to do the best job accommodating the most types of practice as possible. >> well, i appreciate that. i know that the providers that i talk to are constantly not just saying what the problem is, but provider solutions and innovations, and i would hope that we can empower providers to care for their patients without the government getting in the way or messing things up. thank you, mr. chairman. i yield back. >> thank you. the former mayor of paterson, new jersey, is recognized, mr. pascrell, for five minutes. >> thank you very much, mr. chairman.
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administrator slavitt, under your leadership, cms has stressed the importance of better data to improve quality, to improve outcomes, and has made great strides in making that data available. macra included a provision that allows innovators to use qe data to help us make smarter decisions. do you agree that the medical devices used in care -- and i'll focus in on that -- particularly for the most common medicare procedure, joint replacements, play a role in health care quality and outcomes?
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medicare has no information on the medical devices implanted in medicare beneficiaries. i think we should let that settle in for a few seconds. extremely problematic, i think, from an oversight perspective, and most importantly, from a safety perspective. you and i have had discussions. there is a history here that we need to address. so, shouldn't this information be made available? administrator. >> thank you, congressman. so, the question you raise is really one of should there be -- and how should we capture a device identifier in a unique way on every device. and i think that's a goal that we share, it's a goal that the
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fda shares, and it's critical for postmarket surveillance to be able to understand the safety of how these devices work. so, there are several, i think, critical things that we can do and are doing and are trying to do to make this possible. so, despite our enthusiasm for this, and this is an issue that's long preceded me. as you know, it's been an issue for quite some time. there are a number of parties who have a say in the matter of how this happens. i think as a first step, we're moving forward with the incorporation of a unique device identifier into electronic health records. i think this is a strong step, particularly considering the dramatic growth in electronic health records. but i know that there are also -- there is also an interest that on claim forms that there is a way for providers to provide care to
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indicate the device identifier on the claim form. we think that also has merit, particularly from a research perspective. i think there are a couple of issues to making that a reality. one is the committee that essentially designs the claim form, which is made up of a wide group of participants and hospitals and physician groups. second is making sure that if we at cms are given the charge to do this that we can fund it and have the funds to do it operationally. and then the third, there will be an education and training process, because the history is that physicians don't automatically put the information they need to down on a form unless it's critical to them getting paid. so i think we need to work through all of these issues with you. we've pledged to do this with your office and we're working closely with the fda to find the best path forward. >> i think you've used the best word, critical. but if we don't do it this time, then we've got to wait another
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15 years before we change those forms. and our seniors will not be well served. this is important. i've been frustrated with cms's resistance to what i believe is a very important priority, particularly of safety, including the unique device identifiers on health insurance claims. in order for udi to be added to the claims form as part of the next update, it would go into effect i think in 2021. that's the soonest. we need to act now. and i think -- i can't stress enough, mr. chairman, we're talking about the safety of the people who use these devices. and we all want to be on the same page. this is i think a good time for us to address this issue.
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number of cases, a number of stories about not only seniors, by the way, but we're talking about seniors here because we're talking about medicare, that have had the problems. and we need to address that in order to improve safety. i mean, everybody on this committee talks about it, and i believe them in their hearts. here's a chance for us to do something about it. but i want to thank you, mr. slavitt. you've done a great job. thank you for putting up with us, but we're not going away. thank you. >> thank you, congressman. >> thank you, mr. pascrell. ms. jenkins, you're recognized for five minutes. >> thank you, chairman. thank you, mr. administrator, for joining us today. medicare obviously plays an important role for many kansans. it's the larger payer for medical services, an american life-saving benefit for many people. last year, over 485,000 kansans had health coverage through medicare.
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we were pleased macra passed last year in a bipartisan manner. with the passage of macra, we repealed sgr and put in place what hopefully will be a better reimbursement system for physicians. mr. slavitt, the relationship between a physician and a beneficiary cannot be underscored in importance. and i believe this is especially true when talking about seniors. with the moves that macra makes towards higher-value care centered on the quality of care administered by clinicians, it's ever important to ensure that we encourage greater and greater communication around decision-making between the doctors and their patients. so, as macra's implementation continues over the next several years, do you see room to begin including patient activation measures, placing greater responsibility on this relationship with the hopeful result of shared responsibility over health care maintenance, and thus furthering the quality of care? >> yes. thank you, congresswoman, for
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that. i think that's a really important question, and i think there is an opportunity over the next several years to begin to incorporate those engagement measures in. there are a few things that are in the current proposal that i would point to that takes steps in that direction. one is there is a practice improvement focus opportunity on the creation of a joint care plan between a patient and a physician. secondly, in the advancing care information area, there are opportunities that focus on measures around how patients and physicians are communicating using technology and making sure that information's being made available to patients electronically and through other means. but i think this is a, as you point out, a ripe opportunity and a brand-new area of focus for more patient engagement. we have been meeting with a
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number of patient groups as we've been putting this work together, and that's an important area of feedback for us. >> all right. thank you, mr. chairman. i yield back. >> thank you. mr. davis is recognized for five minutes. >> thank you very much, mr. chairman. let me welcome you, mr. slavitt. i know that you spent considerable growing up time in evanston, illinois, which isn't very far from my district, and i also know that your mother lives in my district. and i'm pleased to tell you that i have not had any real complaints from her. and so, that makes me feel good. >> that makes one of us. >> but let me compliment you on your work. medicine is a very complex environment, and there's tremendous complexity.
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and i also want to thank your staff. i have 24 hospitals in my district, four large medical schools, a number of research institutions, and a very activated citizenry. so we get lots of inquiries, lots of calls for assistance, a lot of calls for clarification. and so, we spend considerable time not pestering, but certainly inquiring of your staff. and i want to thank them for the kinds of sensitivities they have displayed. i also have a very activated medical community, physicians associations and organizations. and just last week i had a meeting with the chicago medical society.
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but i've heard concerns that under the proposed rule that we're talking about, only a limited number of physicians will meet the alternative payment model or apm criteria to earn the payment bonus. by your own estimation, you have indicated that there may be only 30,000 to 90,000 physicians who meet these terms, which is a tiny fraction of the total medicare-eligible doctors in the country. and i'm certain that we'll hear some more from these physician groups. they'd like to know what could make it -- how likely is it that anything will make it easier for there to be more pathways to qualify for the apm bonus payments? and how can cms improve the opportunities for physicians to
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meet the advanced apm criteria and achieve the incentive to drive medicare that congress intended? and would you consider additional pathways that qualify as advanced apms to provide assistance for physicians who wish to enter the current model? >> thank you, congressman. and my mother made me promise to tell you that she was a teacher at howe and working with the principal who she knows knows you well. she wanted to make sure i said this publicly, so i've delivered that for my mother. >> thank you. >> and your question is an important question because it speaks to -- physicians, all physicians who participate in the medicare program are going to have a significant
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opportunity to get rewarded and get paid for providing quality medicine, which is exactly what we hear from physicians that they want. some physicians will have the opportunity to go further. and i think the law allows those physicians to get a 5% bonus if they participate in these advanced payment models. so, our goal is not just to make the core program good, but to create as many opportunities for physicians as possible to move into these programs. and we can do that a number of ways. one of the important ways to do that is to simply create more models and more opportunities. we also have to make it easy for people to move back and forth if they choose to between programs. and i think that's one of the things that we're striving to achieve. and then as we talked about earlier with dr. price, how do we -- we also have to look at are there ways we can take
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existing models and make them compliant with this new law? so, we are going to work on all three of those avenues, because it is a goal that for any physician that wants to move to one of these advanced care -- you know, advanced apm or care coordination models, that they have the opportunity to do so. >> thank you very much. thank you, mr. chairman. and i yield back. >> former mayor marchant of texas is recognized for five minutes. >> thank you, mr. chairman. mr. slavitt, does the cms have the resources to approve and implement the new alternative payment model proposals in a timely manner? >> thank you. so, i believe the question is can we implement new models in a timely manner. and one of the things that we have to do, and the answer is yes, we do. we need to, in concert with the committee that was set up by
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congress, the ptac, we need to receive proposals from physicians, because physicians can generate their own proposals for models and quality, and then work with them to as rapidly as possible test them and put them into action. it's one of the things that we have had the opportunity -- and work on through the last six or seven years through the innovation center,tioni somethi have gotten better at, and we're eager to get going with this committee to get as many models in as possible so that we can get more and more models approved. and i had a chance to speak with that committee and speak in front of that committee to try to encourage more model development. >> there is a deadline period, so you're confident that you can get all that done by the deadline? >> well, this, fortunately, this is something that will be ongoing. so you know, as soon as we get models in, we can get them tested. but this committee i believe will be standing for a number of years. i'm not sure if we know the exact number of years, but it
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will be ongoing because physicians will be able to continue to develop new models. >> so the transition in governments that's coming up won't have any effect on this process? >> no. the committee -- the staff at cms will work with the new secretary, whoever that is, and continue moving that forward very much with that, and i think there is, as i've heard today and i think as we continue to hear, there is a strong bipartisan commitment and a strong commitment to this program and moving this forward, so i don't see any concerns at this point. >> and just some input. in my district, i hear from two different groups, and this is concerning the new program where you basically are, let's say a knee replacement or a hip replacement, you're basically going to fund a lump sum for that.
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i'm hearing from seniors who think that the doctors and hospitals are going to cut corners so that they'll make the most amount of profit and just hurry them through the system. and then i'm hearing from the doctors in the hospitals who are afraid that they don't -- they're not going to get enough money to take the kind of care of their patients that they need to take care of. so i guess you've created a pretty -- these two tensions that are working out there. could you just make a comment about that? >> sure. i think what you're referring to is a new type of payment approach, new for medicare, but it's been ongoing in health care for a long time. it's called bundled payment. >> yep. >> and really, the idea behind a bundled payment is so that people -- everyone who's involved in patient care, whether it's before they would have a surgery, the surgeon, the anesthesiologist, but also the
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people that take care of the patient afterwards have an alignment to get on the same page to provide a high-quality outcome and to do it as a team. and so, it's relatively new to medicare. we've had good experience, good feedback so far. but as with anything new, we continue to look for feedback, for data, for experiences, and in particular, if there are beneficiaries in your district or hospitals or physicians in your district that have experience with the program, we would love to get them from you or your staff. >> well, the group that i hear from the most is the in-home health care people who feel like they're kind of at the tail end of the process and that they may be the ones -- they feel like they're the most cost-effective of all, yet they feel like at the end of that process there may be some short-changing going
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on. >> thank you. >> okay. thank you. >> thank you. mr. lewis is recognized for five minutes. >> thank you very much, mr. chairman, for holding this hearing today. mr. administrator, thank you for being with us. thank you for all of your great and good work. can you talk more about what people on medicare might experience as a result of this change in payment policy, how the smaller provider groups will be impacted and the doctors who need help can get up to speed? >> thank you. so, i think the most important thing that we have an opportunity to focus on here is patient care and improving patient care. and i think the ways to do this are several fold. first is this new legislation
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allows us to pay physicians more for providing higher quality care. and the objective is to do this in a way which allows the physician to define what they believe to be the highest quality care from a menu of options and reward them for achieving those benchmarks. and i think physicians have been asking for that in one form or another for quite some time. secondly, though it's important to do that in a way that frees up physicians to actually practice medicine instead of just keeping score. too many programs result in a lot of paperwork and a lot of score-keeping, a lot of reporting, and we need to minimize that by simplifying wherever possible. the role of small physician practices, which you also mentioned, is critical here, and as we mentioned earlier, we believe that small, solo and solo practitioners have every opportunity to be just as successful as larger size
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practices, and our data suggests that that indeed happens so long as the smaller practices report. so that means we need to minimize paperwork. we've also put in place some accommodations for smaller practices, including some technical assistance, some additional models, and ways that they can get excluded from reporting if their volumes are too low. >> thank you. mr. administrator, this is a very large regulation, over 900 pages. that's pretty big. it's a lot to digest, a lot to understand. if you have to tell your doctor the highlights of these changes, what will you tell her? what would your doctor need to know to maximize benefits and avoid payment cuts? >> great. that's a great question, and it may be one of the most important things that i can communicate today.
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first of all, to keep focusing on patient care. there is nothing in here that should distract anybody from patient care. and in fact, it will make it easier by streamlining a patchwork of programs that are already out there today into something simpler. so, that's first. second is they'll have the opportunity to select goals that they believe are right for their practice, right for their patient population, and at some point in time, they'll have the opportunity to do that. third i think would be that over time there will be opportunities for them to participate in more advanced models, like the kinds you asked me about earlier. fourth is they don't need to really worry about reporting anything until spring of 2018, and we will make it clear what needs to be done well before then. and then finally, the last thing, and this is more of my ask of them, is to provide feedback, whether it's to this
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rule, whether it's through the medical society they belong to, the state medical society, directly to us. we really need line physicians who are practicing medicine every day to give us their feedback on what works about this rule and what might be the unintended consequences. >> thank you very much. and again, i appreciate your effort, your good work, and thank you for being willing to serve. >> thank you. >> mr. chairman, i yield back. >> thank you, mr. lewis. mr. paulsen is recognized for five minutes. >> thank you, mr. chairman. mr. slavitt, great to see you here. welcome. rather than on a airplane, going back and forth to minnesota. as has already been said, last year both sides took very historic action to move forward, finally get rid of the flawed medicare payment formula based on the sgr, and then wonder if we're going to fix it every six months or every year. and like any law, passage is just the first step, right? it's the implementation that has to be carried out and followed through.
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and so, and making sure it's done correctly and so that we're achieving the intended results. i want to thank you at the outset for working with patients, working with physicians, having that connecting dialogue with all of the appropriate stakeholders, including members of the committee, to making sure we're implementing in the correct fashion. i want to continue on the common theme and just mention at the outset that it is important to know that i continue to hear from folks back in minnesota as well that aren't in large, integrated practices, solo practices, small group practices, et cetera, that do have that concern. and as you mentioned, you want to make sure that they have every opportunity to participate. i think they want that reassurance. and we just kind of need to keep monitoring that going forward, and i thank you for that. let me ask you this question. i've also heard from a lot of physicians and doctors in minnesota about the meaningful use program for electronic health records and how it doesn't do a very good job of taking into account the way physicians treat patients and use their electronic health care records.
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this rule the same old same old, or do you make real changes in how you are going to be encouraging doctors now to actually use their electronic health care records? >> thank you, congressman. and i would agree that our district practices some of the best medicine. the meaningful use program is something that we took an extremely hard look at. we took a step back. because the meaningful use program actually is responsible for helping to make technology pervasive in medicine. and that's a very good thing. we look back five or six years ago, most physician offices, most hospitals didn't have adequate information technology. today, by and large, 97% of hospitals, 70% of physician practices have technology. but as we look at how to go forward, we spend a lot of time talking to physicians and hearing exactly what you said, congressman, which is that the meaningful use program was focusing on making sure that we're using their computers and
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not focusing on taking care of patients. we also heard that physicians want their technology to be more connected. they want to be able to get information back and forth from other physicians when they refer patients or from hospitals. and they're also frustrated that there isn't enough connectivity and the data doesn't flow as easily as it should. and so, we've been asked to focus on it, and i believe have focused on in this rule changing the program so it becomes much more flexible, moves the focus to the patient, away from the use of the technology, focuses on interaction and communication and allowing the free flow of data to move back and forth. and those are the areas that we emphasized. we look forward to comments during the comment period about whether or not we've done that well. >> does it seem like the proposed rule, you know, replacing meaningful use with this new category, advancing care information. we have all these different acronyms. but accounting for 25% of a physician's performance score in the first year, is that going to
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essentially be interoperability now for electronic health care information for vendors, hospitals, all of the actors, players, physicians and other providers? is that that intent that that information will be that widely shared that readily available, not just on the computer, but actually using the information? >> right, that is the intent. i'll tell you, everybody has a job to do in that regard. if any of us here could wave our magic wand and make the health care system more interoperable, i think we'd do it, but this really requires vendors to share data, to publish who what they call open apis, to not practice data-blocking, which the congress has expressly asked that vendors not do. and physicians to a large extent are really a victim of what the technology allows. they all want to share data. i have not met a physician who when they refer a patient doesn't want to know what happened to that patient and get that back electronically. but it's the technology that
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really needs to do that job we think in the ehr certification that just came out and in a number of the other activities we think vendors are going to move in that direction. they need to move in that direction. >> good. thank you, mr. chairman. appreciate it. i yield back. >> thank you, mr. paulsen. thank you, mr. slavitt. one comment related to that is, we can discuss this more. as you develop a final rule and the performance period begins on january of 2017, vendors are going to have a limited time to reconcile with this new rule. then physicians are going to have to digest the new rule. so i hope that, again, particularly for the small group, rural markets, i hope that you'll work with us to make
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sure that that implementation is done smoothly. and related to that, i don't know if you think you have some authority in this area. so, the gap of time between performance period and then the payment year for physicians is two years. yet, the clinician reporting period is a shorter period of time. do you think cms has the ability through rulemaking, the authority to change that a little bit? >> yep. so, one of the things we do see comment on are the proposed measurement periods and naming periods. what i will say is a couple things. one is we have two feedback periods built in so that -- one in the middle of 2017 and one in the middle of 2018, to provide information back to physicians. so there is a more current feedback loop. second thing i'd say is because we have focused so much on reducing burden and reducing the
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number of measures and so forth, we have had some feedback that people want to make sure that that starts as early as possible. we've had other feedback, of course, which tells us make sure we have enough time, make sure we have enough time to do the things we need to do, make sure we don't get penalized unnecessarily because we didn't have enough time. and to your earlier question, mr. chairman, if people will begin on the older technology and move to the newer technology, they will not get penalized for that. so, we are making those accommodations. but of course, the purpose of the comment period is for people to tell us, what are the things we missed, what are the things that could have an impact on someone's practice or on their patients that we didn't think of. and that's one of the reasons why if there's an important message today to get out, it's to please engage in the rule and give us the feedback that we need to hear. >> well, i can't thank you enough for coming today. as you can tell, in a bipartisan way members have a lot of
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interest in this, and not just the subcommittee level but the committee as a whole as well as the congress. and we really appreciate you taking the time and look forward to working with you and your team as you continue to develop this, and ultimately, put it into process the way that we all intended it to be. >> right. >> and appreciate the fact that you were so kind yesterday as well. look forward to working with you. hopefully, we've treated you nice enough that you'll come back as we have this bipartisan concern about the way this unfolds. so, as a reminder, any member wishing to submit a question for the record will have 14 days to do so. if any members submit questions after the hearing, i ask that the witnesses respond in writing in a timely manner. with that, again, thank you, again, and this committee is adjourned. >> thank you.
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republican presidential candidate donald trump is campaigning today in california.
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c-span will have live coverage of his rally in san diego at 5:00 eastern. california's primary is june 7th. the libertarian party holds its presidential convention this weekend in orlando, florida. it's the only third party on ballots in all 50 states. and c-span will have live coverage. it starts tomorrow night at 8:00 eastern when libertarian presidential candidates debate. then c-span will be live again from the convention sunday morning at 9:45 eastern when the party chooses its presidential candidate. >> president barack obama paid tribute today to the 140,000 victims of the atomic bomb dropped 71 years ago in hiroshima. before speaking, president obama joined japanese prime minister at the memorial in japan and laid a wreath. here's a look.
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president obama was the first u.s. president to visit the site of the world's first atomic bomb attack in japan. he spoke about how the relationship between the u.s. and japan has changed. tonight at 8:00 tonight on c-span. >> next week, american history tv programs are airing in prime time on c-span 3.
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look for the history features at 8:00 eastern including a war summit at the lyndon b. johnson presidential library monday, the first major engagement and the battle and the soldiers battle after the war with physical and psychological trauma and a conversation with henry kissinger. >> as the administration went on, a president who all his life had been known as concerned primarily with domestic policy was engulfed in a division of the country that in a way has lasted to this day. >> authors and historians about how they were divided over the war. how filmmakers lynn burns and novak. >> by the time we got four or five decades away where the triangulation can take place and
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you can have the distance necessary not to take a reactive response and something that is hopefully greater than the sum of its parts. begin to realize everything you thought you knew was not true. >> a look at the war from the perspective of those who fought it and the foreign relations after the war and those with vietnam. thursday, our real america series looks at the 1975 church committee hearings with the intelligence hearings and the irs and nsa. with the african-american history museum opening in september, friday at 8:00 p.m. eastern, an all day conference with talks on african-american religion and culture and as american history. >> i couldn't get that out of my mind. my students were thinking that somehow this african-american history was not real because there was no text book text book
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as there was in all of the american history courses taught in the department of history. so i decided to write a real text book. live on the u.s.-mexico corder, trade issues that affect the region and the country with brand on darby, editor for bright bar, texas. the players involved as well assests to cover the security and humanitarian aspects. local immigration lawyer will discuss practicing immigration law in the area. who she represents and the laws on the books related to citizenship and deportation. and dallas morning news mexico
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city bureau chief examines the cartel s including the violence and smuggling of humans and narcotics. he is the author of midnight in mexico. a country's decent into darkness. the trade reporter will discuss the flow and volume of trade. the congressman will join us to talk about how trade benefits laredo and the country. bob cash, state director for the trade coalition and a nafta critic at how the deal took jobs from texas to mexico and how it hurts mexicans as well. be sure to watch washington journal beginning live at 7:00 a.m. eastern wednesday and thursday, 1st and 2nd from laredo, texas. join the discussion. >> a discussion now on the challenges of combatting isis in
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libya with the envoy, the libyan embassy and middle east scholars. this panel was hosted by the middle east institute. it's about an hour and a half. >> good afternoon, everyone. it gives me great pleasure to welcome you to today's panel examining the challenges of combatting isis in libya. it's gratifying to have a large audience given how beautiful the weather is. thank you very much for your interest. in recent days and weeks we have seen media attention focused on the issue of combatting isis and al qaeda and the panel will examine their role in libya and how they managed to take control
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of cities like gadhafi's hometown and efforts to defeat isis and al qaeda affiliate this is this country. on our panel, we are fortunate to have a diverse group of individuals who are working hard on the issue. it's a great honor to be joined by the senior libyan representative and i want to recognize the u.s. government and taking time out of his busy schedule to share his thoughts. he had to be hauled away on libya. charles lifter and karn dee's fred weary. thank you for joining us and that will be highly informative. thanks to our moderator who is a libya expert in his own right.
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he will be introducing the panelist and running the conversation afterwards. he is a scholar and a former vice president of the institute. he is a frequent commentator andburg hand during his career he served as secretary of state and ambassador to the united arab emirates and including stents. i would like to hand the panel over to you. thank you very much. >> there so many things we can talk about regarding libya, but this program will focus on what the so-called islamic state is up to in libya. although it has wrongfully
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appropriated the word islamic and has not performed most functions of the state, i will refer to it by the acronym. there other people who may call it isil or isis. i won't contradict the president of the united states who insists on calling it isil, but that works for me. that's what i will call it. charles lifter is an expert and in general on terrorism phenomena represented by groups and he is knowledgeable about other substate armed groups that often practice terrorism without covering it very often in the u.s. media. he understands the complexities and he brings a strong grasp on the theory and practice of terrorism as illustrated by his
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book on syria. there full biographies on the sheet you received. he brings that particular perspective to this panel and the others have other perspectives which will be useful in performing the view of the problem. fred wary has expectancies in military affairs and knows military well with the embassy in libya and based on numerous trips to the country. he coulds the complexities of libyan-armed groups and the foreign military establishments that might be involved at some point in interacting with the libyan government. she has shown herself to be an articulate voice for both the libyan government of national accord and for the libyan people
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more broadly. she is a for vent libyan patriot and involved in libyan civil society efforts against the gadhafi regime and responded to her country's call by accepting senior positions in the libyan ministries of education and foreign affairs prior to her current assignment. jonathan wiper is the secretary of state for libya. he was a key member of kerry's staff when john kerry was the chairman of the foreign relations committee. john kerry brought him over to the state department where he performed a number of jobs that might be called thankless because they were really touching issues, but he showed himself able to apply the broad
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principals of u.s. foreign policy to specific circumstances that are penitentiary to national interests. his current assignment as special envoy for libya has been something he is doing for 2 and a half years. it made him very aware of the interests of libya's arab, african and european neighbors as well as the various cross currents within the libyan body politic. that's the order on which i am going to ask our speakers to address the issues for about eight minutes. then i will ask a few questions. we will have a little interchange among members of the panel before we open it up to questions from the audience.
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. >> thank you very much for the kind introduction. we will fly straight into the discussion points. i'm not a libya expert and i will look at how libya got there and what it represents as of today. since isis's declaration of a supposed caliphate in late june, isis as an organization sought to become a transnational or international movement and libya has become the most important secondary area of operations outside of syria and iraq. it has done so by exploiting libya's fundamental and political failures.
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this is a model of exploiting and existing divisions over the last several years. isis aims to enter into areas where there already extensive and intense divisions within the power plays and existing social structures. if you look at how isis entered into syria, this is the same model. this is exactly the same model that was in the city of mosul. the information out there talks about how isis learned local dynamics. it knew all of the tribal
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leaders and all of their dirty histories. it knew how certain tribes were against other tribes and how militias had a history maybe 20 or 30 years prior which it could use to play up the act. estimates in terms of manpower vary, but arguably is represents three to 6,000 fighters. it is made up of non-libyan fighters. tunesians turned out to be a significant recruitment.
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how they left to bolster presence. the same with regards to senior commander who is have been fighting in syria and iraq and they have at least half a dozen been deployed to libya to the structures. particularly considering the organization that is coming under pressure in syria and iraq. 3,000 to 6,000 fighters. they control roughly 200 kilometers of territory. operationally, isis has a capacity to reach over to the
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border and was demonstrated, across the border into tunisia as well as into the capital of tripoli and benghazi and further a field. isil is led by a saudi in libya. having previously been led by a very senior i till leader who came from iraq to bolster i will sill's leadership. isil demonstrated fast growth. roughly 1.5 to 2,000 fighters. the high end is as much as 6,000, although i suspect it's probably three or four. that's at least a doubling. it operates multiple training camps across the country including for children. those are known as cub camps. clearly it's trying to be in
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libya for the long haul. sirte is the de facto capital. it exploits the kind of preexisting social divisions and tribal divisions and political divisions and militia divisions to its own advantage. i'm sure my esteemed panelist will talk about this in more detail than i, but in particular the sirte was ka gaffy's hometown. it was well-known to have been an area where loyalists had gone back to after the fall of the regime. but it was also a town that was under the control of the militias prior to isil's entry into the town. isil used the fact that there were individuals that others accused of being loyal or still loyal to its own advantage and
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many of those individuals who now fight under isil's ranks and you can perhaps use a similar analogy and it's more complicated to talk about how isil exploited the former era officials in iraq. the preexisting tensions they used to their own advantage. i fast forwarded over a little bit of the detail in terms of governance suffice it to say is extremely harsh. as soon as isil took over and imposed a city charter. this is something did in syria and something it did in mosul and iraq. it lays out a full law and order approach to how civilians are expected to behave in sirte as a whole. women are subject to as many as
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seven behavioral and dress code regulations. men have similar regulations with regards to the length of their trousers. they have three prisons that were established depending on the magnitude of your alleged crimes. behavioral police were established that patrol the streets on a day to day basis. internet is restricted to internet cafes run by isis. the acquisition of outside information is particularly restricted unless one is able to travel outside of the city or outside of isil areas of control. there is middle evidence to suggest that isis is making significant money from oil in libya, but it is taxing civilians in sirte and elsewhere at significant levels. all of this basically underlines the same model isis used to
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control through fear populations under their influence. i will have the discussion with regards to libya. i would advocate in this current phase, not rushing. i think there is an impetus within political discussions these days to rapidly bring the fight to isis and kwlab through local forces and deployment of special forces from the u.s. and france and various other countries. isil will exploit this unless that structure used in terms of local fighters are vetted and trained and equipped and under a single command. i don't think we are anywhere near that position as of now. in that sense, i would recommend a strategy that in a sense accepts the fact that people are not necessarily happy under isil
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control and people are willing to be under isil control considering the broader state of chaos. overtime, resentment will continue to grow. this is something we have seen and tried in places like the egyptian sinai. time should be spent now on -- as i'm sure my fellow speakers will talk about, better uniting the structure in libya after the december 2015 agreement. they have the west and east armed structures under the current government that was agreed in 2015 and under the command of the general in benghazi in the east. unless those two forces unite, i can say with pretty significant certainty, isil will exploit the two divisions or certainly it will try to and it will devote
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resources to doing so. in terms of the influx of weaponry, there is a un embargo to militia forces in libya. they have not done a lot of good. various actors have been sending in weapon stock. various outside actors have been sending in weaponry and is now a discussion that kerry spoke last week about finding a way out of that un arms embargo to send weaponry to acquired armed forces on the ground. again, i would urge caution and until that is a unified arm structure until they have been sufficiently vetted and sufficiently trained and sufficiently linked up with preferably external u.s.-french, and british. i would hesitate to accepted them in and we learned many
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lessons from 2011 and 2012 from syria that should be learned in a place like libya today. i'm sure there is plenty nor discuss, but i'm rushing through my notes. >> thank you, charles. we need about 30 seconds to make technical adjustments and among other things, we will get the mike level up to where it will be better for people in the back of the room.
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>> thank you so much and what an introduction. hopefully i will find something new to say and underscore a lot of points that were made and illustrate them from recent trips that i made to libya. we have to understand the fusion and there is a long history that they headline upon and we are seeing a generational evolution with jihadism and these intense debates with jihadists about the nature of the state and the fate and the acceptance of governance. these are all being played out over the last two or three years and they represent the one
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particular strain and not to say there not other strains pushing back against it. the generations that you know them in the 1980s. the post 2001, 2003 generation and the post 2011 generation, a younger generation that was radicalized partly by the syria war by going to participating in jihad. there key notes that they tapped into. when it arrives, they fountain infrastructure already in place set up and much of the state's development has been the flipping of that infrastructure. obviously the syria war was huge and many libyans wnlt to syria after 2011. some of them wanted to volunteer
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and fight. obviously with the islamic state in syria and some defected over to that group and others came back and defected later on. it was a nucleus who came back to libya that implanted the organization first and announcing it in the fall. you had the weakening of the old al qaeda groups. part of that and this is my next point was the political division of kwlab into the camp that was fundamental to insert itself. they were usingly the islamic state to demonize opponents and the state is growing.
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you had the islamic state investing through advisers and the leadership of that. the technical advisers and many of these are foreign. you also had the foreign fighter influx. first in north africa and in general. don't come to syria and iraq. testimony to libya. when i was in benghazi with the libyan forces there, they said that the snipers and the suicide bombers were all foreign. the same thing was said when they were retaken. when we look at recountering the state, you have to understand the case by case basis that the
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roads are quite different. essentially sirte. i think the accepttation ran up against a barrier that pushed it out. so that allows itself to insert itself and how far the state can expand. they inserted itself into an islamist militia. it flipped the shield members and enjoyed support from the social fabric of key neighborhoods under assault by operation dignity. it was bolstered by foreigners coming in from abroad and by boat. the main stronghold is where the
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original infrastructure proved so critically. they went to sirte and really played a role in coopting tribes and tribal mediation in flipping the progadhafi tribes that faced discrimination. that's what the state played upon. this notion that you are the losers and we can protect you. you can't say they came over to isis. it's often very certainlized choices and often very localized. some refugees had this thing, we would rather support this draconian group than go to this group that treated us so poorly.
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next the islamic state is moving south towards tripoli and capitalizing on the exclusion. the dynamics that are more financial and had the long time affiliation, there is a large foreign. this guest house for foreign volunteers. what is the strategy right now? i would argue it's one of consolidation and disruption. we saw this on police training. to peel away the losers of the new order, what are the tribes we can peel away and to shift westward? the key challenges, i have one minute.
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there is no chain of command and the great risk that the u.s. and others face is identifying the risk of working with militias and counter terrorism has the enormous challenge for rebuilding the police. the islamic start should be a platform to do that. as i see it, there three options. this is untenable. we know from experience. there has to be a local element. the second is the west and local enablers or allies and the second, this is fraught with risks in terms of whatsomes
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next. the third is the most desirable and the one with the most time horizon. supporting a libyan let through a national everyday that tackles the menace. >> since the time is too short, it might be a little bit. >> special thanks for posting this important discussion. on a very important topic to my
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country. and to the region. libya is at a dangerous turning point and after we heard analysis from the experts, i'm going to be talking in a different aspect and i will be talking about what you think is a different perspective on defeating isis and libya sustainable defeat. libya is in economic crisis and in a desperate need and threatened by islamic state. libya threatens the region and the chaos is a result of domestic political and economic dynamics that resulted in divisions and confrontations between different arms across the country. military intervention or
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military technical assistance alone will not be enough to defeat isis. libyans will defeat terrorism through addressing domestic drivers of instability. the u.s., the international community should focus on helping libya on stabilization such as the economy and reconciliation between the groups and decentralization of powers. the most effective response the construction of an accountable libyan state with a sector. without an accountable libyan state, the war or other extremist groups will be endless in libya. this is not to say that nothing can be done between isis and libya in the short-term.
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quite the opposite. the fight could strengthen the process and vice-versa. efforts with the command to fight isis can help the wagz and strengthen the political process. more over, new government should be supported to resist threats by militias and help the central bank and government push back against the demands and put constraints on spending on salaries. not only that, but according to the agreement, militias should be dismantled either in civil or military sectors. it is essential for the government to reconcile with the forces dominant in eastern libya, namely the international community that should help in
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devising a proposal for reconciliation. acknowledging the in defeating terrorist groups in the east and acknowledging the sacrifices of the libya in the east is paramount to reconciliation. the u.s. and the international community should support them through policy aspects. in terms of priorities, the crisis should come first. failure will further exasperate the crisis and increase activities and promote the growth of isis. second, political reconciliation is crucial to make libya's institutions work. acting this way will address the two most pressing concerns like
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security and counter terrorism and illegal immigrants on the other. the idea is given insecurity. the international community should not be to put security first and focus on building its forces and control its borders. this strategy has failed before and i was a witness to that as i was secretary for political affairs and security initiatives offered by many countries around in conclusion, the u.s. and the community should not see through the lens of counter terrorism and should not take a purely
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technical approach focused on building equipment and arming, etc. even though they are important. to sustain results, they should help the new government and tackle crisis and help develop functioning kmugzs so it can absorb the support offered bite the community. it can absorb whatever is offered by the international community. to grapple with these problems, very high level of political diplomatic efforts. thank you.
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there has been enormous wisdom expressed and generally speaking i agree with what has come up. and in the last 72 hours, we saw the forces regain critical territory. they grab acts and territory that lead to tripoli and lead to the south and lead to the east and turn with a big bus and improvise a closer device and what has been reported as three dozen libyan soldiers. there were 100 people seriously
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injured. this battle between the lib janes, they are people who believe in a country. and it offers a fantasy vision of gold glory, god, girls and guns which can be attractive to immature men and offer nothing to anybody else in the long run. this battle is being fought right now. chaos is the enemy. dash is an enemy and chaos is the big enemy. dash feeds on chaos. if you want to defeat it, you have to address the factors. that fed chaos in libya where a
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policy has to be based on at its core. the brought interest in libya is to support a unified libya and not that gets divided into parts with an accountable government and not people self proclaiming the resources. you have to talk to me if you want anything. it's me and i do. that was the way he ruled on behalf of the people for 42 years and it didn't work then and it doesn't work with the mini gadhafis who want to control the portions of the country and don't care about the whole. the strategy is rooted in the recognition of the prolonged discourse and they allowed violent groups to what live rate. you have other groups. when you have ungoverned or under goffer earned space, it's an opportunity for bad guys to
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make mischief. whether it's americans or brits or french or people from iraq and syria, they develop anti-s quick. that's one of the reasons why i'm betting on libya and libyans to win and not dash, whatever it is temporary. our approach is therefore tied very slowsly to the efforts to support the national is accord. we think they need a stable government to close the vacuum. that is a precondition to effectively combatting dash and other dad by groups for the long run. is it security or economy first? it's hard to get people to
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invest. if washington, d.c. had no internationals present, we will be a poorer place. our economy would be in shambles. the big global economic super power. that has been bad for libya in terms of foreigners. you get participants in libya's economy. one of the key things i learned in talking to the people, i said what reforms can they put in place with a management and good governance and getting rid of the salaries and so on and so forth. that would make the difference. they said there is nothing you can do and all that territory if libya is not pumping oil. they are responsible for 90 plus percent. they are pumping 150 gallons of
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oil a day. three minutes. we will not get to all four sections. doesn't work. you will eat up all libya's sea corn and then you have real chaos. the current economic problems and the security conditions are intimately interlinked and with a political. we look at security and we continue air strikes, we had two so far against terrorists. if you have one, you can have two. if you have two, you can have three. we have done the equipping or offered it and done a little of it. we will offer more. we secure it and i just came back from there including every
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country in the region. all of the mediterranean neighbors. unified government and exemption to let the governor take on terrorists. we support that and will probably participate in if the libyans ask us and moving ahead to try to build successful national structures. on the economy, there is liquidity and some of that is hoarding and we need to get through it. we have to give libyans hope that there is a future through government and governance. we have to get the next generations of libyans playing a profoundly significant role. they have many fewer bad habits.
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i see hope with incoming generations and they believe in their country and want to see it as a place they can live in. they are founded on the premises of one government and not multiple. compromise and sharing, one political process and not multiple negotiations and multiple places. regional states. anyone who had clients and proxies and aligning on behalf of the government rather than fighting ideological or regional or sectarian battles. and resources being shared on a national level. whether you are east, west, south, or anything else, you have a stake in the government. those are pretty core princip s principals. those are simple in the end from this complicated problem. if you stick with the principals, you may be able to make progress which i think we are starting to see as they
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begin to take hold. thank you. you hearing me well in the back? i will go through and ask a question of each one of the speakers in the order and i may ask them to question one another about points. let me start with charles. your distribution of sirte doesn't look like a fun place for a libyan to be living, but i wonder, is it a place where they can people to safe? this is a very, very close thing
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to the sea born air assets of nato countries. they threaten dash in one way or another. do they really see this as a place where they can build long-term? >> the honest answer is i'm not convinced. it's the best bet they have got for now and the best opportunity they have from late 2015 to 2o 16. as i said, i'm not enough of an expert to say, but from what i
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can see, they meat attempts. there is indications they are requiring foreign fighters and not just through tunisia, but from more on further. i think sirte will be there bastian. i have fairly little doubt there will be a fight for the city at some point. isil knowing how they operate elsewhere and the fact that they appear to be led by commanders who have come from there, they will seek as many divisions as they can. so as to prolong their control and surrounding areas for as long as possible. of course what happens after that, we have to wait and see. i don't think it's a coincidence that isis demonstrated in march of this year the capacity to spill over to tunisia.
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i don't think it's a coincidence that we have seen isis slow down or reduce the mass executions they have carried out. i think it's 49 executions. quite a low number. i don't think it's a coincidence that we have seen that low number. we are aware of what they have here coming into the future. if they feel under pressure, we will see more killings. more spectacular tax. the oil industry may come under attacks. i don't think we are there. and we are in that city building effort that we have seen replicated elsewhere in syria and iraq and elsewhere. >> let me ask you to pick up on
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that and you can building the quasi-state structures there that had has in turkey and in syria. there has got to be competition from the new government of national accord. i just question how much in the way of financial reserves they could bring to bear in trying to attract libyans and other fighters. i realize there is a big reservoir of potential fighters and tunisia and so on, but what are the practical constraints on dash and how would it be possible for the combination of the libyan government of
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national accord and they will compete with them. you have answered it. they are not able to replicate the functions elsewhere because they lack revenue streams. they are not able to and disenchantments. they have these isolated pockets. they have been pushed out and it's episodic. i mentioned this atomization to run up against rival towns wherever they go. again, i think it's the lack of will and capacity of these factions that allowed them to grow.
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they are still capable of disruption and they can plot attacks applaud. as jonathan mentioned, that was a preemptive and it has been violent and a lot of people have lost their lives. again, this goes to the question of inclusive governance. the stuart solution will only get you so far. something has to come after isis. it has to be inclusive and the return of displaced. we don't want to substitute one for another, there reasons they flourished in the locales. i think it's critical that we proceed cautiously and methodically. >> that said, if things
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condition to stag nate in reestablishing stability in libya and if as the weather improves in the mediterranean, we have a wave towards europe, desperate refugees with all the potential for terrorists coming along with them, which countries would be most critical to western militariests y esiest a countries feel most threatened and which are likely to come forward with some kind of military assets if things deteriorated to that extent. >> i think you answered it.
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the european countries that are effective. they have announced willingness and they have been crucial to this and i believe they committed to training the greatish and the french. they have their forces on the ground and i think they would be critical to lending expertise now. there is a huge will and a matter of coordinating. this is crucial so the interactions are not working across purposes. and then making sure that the countries that have capabilities to contribute. the u.s. has capabilities and we need to learn the lessons of our past that were alluded to where
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we did the training before there was anything to absorb. there was no unified government and you train a bunch of soldiers. also making sure you train a military that is representative of all of the factions that you are not just training a town or tribe. >> surely you are not suggesting that we dump military. >> did i say that are? >> no, but that's my question. how much training is going to be required for the forces loyal to them to absorb? >> you might ask that we know from past importances, how long does it take to do?
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how about well did we do in iraq? again, it goes to the question of -- it's not a technical capacity. you can train them to certain unity. it's a long horizon. i think we're looking at a very long time. we have this immediate isis threat but, again, we need to look at the long game in terms of how to rebuild the military. it will take a long time. >> okay. let me follow up on that with you, wafa. the governments that were represented in vienna have indicated support for lifting the arms embargo on sales of military equipment to the government. assuming that gets through the u.n. security council, and it will take a u.n. security council vote.
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i don't know what russia might do at this stage but assuming there is a u.n. security council resolution, is your government also going to request specific assistance in terms of training forces and where? would it be on libyan territory, tunisia or egypt? i don't understand how you form up the armed forces for the new libyan government starting from where you are now. >> okay. thanks. it's not an easy question. let me tell you something. let me go back to something done
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by a couple of countries, among them the u.s. and three european countries where they had proposed to train some libyan soldiers after the g8 summit in 2013. they made a proposal to -- it was the general purpose, the idea was to create a nucleus of national army, the idea was to train them abroad. we failed big time because the vetting was inappropriate. the young people were taken to different countries and there was one critical thing where you have different schools of military. how can you train a military by six or seven skaolchools and ex t them to come back. the vetting failed and the reason was we did not have a
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proper strong institution for vetting. institutions to the existing weak, fragile defense military. right now let me tell you, we have a lot of military professionals all over the country -- south, west and east. we have many different ranks. the military institution existed during a different time just like any other fragile institution. we had big massive military capacity, as you know, during the revolution when the camps were open. the country had a huge, massive amount of arms. those officials, those military ranks are available. they are there. the idea is to gather them. i think this is what's starting to happen. i know the government of
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national accord is already working with these people. the same in the east, the libyan national army composes of these people regardless. sometimes, yes, they had recruited civilians and, yes, the war was tough and, yes, it's street fight not traditional military fight. you have to realize that fighting terrorism is not a traditional classic military confrontation or something. very complicated and devastating because it should depend on intelligence, on special forces, special operations and not by the means of heavy artilleries. to sum that up, i think we do have the nucleus of the army in libya. we have young soldiers in many different towns in the west. gadhafi had trained many and now we are in a period where these people are technocrats.
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their hands are not loaded with blood, and they should come back and they're already there and building on that. we should build on it. we should build their capacity further and with lifting the arms embargo we have to be very careful here. we need to assess what we have already. we need to make sure that it's in the right hands, it's falling in the right hands. we need to solve the problem of the militias, and i spoke about that earlier that the government has to be supported to resist the pressures and their desire to continue. i mean, we don't want to go back in a circle of militias. i wish this would be in one of our u.n. security resolutions at that it's the duty of the government of national accord
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and international community to support us on that. they should be given incentives. and only at that point we can see a proper army being formed and assessing what we have and what is needed and the national accord will be prepared once there is a reconciliation between the armed groups across the country, prepared to make its proper requests. >> wow. thank you for that, wafa. i want to apologize for jumping over the very, i think, well-considered order in which you presented the issues that this government has to face.
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you said it in your prepared remarks of course that security couldn't come first. you had to start with getting the economy going, having political reconciliation and you specified reconciliation of the government of national accord with the libyan national army in the east. i want to recognize that you have a kind of a well thought out approach to that and i didn't mean to distort your views by getting you on to the military preparedness and rebuilding the military topic, but you did that extremely well, thank you. jonathan, i want to come to you last here. noting that some of the things we indicated, the u.s. government indicated what seems to me to have been a successful meeting in vienna, we were going to be prepared to be quite forthcoming in support of a wide range of support for the libyan government national accord, in effect, saying that if they
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would form themselves up as a partner, we would be there to partner with them. i really wonder to what degree this will have the necessary level of support from the congress of the united states which hasn't shown itself to be notably enthusiastic for sometimes for all the things that need to be done, to what extent do we need to build more support within the united states and particularly even though there were, as you noted, all the governments in the region signed on in vienna. in the past it's been my impression that we haven't had
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wholehearted support for the idea of the international community getting behind a single government and i wonder to what degree this issue needs to be higher on the agenda of our relations with egypt, for example, in terms of making certain that the international community carries out the kind of high-minded pledges that it made in vienna. >> thank you very much, ambassador mack. we were talking with egypt about libya all week this week, probably most of last week, and probably much of the week before. you forget when you continue to have conversation after conversation with one another. getting alignment among all of the regional players, all of the original players as well as the european neighbors has been at the core of our policy for the past several years.
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libya can't afford to get divided up by people with different interests fighting with one another. that's part of what leads to the chaos. if you have one regional state supporting one player and a different regional state supporting another player, that's not going to work well. i think everybody understands that. egypt, the united arab emirates, qatar, saudi arabia, sudan, chad, niger, morocco, i hope i've not missed any of the north african players -- jordan -- i did miss one -- as well as the united kingdom, france, the european union, all signed on to this communique which is a full-throated endorsement to the government of national accord. it's like water hydraulics. i don't know if there are other

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