[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


 
BETWEEN YOU AND YOUR DOCTOR: THE PRIVATE HEALTH INSURANCE BUREAUCRACY--
                                 DAY 2

=======================================================================

                                HEARING

                               before the

                    SUBCOMMITTEE ON DOMESTIC POLICY

                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 17, 2009

                               __________

                           Serial No. 111-128

                               __________

Printed for the use of the Committee on Oversight and Government Reform


         Available via the World Wide Web: http://www.fdsys.gov
                     http://www.oversight.house.gov
BETWEEN YOU AND YOUR DOCTOR: THE PRIVATE HEALTH INSURANCE BUREAUCRACY--
                                 DAY 2





BETWEEN YOU AND YOUR DOCTOR: THE PRIVATE HEALTH INSURANCE BUREAUCRACY--
                                 DAY 2

=======================================================================

                                HEARING

                               before the

                    SUBCOMMITTEE ON DOMESTIC POLICY

                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 17, 2009

                               __________

                           Serial No. 111-128

                               __________

Printed for the use of the Committee on Oversight and Government Reform


         Available via the World Wide Web: http://www.fdsys.gov
                     http://www.oversight.house.gov



                  U.S. GOVERNMENT PRINTING OFFICE
64-918                    WASHINGTON : 2011
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202ï¿½09512ï¿½091800, or 866ï¿½09512ï¿½091800 (toll-free). E-mail, [email protected].  

              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                   EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania      DARRELL E. ISSA, California
CAROLYN B. MALONEY, New York         DAN BURTON, Indiana
ELIJAH E. CUMMINGS, Maryland         JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio             JOHN L. MICA, Florida
JOHN F. TIERNEY, Massachusetts       MARK E. SOUDER, Indiana
WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts      LYNN A. WESTMORELAND, Georgia
JIM COOPER, Tennessee                PATRICK T. McHENRY, North Carolina
GERALD E. CONNOLLY, Virginia         BRIAN P. BILBRAY, California
MIKE QUIGLEY, Illinois               JIM JORDAN, Ohio
MARCY KAPTUR, Ohio                   JEFF FLAKE, Arizona
ELEANOR HOLMES NORTON, District of   JEFF FORTENBERRY, Nebraska
    Columbia                         JASON CHAFFETZ, Utah
PATRICK J. KENNEDY, Rhode Island     AARON SCHOCK, Illinois
DANNY K. DAVIS, Illinois             BLAINE LUETKEMEYER, Missouri
CHRIS VAN HOLLEN, Maryland
HENRY CUELLAR, Texas
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
PETER WELCH, Vermont
BILL FOSTER, Illinois
JACKIE SPEIER, California
STEVE DRIEHAUS, Ohio
JUDY CHU, California

                      Ron Stroman, Staff Director
                Michael McCarthy, Deputy Staff Director
                      Carla Hultberg, Chief Clerk
                  Larry Brady, Minority Staff Director

                    Subcommittee on Domestic Policy

                   DENNIS J. KUCINICH, Ohio, Chairman
ELIJAH E. CUMMINGS, Maryland         JIM JORDAN, Ohio
JOHN F. TIERNEY, Massachusetts       MARK E. SOUDER, Indiana
DIANE E. WATSON, California          DAN BURTON, Indiana
JIM COOPER, Tennessee                MICHAEL R. TURNER, Ohio
PATRICK J. KENNEDY, Rhode Island     JEFF FORTENBERRY, Nebraska
PETER WELCH, Vermont                 AARON SCHOCK, Illinois
BILL FOSTER, Illinois
MARCY KAPTUR, Ohio
                    Jaron R. Bourke, Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on September 17, 2009...............................     1
Statement of:
    Collins, Richard A., senior vice president of underwriting, 
      pricing, and healthcare economics, UnitedHealthcare Group, 
      CEO, Golden Rule Insurance Co., president, UnitedHealthone; 
      Brian A. Sassi, president and CEO, consumer business, 
      Wellpoint, Inc.; Patricia Farrell, senior vice president, 
      National and International Business Solutions, Aetna, Inc.; 
      James H. Bloem, senior vice president, chief financial 
      officer, and treasurer, Humana, Inc.; Thomas Richards, 
      senior vice president of product, Cigna Healthcare; and 
      Colleen Reitan, executive vice president and chief 
      operating officer, Health Care Service Corp................    14
        Bloem, James H...........................................    49
        Collins, Richard A.......................................    14
        Farrell, Patricia........................................    33
        Reitan, Colleen..........................................    90
        Richards, Thomas.........................................    67
        Sassi, Brian A...........................................    22
Letters, statements, etc., submitted for the record by:
    Bloem, James H., senior vice president, chief financial 
      officer, and treasurer, Humana, Inc., prepared statement of    51
    Collins, Richard A., senior vice president of underwriting, 
      pricing, and healthcare economics, UnitedHealthcare Group, 
      CEO, Golden Rule Insurance Co., president, UnitedHealthone, 
      prepared statement of......................................    16
    Farrell, Patricia, senior vice president, National and 
      International Business Solutions, Aetna, Inc., prepared 
      statement of...............................................    35
    Jordan, Hon. Jim, a Representative in Congress from the State 
      of Ohio, prepared statement of.............................     7
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio:
        Article dated August 24, 2009............................   121
        Article dated February 11, 2009..........................   102
        Prepared statement of....................................     4
    Reitan, Colleen, executive vice president and chief operating 
      officer, Health Care Service Corp., prepared statement of..    92
    Richards, Thomas, senior vice president of product, Cigna 
      Healthcare, prepared statement of..........................    69
    Sassi, Brian A., president and CEO, consumer business, 
      Wellpoint, Inc., prepared statement of.....................    24


BETWEEN YOU AND YOUR DOCTOR: THE PRIVATE HEALTH INSURANCE BUREAUCRACY--
                                 DAY 2

                              ----------                              


                      THURSDAY, SEPTEMBER 17, 2009

                  House of Representatives,
                   Subcommittee on Domestic Policy,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:25 p.m., in 
room 2154, Rayburn House Office Building, Hon. Dennis J. 
Kucinich (chairman of the subcommittee) presiding.
    Present: Representatives Kucinich, Cummings, Tierney, 
Kennedy, Foster, Towns (ex officio), Jordan, and Schock.
    Also present: Representative Conyers.
    Staff present: Jaron R. Bourke, staff director; Yonathan 
Zamir, counsel; Jean Gosa, clerk; Charisma Williams, staff 
assistant; Ron Stroman, chief of staff, full committee; Carla 
Hultberg, chief clerk, full committee; Leneal Scott, IT 
specialist, full committee; Adam Hodge, deputy press secretary, 
full committee; Rob Borden, minority general counsel; Dan 
Blankenburg, minority director of outreach and senior advisor; 
Adam Fromm, minority chief clerk and Member liaison; Ashley 
Callen, minority counsel; and Molly Boyl, minority professional 
staff member.
    Mr. Kucinich. The Domestic Policy Subcommittee of the 
Oversight and Government Reform Committee will now come to 
order.
    Today is the second of this subcommittee's 2-day hearings 
examining how the bureaucracy of the private health insurance 
industry influences the relationship between physicians and 
their patients.
    Yesterday, the subcommittee heard the testimony from 
individuals, doctors, whistleblowers, and policy analysts, all 
of whom related their experiences with, and opinions about, the 
private health insurance bureaucracy and its impact on health 
care in America.
    Today, the subcommittee will hear testimony from top 
executives of the six largest health insurance companies in the 
United States, and I want to welcome the witnesses and thank 
them for their presence here, and we look forward to hearing 
from you.
    Now, without objection, the Chair and ranking minority 
member will have 5 minutes to make opening statements, followed 
by opening statements not to exceed 3 minutes by any other 
Member who seeks recognition.
    Without objection, Members and witnesses may have 5 
legislative days to submit a written statement or extraneous 
materials for the record.
    I want to add that the House has adjourned for the weekend, 
and while generally that means that there would be very few 
Members here, there are a number of Members who have expressed 
an interest, and you may see them come in throughout the course 
of the hearing. But good afternoon and thank you very much for 
your presence before this subcommittee.
    Yesterday, we received testimony from the daughter of a man 
whose bone marrow transplant was delayed an agonizing 126 days 
while authorization from his insurer was denied and sustained 
on appeal. She asks, ``Would there have been a different end to 
my dad's story if he had been given approval of the first 
transplant request in April 2006? Would he be alive today? We 
don't know. What we do know is that his chance for survival 
most assuredly did not increase because''--and she is talking 
about the insurer--``built the bureaucratic roadblocks that 
changed the course of my father's treatment and made him wait 
for his potentially life-saving bone marrow transplant.''
    We also heard from the father of a 2-year-old who was born 
with a severe cognitive disorder. He has had to struggle to get 
the coverage his premiums pay for. Recounting the toll on his 
family that the repeated delays and denials of care for his 
daughter caused by his health insurer, here is what he told us. 
He said, ``The stress of constantly of having to hold the HMO 
and their agents to their agreed-upon obligations has relegated 
me to the role of my daughter's care manager and all too often 
robbed me of my role as Sidney's loving daddy.''
    The experiences of these individuals are the tip of an 
iceberg. Court and State regulatory records are replete with 
recent findings of wrongful denial and delay of health care by 
private health insurance bureaucrats. Hundreds of thousands of 
people have been wrongly denied health care coverage, hassled 
with unnecessary documentation requests, underpaid claims, 
ripped off by fixed data bases that underpaid claims. The 
actions of insurance company bureaucrats in causing needless 
delays and denials of coverage for prescribed treatment can be 
as detrimental as the disease itself.
    Now, this was the conclusion of the Ohio Supreme Court when 
it upheld the largest jury award in Ohio's history against 
Anthem for denying life-saving treatment to Esther Dardinger. 
Here is what the Court said in that decision.
    ``Then came the bureaucracy. Anthem had worn''--talking 
about the Dardingers--``Anthem had worn the Dardingers down as 
surely as the cancer had. Like the cancer, Anthem relentlessly 
followed its own course, uncaring, oblivious to what it 
destroyed, seeking only to have its own way.''
    That is from the court decision.
    Now, regulatory actions and jury awards do not, however, 
tell the whole story, since these measures consist only of 
instances in which insurers were caught and punished for a 
violation. There is no record of the silent suffering that our 
constituents endure without filing a complaint or a lawsuit.
    Recently, however, the research arm of the California 
Nurses Association published results of its analysis of claims 
payment data maintained by the California Department of Managed 
Health Care. They found that claim denials by health insurers 
operating in California averaged 21 percent in the period 2002 
to June 2009. Unfortunately, we learned yesterday from another 
witness that there is no comprehensive national data source on 
all health care coverage that has been denied, substituted, or 
delayed.
    In this absence of transparency, health insurance companies 
promote the public image that they encourage healthy living. 
All of the insurance companies here today wanted to be 
represented by their top doctors, known as chief medical 
officers. Had we allowed that, their preferred representatives 
would have been consistent with the public image that the 
companies like to project, but it would have denied the 
subcommittee the ability to probe how health insures really 
work. What is your business model?
    Whether a health insurer follows a doctor's order or 
interferes with it by denying a pre-authorization is in large 
part a business decision. It is not a medical one. Financial 
analysts of the health insurance industry carefully chart the 
medical loss ratio, which you are all familiar with, the MLR, 
the amount of each dollar received in premiums that health 
insurers spend on medical expenses. Investors consider MLR to 
be a key indicator of an insurer's ability to control its 
spending on health care and thereby is a predictor of 
profitability.
    Insurance company executives pay attention first to the 
concerns of Wall Street. We understand that. According to a 
former executive of one of the Nation's largest for-profit 
insurers, quote, investors want that MLR to keep shrinking. And 
if they see that an insurance company has not done what they 
think meets their expectations with the medical loss ratio, 
they'll punish them. I've seen a company stock price fall 20 
percent in a single day, when it did not meet Wall Street's 
expectations with this medical loss ratio.
    That's a quote.
    Private health insurers have developed a sophisticated 
bureaucracy to find reasons to avoid paying for expensive 
treatment. They are developing new products, with high 
deductibles and copayments, so they don't have to pay the 
health care bills. Private health insurers refuse to abandon 
the practice of rescissions, in which they revoke a policy 
after receiving premium payments once large claims are filed. 
Over 60 percent of people who entered bankruptcy due to medical 
costs that caused them to become insolvent had private 
insurance at the start of the illness.
    Finally, private health insurers are insuring fewer people 
and earning higher profits by avoiding providing coverage to 
people who get very sick and have very high medical bills. That 
is what Wall Street wants to see; and today, thankfully, we 
have before us senior executives from the six largest private 
insurers in the Nation who are here to explain to this 
committee and to Congress how you can reconcile the demands of 
Wall Street--which are quite significant and severe sometimes--
the demands of Wall Street with the health care needs of your 
policyholders. That is what we are going to be exploring today.
    So, with that, I am going to recognize the distinguished 
ranking member of the subcommittee, Mr. Jordan of Ohio.
    [The prepared statement of Hon. Dennis J. Kucinich 
follows:]

[GRAPHIC] [TIFF OMITTED] T4918.001

[GRAPHIC] [TIFF OMITTED] T4918.002

    Mr. Jordan. Thank you, Mr. Chairman, for holding this 
hearing. I want to thank our witnesses for being here today.
    Yesterday, we heard some heart-breaking stories of families 
dealing with severe illnesses and the mounds of paperwork they 
were forced to wade through when trying to get treatment. 
Bureaucracy, whether in government or private industry, should 
not be the final arbiter of health care decisions. In my 
opinion, those decisions should be between doctors, patients, 
and their families.
    My constituents come into our office and say that their 
child got sick and their insurance got canceled. Practices like 
this are inexcusable. People purchase health insurance to guard 
against the day their child or spouse becomes gravely ill. It 
is precisely these instances when people most need coverage. 
Individuals who have acted in good faith, paid their premiums, 
and upheld their contractual responsibilities should, in fact, 
be covered and get coverage.
    Last year, in the full committee, we held a hearing on 
improper health insurance rescissions. This was a problem in 
California and Connecticut. Rescissions should only occur when 
there is a material misrepresentation of fact or other breach 
of contract. It must be noted that any rescission, even when 
proper, leaves individuals uninsured. All stakeholders, 
regulators, insurers, and consumers should obviously try to 
prevent these occurrences.
    So what can we do to make sure that all Americans have 
access to coverage? My friends on the other side believe that 
more and bigger government is the answer. I think most 
Americans instinctively realize that trading some challenges 
with private insurance for the bureaucracy of the Federal 
Government is certainly not the solution. Instead, we should 
keep what works best in the current system and try to reform 
what is not working.
    The plan I support has four principles that I think need to 
be a part of any health care reform proposal: First, all 
Americans must have access; second, that coverage should be 
truly owned by the patient; third, we must improve the health 
care delivery structure; and, finally, any reform must attempt 
to rein in out-of-control costs.
    As we address these challenges in our health care system, 
it is important that everyone has a seat at the table. I am 
glad that our witnesses can be here today, and I look forward 
to hearing their testimony.
    Thank you, Mr. Chairman. I yield back.
    [The prepared statement of Hon. Jim Jordan follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.003
    
    [GRAPHIC] [TIFF OMITTED] T4918.004
    
    Mr. Kucinich. I want to thank my colleague from Ohio. We 
have a bipartisan effort here on these committee hearings; and 
I have always appreciated his perspective and also the fact 
that you sometimes offer a contrary point of view, which is 
needed to get to the truth. So thank you.
    We have the privilege of having the chairman of the full 
committee here, and I am sure all Members would agree that it 
is our responsibility when the chairman of the full committee 
shows up to provide the chairman of the full committee with an 
opportunity to be recognized. So at this time I want to thank 
Mr. Towns for the support that he has given this subcommittee 
in our effort to get to the bottom of some of these serious 
health care issues and thank you for your support on the whole 
range of concerns that the American people have.
    The Chair recognizes the chairman of the full committee, 
Mr. Towns of New York.
    Mr. Towns. Thank you very much. I would like to thank you, 
Chairman Kucinich and Ranking Member Jordan, for holding this 
important hearing on unfair practices engaged in by private 
health insurance carriers.
    And let me begin by saying I agree with President Obama's 
statement last week to the joint session that private, for-
profit health insurance companies perform valuable services to 
their subscribers and our Nation. However, President Obama 
rightly called for health care reform legislation that, No. 1, 
ends discrimination against people with pre-existing 
conditions; limits discrimination because of age and gender, so 
that seniors and women will pay the same coverage as others; 
prevents insurance companies from dropping coverage when people 
are sick and need it most; caps out-of-pocket expenses so 
people do not become broke when they become sick; and 
eliminates additional charges for preventative care such as 
mammograms.
    In many States, insurance companies can simply cancel a 
person's insurance if any existing medical condition is not 
listed on the application, and this can happen whether the 
person is even aware of the condition or not. We hear repeated 
reports that insurance companies limit benefits, simply drop or 
deny coverage for high-risk patients whose claims eat into the 
carrier's profits, and purge small businesses with high claims. 
Carriers are doing this at the same time that their executives 
are receiving millions and millions of dollars compensation 
packages.
    Businesses cannot provide their employees with coverage due 
to their own eagerness to make a profit. On the other hand, 
patients are afraid to disclose health conditions and might 
even be forced to lie in order to receive medical treatment. 
Some patients suffer greatly as their health declines without 
necessary medical treatment. These insurance carriers' 
practices are unacceptable and must be reformed.
    I believe insurance carriers must be held accountable. If a 
company sells insurance, it must provide insurance coverage. 
When claims are made in that regard, it is essential that 
Congress enact health care legislation that includes provisions 
designed to ensure accountability and strong enforcement.
    Mr. Chairman, I applaud you and Mr. Jordan for the work 
that you are doing and the members of the committee, but I want 
you to know that we have a lot of work to do because as we look 
and we see in terms of what people are going through, that we 
must reform it and we must reform it in a positive way.
    On that note, I yield back the balance of my time.
    Mr. Kucinich. I thank Chairman Towns.
    The Chair recognizes Mr. Foster, who was here even before 
anybody else.
    Mr. Foster. I yield back.
    Mr. Kucinich. OK. We will go to Mr. Cummings then.
    Mr. Cummings. Thank you very much, Mr. Chairman. And, Mr. 
Chairman, thank you again for holding this hearing; and I want 
to thank our panelists for being here this afternoon.
    Yesterday, we heard chilling testimony, shocking to the 
conscience--and, to be frank with you, after hearing that 
testimony, it was very difficult for me to sleep--about what 
insurance companies do to regular, everyday people like the 
people that I represent.
    We heard from a Mr. Potter, Wendell Potter, and let me just 
give you some of the words that he said.
    He said, ``For weeks now we've been hearing industry 
executives saying the same things and making the same 
assurances; and I am sure you will hear the same refrain 
tomorrow. This time, though, the industry is bigger, richer, 
and stronger; and it has a much tighter grip on our health care 
system than ever before.''
    ``In the 15 years since the insurance companies killed the 
Clinton plan, the industry has consolidated to the point that 
it is now dominated by a cartel of large, for-profit insurers. 
The average family doesn't even understand how Wall Street 
dictates determine whether they will be offered coverage and 
whether they can keep it and how much they will be charged for 
it. But in fact Wall Street plays a powerful role. The top 
priority of for-profit companies is to drive up the value of 
their stock. Stocks fluctuate based on companies' quarterly 
reports, which are discussed every 3 months in conference calls 
with investors and analysts.''
    ``On these calls, Wall Street investors and analysts look 
for two key figures: earnings per share and the medical loss 
ratio, or medical benefit ratio as some companies now call it. 
That is a ratio between what the company actually pays out in 
claims and what is left over to cover sales, marketing, 
underwriting, and other administrative expenses and, of course, 
profits.''
    And I will end it there.
    Basically, what they were telling us is that too many 
people are paying loyally, year after year after year, but when 
they want the insurance company to pay, the insurance companies 
quite often slap them in the face and say, no, we are going to 
give you a rescission. We are going to find a pre-existing 
condition so we can save money.
    But one of the things that was most chilling was the 
testimony that came when they told us that, quite often, these 
panels in the insurance companies get together and they wait 
out people while they are sick. They wait out while they are 
trying to get a decision; and, quite often, they wait so they 
can die. That is what we heard in here yesterday.
    And I said to them at that time that if that is the case 
then that is fraud, and it is criminal, and we as a country can 
do better than that.
    So I look forward to the testimony, Mr. Chairman; and, with 
that, I yield back.
    Mr. Kucinich. I thank the gentleman.
    The Chair recognizes Mr. Tierney of Massachusetts.
    Mr. Tierney. Thank you, Mr. Chairman.
    I don't intend to take my full 5 minutes except to note 
that you have all heard a little bit about the testimony we 
have been hearing from individuals, and I hope you take a 
moment rather than to read any pro forma statements that you 
may have made to address the particular issues like the medical 
loss ratio.
    Can you explain how it is as medical costs rise faster than 
inflation companies still manage to keep the same ratio--
medical loss ratio? Meaning they are putting less money into 
actual medical care and more money into profits, into salaries 
for executives, and into underwriting?
    And when it gets to underwriting, I think we would like to 
hear a little bit about why it is that other executives from 
firms like yours came before Congress and said that they would 
not do away with such practices like rescission, where somebody 
is ill and getting treatment only to find out the company then 
reaches back and tells them they are disqualified for some 
reason or why it is that you won't stop the practice of pre-
existing conditions unless you are regulated to do it or why it 
is you continue to put caps on coverage.
    It is all those reasons and things that lead this Congress 
to think that the only protection we can have for consumers is 
to put up a viable competitor against your companies to make 
them behave, make them come back and do more for consumers and 
less for their own self-interests and Wall Street's self-
interest.
    I see and we heard testimony yesterday about all sorts of 
new plans that you have coming out, voluntary benefits, limited 
medical benefits. And the voluntary usually means that 
employees are going to pay 100 percent of the premiums and that 
really the employers pay nothing, while limited benefit plans 
mean that they are providing limited coverage, maybe 
prescription drugs or maybe some lab work and X-rays, maybe 
through doctors' visits, but essentially the premiums are again 
paid entirely for by the employees. Those monthly premiums are 
usually 30 to 50 percent less than major medical plans, and the 
employees get left holding the bag because they are not really 
covered at the end.
    I know some of your companies are sponsoring a medical 
conference in Los Angeles next month promoting those types of 
plans. I want you to address for us how you think that is that 
will help small businesses. You say that they are doing it 
because you can't afford it, when in fact you are the ones who 
set the rates. You determine how high you are going to raise 
the premiums on other policies, driving them into policies like 
this for the small business employees.
    My small businesses aren't impressed with it, and they 
don't want to go in that direction. They want their employees 
to have good, solid coverage.
    So I hope you answer all of those questions, and I look 
forward to your testimony and maybe discussion afterwards of I 
think the sorry direction that we are going in the private 
health care industry, and maybe you can convince us why it is 
not essential that we do something in terms of regulation and 
competition to put a stop to those practices which really 
haven't shown or reflected well on your industry.
    I yield back. Thank you, Mr. Chairman.
    Mr. Kucinich. If there are no further opening statements, 
we will proceed to receive testimony from the witnesses before 
us today.
    I want to start by introducing our first panel:
    Mr. Richard Collins, welcome, Mr. Collins.
    Mr. Collins is the senior vice president of Underwriting, 
Pricing, and Healthcare Economics at UnitedHealthcare Group. He 
also serves as CEO of Golden Rule Insurance Co. and president 
of UnitedHealthOne, UnitedHealthcare's individual line of 
business. He has served in this capacity since July 2005. Mr. 
Collins also manages the individual business of American 
Medical Security Life Insurance Co. and PacifiCare.
    Next, Mr. Brian Sassi, welcome. Thank you for being here.
    Mr. Sassi is president and CEO of the Consumer Business 
unit for WellPoint, Inc. Mr. Sassi is responsible for the 
company's seniors, State-sponsored, and individual under 65 
businesses. Previously, Mr. Sassi was president of Blue Cross 
of California and chief executive officer of its life and 
health affiliate. He also served as vice president of 
Operations and Strategic Initiatives for Blue Cross of 
California and general manager of Small Group Accounts for the 
west region for WellPoint, Inc., the parent company of Blue 
Cross of California. Thank you.
    Ms. Patricia A. Farrell. Welcome, Ms. Farrell.
    Ms. Farrell is senior vice president of National and 
International Business Solutions for Aetna, Inc., leading 
divisions which provide health insurance for the Federal 
Government, TRICARE and State Medicaid programs and other 
businesses in the United States and abroad. Previously, she was 
the senior vice president of Aetna Specialty Products and 
Medicaid. This included Aetna dental, life, disability, long-
term care, and voluntary products, and Aetna's Medicaid and 
children health insurance program business. Ms. Farrell has 
also served as senior vice president for Strategic Planning.
    Mr. James H. Bloem--is that correct? The pronunciation?
    Mr. Bloem. Bloem.
    Mr. Kucinich. Mr. James H. Bloem.
    Mr. Bloem is senior vice president, chief financial officer 
and treasurer for Humana, Inc. He has primary responsibility to 
supervise all accounting, actuarial, analytical, financial, 
tax, risk management, treasury, and investor relations 
activities for that company. Thank you for being here.
    Mr. Thomas Richards. Appreciate your attendance here, Mr. 
Richards.
    Mr. Richards is senior vice president for Product 
Management and New Product Development for CIGNA Healthcare and 
CIGNA's Choice Link subsidiary, which provides customer 
benefits and online enrollment. Previously, Mr. Richards ran 
CIGNA's stop loss business, which provides reinsurance to 
middle market and national segment customers. During his 
career, Mr. Richards has held a variety of product positions in 
CIGNA Healthcare, including in CIGNA Healthcare's marketing 
department, where he helped design and bring to market 
preferred provider organization products and networks.
    And, finally, Ms. Colleen Reitan.
    Ms. Reitan. Reitan.
    Mr. Kucinich. Reitan. Ms. Reitan is executive vice 
president and chief operating officer of Health Care Service 
Corp., where she is responsible for its internal operations, as 
well as numerous divisions of the company, including subscriber 
services, government services, enterprise information, strategy 
and management financial services, among others. Previously, 
Ms. Reitan was president and chief operating office of Blue 
Cross Blue Shield of Minnesota, 20 years of experience in the 
health insurance field. She was also the co-creator of the 
Minnesota Health Information Exchange, a national model for 
sharing electronic health information.
    I want to thank you, Ms. Reitan, for appearing, and I want 
to a thank all the witnesses for appearing before our 
subcommittee today.
    I have to say, in just these first few minutes, in looking 
out at you and looking at your accomplishments in the insurance 
industry, this hearing is not and any of the questions that are 
asked, this isn't about anything personal. We respect who you 
are. But the institutions that you represent are here to be 
questioned today and challenged today, and we are going to need 
your cooperation in understanding your business model.
    With that, I will proceed to the swearing in. It is the 
policy of the Committee on Oversight and Government Reform to 
swear in all witnesses before they testify. I would ask that 
you please rise, each of the witnesses, and raise your right 
hands.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record reflect that each of the 
witnesses stood, raised their right hand and answered in the 
affirmative.
    You may be seated.
    Mr. Cummings. Mr. Chairman.
    Mr. Kucinich. Yes, Mr. Cummings.
    Mr. Cummings. Mr. Chairman, just a point of information. 
Mr. Chairman, you just swore in the witnesses. Should a witness 
fail to be truthful with this committee, is there a penalty 
connected with that?
    Mr. Kucinich. Staff attorneys have just handed this to me. 
This is pretty pro forma for any congressional hearing where 
witnesses testify and swear under oath. There are two sections 
covered.
    One is 18 U.S.C., section 1001, which relates to knowingly 
and willfully falsifying any statement. There are provisions in 
this for penalties that include fine and imprisonment.
    There is another section that I was given, 2 U.S.C., 
section 194, that relates to congressional and committee 
procedure. If anyone fails to answer any pertinent question, we 
would have to, according to this, certify through the House of 
Representatives the facts as we see them to the U.S. attorney's 
office.
    So, you know, it is a standard operating procedure in this 
committee, Mr. Cummings, that you know we expect witnesses to 
tell the truth, but, if they don't, there are penalties under 
law.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    Mr. Kucinich. Let's go to opening statements.
    Mr. Collins, you may begin with your opening statement. 
Thank you. And make sure that mic is close so we can hear what 
you have to say.

  STATEMENTS OF RICHARD A. COLLINS, SENIOR VICE PRESIDENT OF 
       UNDERWRITING, PRICING, AND HEALTHCARE ECONOMICS, 
    UNITEDHEALTHCARE GROUP, CEO, GOLDEN RULE INSURANCE CO., 
PRESIDENT, UNITEDHEALTHONE; BRIAN A. SASSI, PRESIDENT AND CEO, 
 CONSUMER BUSINESS, WELLPOINT, INC.; PATRICIA FARRELL, SENIOR 
VICE PRESIDENT, NATIONAL AND INTERNATIONAL BUSINESS SOLUTIONS, 
   AETNA, INC.; JAMES H. BLOEM, SENIOR VICE PRESIDENT, CHIEF 
    FINANCIAL OFFICER, AND TREASURER, HUMANA, INC.; THOMAS 
 RICHARDS, SENIOR VICE PRESIDENT OF PRODUCT, CIGNA HEALTHCARE; 
    AND COLLEEN REITAN, EXECUTIVE VICE PRESIDENT AND CHIEF 
          OPERATING OFFICER, HEALTH CARE SERVICE CORP.

                STATEMENT OF RICHARD A. COLLINS

    Mr. Collins. Thank you.
    Chairman Kucinich, Ranking Member Jordan and members of the 
subcommittee, my name is Richard Collins. I'm the head of 
underwriting, pricing, and health care economics for 
UnitedHealthcare. I am also the CEO of Golden Rule Insurance 
Co., a UnitedHealth Group company that provides individual 
health insurance to individuals and their families.
    Today, I will start with some relevant facts about 
UnitedHealth Group, our industry, and try to demonstrate how we 
are improving the quality of health care while reducing costs 
and streamlining administration.
    First, UnitedHealth Group provides high-quality health 
services and products for more than 70 million people in 
partnership with 5,000 doctors--5,000 hospitals and 600,000 
doctors across all 50 States.
    Second, we employ 75,000 committed and dedicated men and 
women. These people work hard to improve the health care and 
well-being of our health plan members.
    Third, we have prudently managed our finances during these 
challenging economic times and can back the promises that we 
make to our stakeholders.
    Fourth, our industry is already one of the most highly 
regulated in the United States. UnitedHealth Group has long 
advocated for comprehensive, bipartisan health care reform. We 
have proposed constructive changes that would ensure rates do 
not vary because of health status and gender and will guarantee 
coverage regardless of pre-existing conditions for those that 
maintain continuous coverage. These reforms would also require 
that individuals obtain and maintain health insurance coverage 
so that everyone participates in both the benefits and the 
costs of the system.
    Discussions of administration processes and health begin 
with benefits of a strong provider network. Our members receive 
great value from our extensive network, which includes more 
than 85 percent of the physicians and hospitals in the United 
States.
    We perform periodic credential reviews to make sure that 
network physicians and hospitals continue to meet standards of 
quality. Our members receive negotiated savings and discounts 
when they are cared for by one of our contracted providers. A 
key element to the success of this network is health 
information technology that we use to increase the speed and 
accuracy of claim processing.
    We pay more than 250 million claims annually, and more than 
95 percent are processed on our primary commercial platforms 
within 10 days. In fact, over 80 percent are processed 
automatically.
    Across our entire business, we have identified 100,000 
physicians through our premium designation program that 
consistently deliver quality in accordance with evidence-based 
standards, and they do so at costs 10 to 20 percent below their 
peers. These physicians use data, efficient practice 
management, and evidence-based medicine to guide and 
consistently improve patient care.
    This network system extends to doctors and hospitals that 
are best at managing complex medical conditions such as organ 
transplants, cancer, and congenital heart disease. This helps 
the sickest patients receive the best possible care, often 
resulting in better outcomes and often at prices with savings 
as much as 60 percent.
    Partnerships with physicians and hospitals are critical to 
streamlining administrative processes and providing greater 
value to our members. To that end, we have established two 
national and numerous local physician advisory committees. They 
provide us with feedback and help us ensure that we maximize 
the health care quality and minimize the administrative burden.
    We're also introducing innovative and practical tools that 
allow doctors and nurses and other health care providers to 
spend more time with their patients and less on paperwork. For 
instance, our eSync program synchronizes a person's medical 
history to help identify gaps in care that they should be 
receiving. Electronic medical records and e-prescribing 
technology help physicians practice better medicine through 
clinical decision support and reduce administrative costs 
through automation and Web-based transactions.
    In conclusion, UnitedHealth Group provides critical 
services and support at every point in the health care delivery 
system. We are privileged to serve our members and take 
seriously our responsibilities to serve Americans in this 
socially sensitive area of health care. Through innovative 
technology and programs, as well as close collaboration with 
the provider community, we are successfully improving quality, 
reducing costs, and making the administration of health care 
more efficient.
    Thank you, Mr. Chairman.
    Mr. Kucinich. Thank you, Mr. Collins.
    [The prepared statement of Mr. Collins follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.005
    
    [GRAPHIC] [TIFF OMITTED] T4918.006
    
    [GRAPHIC] [TIFF OMITTED] T4918.007
    
    [GRAPHIC] [TIFF OMITTED] T4918.008
    
    [GRAPHIC] [TIFF OMITTED] T4918.009
    
    [GRAPHIC] [TIFF OMITTED] T4918.010
    
    Mr. Kucinich. Mr. Sassi, you're recognized for 5 minutes. 
You may proceed. Make sure you bring that mic close enough.

                  STATEMENT OF BRIAN A. SASSI

    Mr. Sassi. Thank you, Chairman Kucinich, Ranking Member 
Jordan, and members of the subcommittee for allowing me to 
testify before you today. I'm Brian Sassi, president and CEO of 
the consumer division of WellPoint.
    WellPoint provides insurance and health benefits to 35 
million people across the country, representing almost one in 
nine Americans. We recognize we have the ability to help change 
health care for the better; and with this ability comes a 
responsibility to our members and to all Americans to advance 
health care quality, safety, and affordability.
    I look forward to discussing how WellPoint helps create 
health care value for our customers. At WellPoint, we develop 
evidence-based medical policy based on the latest clinical 
research. Our nurses and other health care professionals 
support our members to ensure that care is safe, necessary, and 
timely. And looking to the future, we continue to explore new 
ways to reward value over volume and stress safety, efficiency, 
and patient satisfaction.
    One of the areas under discussion in the current health 
care reform debate is health plan administrative costs. Last 
year, PricewaterhouseCoopers conducted an analysis of how the 
typical health insurance premium dollar is spent. My written 
testimony includes a chart that shows that 87 cents of every 
premium dollar is paid out to cover the cost of health care 
claims. Of the remaining 13 cents, 6 cents goes toward taxes, 
other government payments, claims processing, and other 
administrative costs. Four cents go to consumer services such 
as care coordination, disease prevention, chronic care 
management, provider support, and marketing. And only three 
cents of premium dollars remains for profit or surplus.
    I understand the subcommittee is interested in knowing how 
we determine medical policy and how our medical policy relates 
to how we process our members' health care claims. Our medical 
policies reflect input from premier academic institutions and 
experts within the medical profession, as well as considering 
the standards of care within our local communities. These 
medical policies are available online to all providers and to 
the public at large.
    Last year, WellPoint received 380 million claims; and we 
processed 97 percent of those in 30 days.
    The subcommittee's letter asked for some information on 
deferral of claims. I should note that we do not defer claims. 
What happens sometime is that claims are pending as we await 
additional information or conduct additional reviews. Some 
common reasons for pending claims are that premiums have not 
been paid; the claim is incomplete, such as missing diagnosis 
codes; or when members have health coverage--other health 
coverage that may be primary.
    The subcommittee's letter also asked about administrative 
costs. Our administrative costs include a variety of 
initiatives designed to promote the health and well-being of 
our members. For instance, WellPoint employs thousands of 
health professionals, including nurses, dieticians, social 
workers, and pharmacists, among others. These professionals 
speak with thousands of members each day, encouraging them to 
learn more about their conditions and how they can better 
manage their care. Our health professionals help members 
schedule the necessary followup care and specialist care, 
remind them to pick up important prescriptions, and serve as a 
valuable resource to our members, 24 hours a day, 7 days a 
week.
    Another example of our clinical--is our clinical research 
subsidiary, HealthCore, which has produced noteworthy studies 
on best practices for treating low back pain, high cholesterol, 
asthma, to name just a few. We take these recommendations and 
share them with physicians to help them improve our members' 
health. HealthCore also works with the FDA and the CDC to 
improve drug and vaccine safety and has created a sentinel 
system that helps these agencies monitor emerging drug safety 
issues in real time.
    My written testimony includes more detail of these types of 
initiatives, which are typically not included in government-run 
programs. Efforts like these, funded out of our administrative 
expenses, are critical to our ability to follow through on our 
primary commitment, which is to improve the lives of the people 
we serve and the health of our communities.
    In closing, I would like to assure the subcommittee that 
WellPoint supports responsible health care reform, but reform 
must go beyond the insurance marketplace to address system-wide 
challenges and associated costs. Changing how we finance health 
care without changing how we deliver health care would be 
incomplete reform at best.
    I appreciate the opportunity to testify before you today 
and to respond to your questions.
    Mr. Kucinich. Thank you, Mr. Sassi.
    [The prepared statement of Mr. Sassi follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.011
    
    [GRAPHIC] [TIFF OMITTED] T4918.012
    
    [GRAPHIC] [TIFF OMITTED] T4918.013
    
    [GRAPHIC] [TIFF OMITTED] T4918.014
    
    [GRAPHIC] [TIFF OMITTED] T4918.015
    
    [GRAPHIC] [TIFF OMITTED] T4918.016
    
    [GRAPHIC] [TIFF OMITTED] T4918.017
    
    [GRAPHIC] [TIFF OMITTED] T4918.018
    
    [GRAPHIC] [TIFF OMITTED] T4918.019
    
    Mr. Kucinich. The Chair recognizes Ms. Farrell. You may 
proceed for 5 minutes.

                 STATEMENT OF PATRICIA FARRELL

    Ms. Farrell. Good afternoon. My name is Pat Farrell, and I 
am the senior vice president at Aetna.
    Aetna's one of the Nation's leading insurance companies 
providing medical, dental, pharmacy, disability, life 
insurance, and other health benefits. We provide those products 
and services in all 50 States, and we provide those products 
and services to 37 million Americans.
    I'm proud to have worked at Aetna for over 20 years in a 
variety of capacities. On behalf of the thousands of employees 
at Aetna, I look forward to talking to you today about the 
value we bring to the health care system and in discussing 
Aetna's commitment to reforming the health care system.
    Aetna today is a health care solutions company that helps 
Americans manage their health care and get the most out of 
their health care dollar. Since 2005, Aetna has called for 
major fundamental reform of the insurance market so that all 
Americans have guaranteed access to affordable coverage with no 
exclusions for pre-existing conditions. This, combined with the 
requirement that everyone have insurance coverage and financial 
assistance for those who can't afford it and who need it, will 
get and keep everyone covered in our system.
    I expect that many of the issues we will discuss today will 
illustrate the need for reform. Aetna is committed to health 
reform that addresses access, affordability, and quality. We 
operate in a dynamic and highly competitive marketplace. Our 
business can only be successful when health care consumers are 
confident that we can provide the greatest value for their 
health care dollar and helping them improve or maintain their 
health care status.
    Our employees come to work every day--doctors, nurses, and 
customer service professionals--with the same commitment, to 
make sure our members get the best health care coverage 
possible.
    Much of our focus during the health care reform debate has 
been on building what works well in the employer- sponsored 
market today while addressing the problems in the small group 
market and in the individual marketplace. These solutions, 
which now seem to be broadly accepted, should go a long way to 
addressing the problem of access to health insurance.
    What we strongly believe is that for health care reform to 
be enduring and affordable in the Nation we must address the 
underlying problem of rising health care costs. Health care 
costs drive insurance premiums, not the other way around. Over 
the last decade, health care costs have risen about 7\1/2\ 
percent, and premiums have risen that very same amount.
    It's fundamental to our discussion today to understand the 
value that Aetna brings to the health care system and how our 
business practices are focused on empowering consumers and 
health care providers to make the best decisions possible.
    We process hundreds of millions of claims every year, and 
getting them right every single time is our goal. We recognize 
even a small percentage of problems represent real issues for 
our customers and for our providers. When we do get it wrong, 
we have processes in place to help get it back on track 
quickly.
    Aetna's driving innovation is to improve the lives and the 
health of our members. In just the past 4 years, we've invested 
over $1.8 billion in health information technology. For 
example, some of that investment went to having personal health 
records that can empower consumers' decisions around their 
health.
    Finally, we're also leaders in promoting wellness and 
prevention and the management of chronic diseases. Refocusing 
our system to prevent disease and promote wellness can lead to 
better health for all Americans and positively impact costs 
system-wide.
    I believe the competitive marketplace has played, and 
should continue to play, an important role in fostering the 
innovation that's necessary for our country to achieve true and 
widespread quality and affordability in our health care system.
    Thank you, and I look forward to continuing to work with 
Congress to pass health care reform this year.
    Mr. Kucinich. Thank you, Ms. Farrell.
    [The prepared statement of Ms. Farrell follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.020
    
    [GRAPHIC] [TIFF OMITTED] T4918.021
    
    [GRAPHIC] [TIFF OMITTED] T4918.022
    
    [GRAPHIC] [TIFF OMITTED] T4918.023
    
    [GRAPHIC] [TIFF OMITTED] T4918.024
    
    [GRAPHIC] [TIFF OMITTED] T4918.025
    
    [GRAPHIC] [TIFF OMITTED] T4918.026
    
    [GRAPHIC] [TIFF OMITTED] T4918.027
    
    [GRAPHIC] [TIFF OMITTED] T4918.028
    
    [GRAPHIC] [TIFF OMITTED] T4918.029
    
    [GRAPHIC] [TIFF OMITTED] T4918.030
    
    [GRAPHIC] [TIFF OMITTED] T4918.031
    
    [GRAPHIC] [TIFF OMITTED] T4918.032
    
    [GRAPHIC] [TIFF OMITTED] T4918.033
    
    Mr. Kucinich. The Chair recognizes Mr. Bloem.

                  STATEMENT OF JAMES H. BLOEM

    Mr. Bloem. Thank you, Mr. Chairman.
    Mr. Kucinich. Make sure that mic is close. We want to hear 
you. Go ahead.
    Mr. Bloem. Mr. Chairman, Ranking Member Jordan, members of 
the subcommittee, I'm James H. Bloem. I am a senior vice 
president and I'm the chief financial officer and treasurer of 
Humana, Inc.
    Humana's a health benefits company headquartered in 
Louisville, Kentucky, offering health benefit plans for 
employer groups, government programs, and individuals. We have 
10.3 million medical members and 6.8 million specialty members 
in all 50 States and Washington, DC, and in Puerto Rico. Humana 
employs 28,600 employees and contracts with nearly 400,000 
physicians around the country.
    We've provided extensive written testimony on today's 
subject matter, and I will briefly summarize a few key points 
here.
    Every aspect of Humana's operations is governed by Federal 
and/or State laws and regulations, and Humana continues to both 
support and advocate for responsible health system reform. We 
believe that doing nothing is--doing nothing is not an option. 
We believe that all Americans should have affordable, quality 
health coverage. It's essential that everyone participate in 
the health system, with subsidies for those who can't afford 
coverage; and, in return, coverage should be guaranteed and not 
based on pre-existing conditions or health status.
    To ensure affordability, reform must focus on improving 
health outcomes, reducing variations in care, and reducing 
costs.
    Humana also supports America's Health Insurance Plans' 
comprehensive reform plan which provides for universal coverage 
with insurance rating reforms. These reforms, voluntarily 
offered, will obviate the need for business practices that were 
put into place because there currently is no requirement that 
individuals have health insurance coverage.
    The subcommittee has specifically requested that we comment 
on our processes for both coverage determination and processing 
claims, as well as the physician feedback on these processes.
    For 2009, Humana ranked No. 1 among national payers as the 
easiest to do business for both doctors and hospitals. 
Specifically, Athena Health found Humana to have the lowest 
denial rate among all major payers. In contrast, the Medicare 
Part B program ranked fifth. Humana also ranked as the fastest 
payer to physicians, with the Medicare Part B program again 
ranking in fifth place.
    The subcommittee also asked that we address how Humana 
makes coverage decisions. Let me summarize.
    Coverage decisions are based on evidence-based medical 
criteria, developed and approved by physicians. Under our 
policy, a nurse or a non-clinician can authorize any service 
that's under review. However, only a licensed, board-certified 
physician medical director can issue a denial based on a 
medical criterion. To the extent that a practicing physician 
disagrees with a decision, there are timely internal appeal 
processes allowing peer-to-peer input. These grievance and 
appeals processes are governed by State and Federal 
regulations. Internal appeal decisions can be further appealed 
to an independent external review entity, whose decision is 
binding on Humana.
    Humana's worked effectively over the past few years to 
streamline and simplify our administrative practices. We've 
partnered closely with the hospitals and physicians who care 
for our members and our members themselves. Here's one example.
    Availity is an industry leading multipayer, multiuse 
electronic medical provider information exchange. Humana 
cofounded Availity with the Blues of Florida. It fulfills the 
President's and Congress' call for a workable health care 
information technology superhighway. It has standardization, 
speed, accuracy, transparency; and it results in significant 
cost savings.
    Today, across the country, 50,000 physicians, 1,000 
hospitals, 100 million members, and 1,000 payers, including 
public payers, access or connect with Availity every year. This 
will result this year in approximately 600 million 
transactions. Availity, what it does is provides seamless 
provider interactions and improves patient safety, saving 
money. It has digitized most of the nonstandard administrative 
processes that providers have complained about for years. And 
for those who use e-prescribing, preventable adverse drug 
events have been reduced by 61 percent; and, most importantly, 
there are no charges to providers for using Availity.
    In closing, Mr. Chairman, let me say that Humana's 
committed to continue to work closely with the administration 
and Congress to increase the likelihood that measures designed 
to solve the most significant problems in our health care 
system become the focal points of responsible and real health 
reform efforts.
    I look forward to your questions. Thank you very much.
    Mr. Kucinich. Thank you, Mr. Bloem.
    [The prepared statement of Mr. Bloem follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.034
    
    [GRAPHIC] [TIFF OMITTED] T4918.035
    
    [GRAPHIC] [TIFF OMITTED] T4918.036
    
    [GRAPHIC] [TIFF OMITTED] T4918.037
    
    [GRAPHIC] [TIFF OMITTED] T4918.038
    
    [GRAPHIC] [TIFF OMITTED] T4918.039
    
    [GRAPHIC] [TIFF OMITTED] T4918.040
    
    [GRAPHIC] [TIFF OMITTED] T4918.041
    
    [GRAPHIC] [TIFF OMITTED] T4918.042
    
    [GRAPHIC] [TIFF OMITTED] T4918.043
    
    [GRAPHIC] [TIFF OMITTED] T4918.044
    
    [GRAPHIC] [TIFF OMITTED] T4918.045
    
    [GRAPHIC] [TIFF OMITTED] T4918.046
    
    [GRAPHIC] [TIFF OMITTED] T4918.047
    
    [GRAPHIC] [TIFF OMITTED] T4918.048
    
    [GRAPHIC] [TIFF OMITTED] T4918.049
    
    Mr. Kucinich. The Chair recognizes Mr. Richards. You may 
proceed for 5 minutes. Thank you.

                  STATEMENT OF THOMAS RICHARDS

    Mr. Richards. Chairman Kucinich, Ranking Member Jordan, and 
members of the subcommittee, I appreciate the opportunity to 
address the subcommittee and to discuss the issues raised in 
your letter to Mr. Hamm on August 26th.
    My name is Tom Richards. I am the senior vice president of 
Product for CIGNA Corp., which is based in Philadelphia.
    At the outset, I want to emphasize, on behalf of the 26,000 
CIGNA employees, that we support health care reform that 
provides security, affordability, and stability for all 
Americans. We believe such a goal is achievable by 
strengthening the current system to include both a personal 
coverage requirement and a helping hand for those who can't 
afford coverage.
    We support guaranteed coverage for everyone and no 
exclusion for any pre-existing condition. We support reforms in 
the way premiums are calculated, without taking into 
consideration health status or gender. We support providing 
subsidies to individuals who have difficulty affording health 
insurance, including subsidies to small businesses. We support 
administrative standardization and simplification. We support a 
focus on health and wellness. Further, we support the 
establishment of exchanges to provide a choice of plan options 
for all Americans. We also support reimbursement reforms to the 
current fee-for-service delivery system.
    It's also important to understand CIGNA's role in health 
care. While we have some insurance business, nearly 80 percent 
of CIGNA's health care business is administrative services 
only. This means we administer the programs for employers in 
accordance with their policies and pay claims for them. It is 
not risk-based, as would be traditional insurance. These 
employers are self-insuring, and the claim payments come out of 
their employer funds. There is no financial incentive for our 
employees to accept or deny claims.
    At CIGNA, in 2008, 89 cents of each premium dollar was 
spent on medical care. Our support for reform is aligned with 
what we stand for as a company. Our mission is to improve the 
health, well-being, and sense of security of the customers we 
serve.
    Our results demonstrate our focus on health improvement. 
Competitive data from NCQA's 2008 State of Health Care Quality 
Report shows this difference. Against a baseline of standard 
care provided by doctors and hospitals in a fee-for-service 
unmanaged situation, we have better results. If you turn to 
figure 1 on page 4 of my written testimony, you will see a 
chart that reflects these results.
    All of our coverage policies follow best practices and are 
evidence-based, which means they're based on the most recently 
published scientific evidence. We consider safety and 
effectiveness. It's important to note that cost is not a factor 
unless there are multiple items or services with equivalent 
safety and effectiveness.
    We are very proud to employ over 3,000 clinicians. These 
doctors and nurses make decisions about clinical policy, review 
medical necessity, and advocate for individuals. They make the 
system easier to understand. They help our customers navigate 
the health care system when they need help, and they literally 
save lives. We've included the words of several of these 
individuals in our written testimony telling you how we have 
helped them.
    In 2008, CIGNA processed approximately 91 million claims 
for payment. More than 90 million of these claims were paid 
without question. I call your attention to figure 2 on page 10 
of the written testimony. Of the approximately 1 million claims 
that did require prior authorization, all but 0.80 percent were 
approved on initial review. What that means is at CIGNA more 
than 99.9 percent of the time the person received the care that 
the doctor recommended and the services were covered.
    At CIGNA, all medical coverage decisions are made by 
doctors and nurses; and, ultimately, the chief medical officer 
is responsible for all coverage decisions. We recognize the 
doctor-patient relationship is critical and do everything we 
can to enhance it. Let me cite just a few examples.
    First, CIGNA is simplifying and reducing administrative 
complexities from payment methodologies and claim process to 
problem resolution and education.
    Second, CIGNA's further innovating our payment 
methodologies. An example of this is CIGNA's patient-centered 
medical home initiative, such as the one we have with 
Dartmouth-Hitchcock, New Hampshire. Our joint goal is to 
improve patient access, continuity, and coordination of care, 
quality of care for patients, and lower medical costs for 
everyone.
    At CIGNA, we focus on helping people improve their health. 
We believe the health care is a shared responsibility of the 
individual, the private sector, the medical community, and the 
Government. Such a shared responsibility is right for 
individuals, families, and the country as a whole. We look 
forward to how we can work together to improve the health and 
wellness and quality of care for all Americans.
    Mr. Chairman, this concludes my remarks.
    Mr. Kucinich. Thank you very much, Mr. Richards.
    [The prepared statement of Mr. Richards follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.050
    
    [GRAPHIC] [TIFF OMITTED] T4918.051
    
    [GRAPHIC] [TIFF OMITTED] T4918.052
    
    [GRAPHIC] [TIFF OMITTED] T4918.053
    
    [GRAPHIC] [TIFF OMITTED] T4918.054
    
    [GRAPHIC] [TIFF OMITTED] T4918.055
    
    [GRAPHIC] [TIFF OMITTED] T4918.056
    
    [GRAPHIC] [TIFF OMITTED] T4918.057
    
    [GRAPHIC] [TIFF OMITTED] T4918.058
    
    [GRAPHIC] [TIFF OMITTED] T4918.059
    
    [GRAPHIC] [TIFF OMITTED] T4918.060
    
    [GRAPHIC] [TIFF OMITTED] T4918.061
    
    [GRAPHIC] [TIFF OMITTED] T4918.062
    
    [GRAPHIC] [TIFF OMITTED] T4918.063
    
    [GRAPHIC] [TIFF OMITTED] T4918.064
    
    [GRAPHIC] [TIFF OMITTED] T4918.065
    
    [GRAPHIC] [TIFF OMITTED] T4918.066
    
    [GRAPHIC] [TIFF OMITTED] T4918.067
    
    [GRAPHIC] [TIFF OMITTED] T4918.068
    
    [GRAPHIC] [TIFF OMITTED] T4918.069
    
    [GRAPHIC] [TIFF OMITTED] T4918.070
    
    Mr. Kucinich. The Chair recognizes Ms. Reitan. Thank you. 
Please proceed for 5 minutes.

                  STATEMENT OF COLLEEN REITAN

    Ms. Reitan. Good afternoon, Mr. Chairman, Ranking Member 
Jordan, and members of the subcommittee. I'm Colleen Reitan. I 
am the executive vice president and chief operating officer of 
Health Care Service Corp. We are a mutual legal reserve 
corporation that does business as the BlueCross BlueShield 
plans in Illinois, New Mexico, Oklahoma and Texas.
    By way of background, HCSC is the largest customer-owned 
health insurance company in the Nation. We are not investor-
owned. We are a customer-owned mutual. We have a work force of 
more than 16,000 employees serving 12.3 million members through 
our BlueCross plans in those four States. Our mission is to 
promote the health and wellness of health care for our members 
and the communities that we serve through accessible, cost-
effective, high-quality care.
    Prior to joining HCSC in 2008, I was the president and 
chief operating officer of BlueCross BlueShield in Minnesota, 
that State's largest health insurer. And they are a not-for-
profit health plan. I have 28 years of experience in the 
BlueCross system. The areas of accountability I have with the 
HCSC is for management of our subscriber services division 
which processes member claims and handles health care 
inquiries. I'm also responsible for information technology, 
finance and actuarial functions.
    We certainly recognize and share the public's concern with 
the current health care system. But fundamentally we believe in 
the strength and the value of the American health care system. 
We believe that insurers like HCSC are uniquely positioned to 
help foster and form improvements to the health care system. 
And we really welcome the opportunity to serve in that role.
    HCSC has been an advocate of health care reform. To that 
end, we support the proposition that health insurance companies 
are required to offer coverage to all applicants regardless of 
their current health status, coupled with a personal 
responsibility for all Americans to obtain and maintain 
coverage.
    Second, we support subsidies for those Americans who cannot 
afford health care coverage.
    Third, we support health and wellness initiatives that 
focus on the prevention of chronic illness.
    And finally, we support initiatives that promote effective 
care and treatment and for information technologies that 
improve quality and provide value for every health care dollar.
    We are pleased to share with the subcommittee some examples 
of how HCSC has incorporated evidence-based approach into 
medical policy, into two key tenets that underpin the core 
values of our company, and that of access and quality.
    My written statement outlines our approach in each of those 
areas in greater detail, but a few items are just worth noting 
before the discussion today.
    First, our members need access to proven medical care. One 
of HCSC's four guiding principles is our belief that the 
interests of our members are of primary importance to our 
company. The members we serve provide the reason for our 
existence and the rationale for the resources with which we 
operate.
    Second, but equally important, is to continually improve 
the quality of care.
    Another of our guiding principles is our belief that we as 
representatives of our members have an obligation to provide 
leadership in the health care field. We are promoting evidence-
based medicine to increasingly focus our plans around proven 
health care services. We also work closely with our very broad 
network of doctors and hospitals to invest in data-sharing 
technology that works to improve clinical decisionmaking, and 
these efforts help improve quality and ensure that doctors and 
hospitals treat patients effectively and get paid efficiently.
    HCSC is committed to working with the administration and 
Congress to achieve comprehensive health care reform, to expand 
access and improve quality of care for all Americans.
    On behalf of our company and its members, I thank the 
subcommittee for the opportunity to discuss these important 
issues today.
    Mr. Kucinich. Thank you very much for your testimony.
    [The prepared statement of Ms. Reitan follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.071
    
    [GRAPHIC] [TIFF OMITTED] T4918.072
    
    [GRAPHIC] [TIFF OMITTED] T4918.073
    
    [GRAPHIC] [TIFF OMITTED] T4918.074
    
    [GRAPHIC] [TIFF OMITTED] T4918.075
    
    [GRAPHIC] [TIFF OMITTED] T4918.076
    
    [GRAPHIC] [TIFF OMITTED] T4918.077
    
    [GRAPHIC] [TIFF OMITTED] T4918.078
    
    [GRAPHIC] [TIFF OMITTED] T4918.079
    
    Mr. Kucinich. Without objection, the Chair and the ranking 
member will proceed for 10 minutes each for questions, and then 
each member after that will have 5 minutes. So we may have 
several rounds. We will see how it goes.
    The only thing I want to share with the members of the 
panel here is this: Members of Congress generally like to get 
answers. If you are able to give us a brief answer and it 
covers the territory, that's fine. If you start to go on and on 
on something--I don't want to appear confrontational, but I may 
have to encourage you to hurry up your answer or maybe have to 
cut you off. I don't want to do that. But I do want you to know 
that we are here to get answers and we need your help.
    So without objection, I will begin. I just want to add one 
other thing. We may be joined by other Members of Congress who 
are not members of this committee. That's not unusual. And 
without objection, if other Members choose to come here from 
either side of the aisle, even though they are not on this 
committee, without objection, we will permit them to sit in, to 
participate and to ask questions.
    So with that, I would like to start the questioning with 
Mr. Sassi of WellPoint. Sir, in your testimony you state, 
``Last year WellPoint received 380 million claims and processed 
97 percent of them within 30 days.'' I'm looking at the 
arithmetic. And if the arithmetic is correct, it means that you 
did not pay within 30 days over 11 million claims.
    Would you tell this subcommittee what is the value in 
dollars to WellPoint of the 11 million claims that were not 
paid in that time period?
    Mr. Sassi. Chairman, I don't know the value of that.
    Mr. Kucinich. Can you provide this subcommittee with such 
information? There has to be a way to calculate it.
    Mr. Sassi. I'm not sure, because that is at a point in 
time--the vast majority of those claims most likely were paid 
at a future point, either on the 31st day, or if we had 
requested additional information that was provided and then 
subsequently paid.
    Mr. Kucinich. Maybe you could then chart out 30 days, 60, 
90. Businesses operate that way, of course, 120. And maybe if 
you could provide us information with what was the average cost 
of each claim that you did not immediately pay, it would be 
helpful. You could either look at it as a cost or a value. And 
we will followup with written questions so we can keep going. 
We are not going to belabor that.
    Mr. Sassi, on a 2008 earnings conference call with Wall 
Street, your CEO said the following, ``We will not sacrifice 
profitability for membership.'' As you know, WellPoint was 
forced to pay $1 million last year to settle claims or charges 
by the California Department of Insurance that you removed 
coverage from 2,330 members after they submitted claims for 
expensive medical care.
    I am going to submit for the record the article on the 
settlement from the Los Angeles Times from February of this 
year.
    [The information referred to follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.080
    
    Mr. Kucinich. WellPoint settled similar charges the 
previous year and paid a $10 million fine for removing coverage 
from 1,770 members of its HMOs in California.
    Mr. Sassi, is dropping members just when they need health 
care what your CEO meant when she said that she wouldn't 
sacrifice profitability for membership?
    Mr. Sassi. Absolutely not.
    Mr. Kucinich. What did she mean, then?
    Mr. Sassi. I believe what was meant was that we would not 
reduce prices artificially to essentially buy membership in the 
open marketplace.
    Mr. Kucinich. And Mr. Sassi, what characteristics did those 
2,330 individuals have in common that resulted in WellPoint's 
decision to drop members just as their medical bills threatened 
to reduce WellPoint's profitability?
    Mr. Sassi. That settlement pertained to a settlement 
agreement that we reached with the Department of Managed Health 
Care and the Department of Insurance in California relative to 
recissions in the individual marketplace. I'm sure you're aware 
that companies agree to settle lawsuits or situations for a 
variety of reasons and----
    Mr. Kucinich. But you're in front of a congressional 
committee here. There is--unless your counsel is advising you 
that you can't answer that question, you should answer the 
question.
    Mr. Sassi. I did answer the question, sir.
    Mr. Kucinich. You didn't really say what characteristics 
those individuals had in common that resulted in WellPoint's 
decision to drop members just as their medical bills threatened 
to reduce WellPoint's profitability. You did not answer the 
question. I would just ask you if you would answer the 
question.
    Mr. Sassi. Those members were rescinded in the individual 
market because they materially misrepresented their medical 
history on their insurance application at the time that they 
applied for coverage.
    Mr. Kucinich. How did WellPoint discipline the executives 
who committed the practices that led to the enforcement action 
against you?
    Mr. Sassi. We did not admit--we did not agree with the 
findings of the Department of Managed Health Care. That is on 
public record. They did issue a report. We did append a report 
to that. The settlement--we agreed to settle with the 
Department of Managed Health Care----
    Mr. Kucinich. I understand.
    Mr. Sassi [continuing]. To put the issue behind us.
    Mr. Kucinich. Mr. Collins, in UnitedHealthcare Group's 
social responsibility report in 2008, your CEO writes, ``The 
businesses of UnitedHealthcare Group are fundamentally 
organized around advancing our mission of helping people live 
healthier lives.''
    Now, if your business is fundamentally organized around 
that mission, will you explain UnitedHealthcare's settlement of 
charges last year that its PacifiCare subsidiary wrongfully 
denied 130,000 claims in California, paid claims incorrectly, 
lost documents that included medical records, failed to 
acknowledge claims in a timely manner, and hassled its members 
with multiple requests for documentation that was previously 
provided?
    Mr. Collins. Yes, sir. We are vigorously contesting the 
findings of the State. I do not contest that there is room for 
improvement in our California operations. We have put a lot of 
resources into improving our operations. And we regret 
inconvenience to our membership. But I don't see our 
aspirations provide products, services and financing of the 
health care of Americans as inconsistent with our behavior.
    Mr. Kucinich. Then that is fine. You have answered that 
question. But in 2007, what was the compensation of the top 
executives at PacifiCare?
    Mr. Collins. In 2007, sir, PacifiCare was a wholly owned 
subsidiary of UnitedHealthcare. So the top executives would 
have been the top executives of United Health Group. And that 
is public record, sir.
    Mr. Kucinich. Was the compensation possibly in millions?
    Mr. Collins. I don't have those numbers off the top of my 
head, Congressman.
    Mr. Kucinich. Would you provide them to this committee?
    Mr. Collins. Absolutely. They are public record in our 10-
K, sir.
    Mr. Kucinich. Other members may have this question. But I 
think it would be great if each of you could provide us that 
compensation information of officers and also information about 
bonuses and incentives received by PacifiCare executives and 
employees that would have rewarded the denial of claims in 
California in 2006 and 2007. We want to see if there is any 
connection there. And we need that information, if you can 
cooperate and provide it.
    Mr. Collins. I'm confident, sir, that there was no bonuses 
awarded for denial of claims or other activity that was 
illegal. And as I said before, we are vigorously contesting the 
findings of the Department and the characterization of the 
actions there as denial of claims.
    Mr. Kucinich. Thank you, Mr. Collins.
    Mr. Richards of CIGNA. On page 8 of your written testimony 
you state, ``We do not consider costs in establishing coverage 
policy in our decisions to provide access to care.''
    But we heard from a former senior executive with CIGNA, who 
told us yesterday that CIGNA has meetings every quarter which 
are called ``town hall meetings,'' internal town hall meetings, 
in which executives go over the past quarter's financial 
statements and talk about how they can tighten utilization to 
lower the share of CIGNA's premium income spent on medical 
expenses.
    Isn't it true that CIGNA has held internal town hall 
meetings at which those topics are discussed?
    Mr. Richards. It is absolutely true that we hold town hall 
meetings to communicate with our employees, to reinforce our 
mission and to talk about our financial results.
    Mr. Kucinich. And those town hall meetings are videotaped, 
are they not, and audiotaped?
    Mr. Richards. I do not believe they are videotaped. We 
certainly audiotape them so that individual employees who are 
not able to attend are able to----
    Mr. Kucinich. Are there audiotapes available?
    Mr. Richards. Yeah.
    Mr. Kucinich. I would like you to provide this subcommittee 
with copies of those audiotapes and any videotapes that you 
have. Our staff will work with you to achieve the----
    Mr. Richards. Again, what I would like to emphasize, Mr. 
Chairman, is those internal meetings are to communicate to our 
employees----
    Mr. Kucinich. I understand. And we--I understand that they 
are. And we will be in touch with you regarding our request 
that we get those audiotapes.
    I just would like to conclude with this question for each 
and every one of you. The premise of this hearing is that 
health insurers wield strong influence in the kind of care, 
whether there is care, for their policyholders who become very 
sick.
    According to the American Cancer Society, ``Cancer patients 
and survivors may delay or forego care, in the face of cost 
sharing, that they find difficult to afford.''
    A recent study found that 5 percent of non-elderly adults 
with private health insurance who have been diagnosed with a 
chronic condition such as cancer reported they went without 
needed care in 2006. This is the American Cancer Society saying 
this.
    I want to give you a chance to express for the record what 
you think about this question, and really with a simple yes or 
no answer. And we are going to go down the line and I want you 
to answer this question. Do you believe that a health insurer's 
refusal to pay for a patient's cancer treatment can directly or 
indirectly cause harm or death to that patient?
    I'm going to ask the question one more time. Do you believe 
that a health insurer's refusal to pay for a patient's cancer 
treatment can directly or indirectly cause harm or death to 
that person?
    I would like to go right down the line, Mr. Collins, and 
just give me a simple answer go. All the way down the line and 
then my question time is completed. Mr. Collins.
    Mr. Collins. Yes, sir.
    Mr. Kucinich. Pardon?
    Mr. Collins. Yes, sir.
    Mr. Kucinich. Mr. Sassi.
    Mr. Sassi. Yes, sir.
    Mr. Kucinich. Ms. Farrell.
    Ms. Farrell. Yes.
    Mr. Kucinich. Mr. Bloem.
    Mr. Bloem. Yes.
    Mr. Kucinich. Mr. Richards.
    Mr. Richards. Yes. But CIGNA only allows clinicians to make 
coverage decisions and those coverage decisions are only based 
on external scientific evidence.
    Mr. Kucinich. The answer is yes. OK. Ms. Reitan.
    Ms. Reitan. Yes, sir.
    Mr. Kucinich. Thank you. I want to thank each and every one 
of you for your candor.
    The Chair recognizes for 10 minutes Mr. Jordan of Ohio. You 
may proceed.
    Mr. Jordan. Thank you, Mr. Chairman. I appreciate the 
chairman's having this hearing. I appreciate the chairman's 
intensity and passion that he brings to any debate, but I 
fundamentally disagree with sort of the underlying premise 
here, the idea that because there has been--as I stated in my 
opening statement, that there has been some problems with the 
way private insurance works; that somehow that should cause us 
to move to a government-run system. I just fundamentally 
disagree with that.
    Frankly, I think the majority of Americans, as pointed out 
over the last several months in any poll you look at here of 
recent date, is--would say the same thing.
    So I have really kind of two focuses here in the few 
minutes I have with you. And, again, I appreciate you being 
here. One, I want to get the facts. And then I want to get at 
this idea that I think is fundamental to real reform and what 
needs to happen in this country, and that is a health care 
system that empowers the patient.
    There is a great--I think a great article in this month's 
Atlantic which talks about the idea that it is always somebody 
else who is paying. And when somebody else is paying, that is--
I think Ms. Farrell said it well. She said insurance premiums 
don't drive health care costs; health care costs drive 
insurance premiums. We have to get at health care costs. And 
that only happens when the consumer, the patient, the family, 
the small business owner out there, has a better handle on what 
is happening, more transparency so they can figure this out and 
make some real market--real market-type decisions.
    So let me start with this. One of the things we heard 
yesterday, again in an effort to get to the facts, one of the 
things we heard yesterday was from the panel we had; 57 percent 
of every dollar is all that goes toward health care of the 
premiums that you take in. And so we heard about the cartels 
and--I'm actually looking now at a piece the Journal ran this 
Monday. And they actually talk about an example in Alabama 
where it was 92 percent, according to what is happening in the 
State of Alabama, where one insurer, BlueCross BlueShield of 
Alabama, has 70 percent of the market share.
    So I would like to know, do you agree with that 57 percent 
figure; and if not, what it is in each of your companies' 
situation? We'll just go down the list. Mr. Collins.
    Mr. Collins. Thank you, Congressman Jordan. The statistics 
cited in Mr. Sassi's testimony come from a 
PriceWaterhouseCooper's study that cites 83 cents on the 
dollar. That is a credible study. It is a recent study. There 
is another study that just came out from Sherlock & Co., just 
in the last few weeks, which corroborates the PriceWaterhouse 
study.
    Mr. Jordan. What is United? What do you say? What do you 
pay? With every dollar you take in, how much goes for patient 
care?
    Mr. Collins. That's not a real simple answer to----
    Mr. Jordan. Is it 57 percent? Is it less? Is it more?
    Mr. Collins. No, sir. It's consistent with the findings in 
the Sherlock and the PriceWaterhouseCooper's studies.
    Mr. Jordan. Have you done an internal investigation? Do you 
know? Do you have a good idea what United would be?
    Mr. Collins. Sir, a loss ratio for 2008 was approximately 
83 percent, 83\1/2\ percent for the company. But that is across 
a wide spectrum of businesses.
    Mr. Jordan. Mr. Sassi, WellPoint?
    Mr. Sassi. Same question?
    Mr. Jordan. Yeah.
    Mr. Sassi. The loss ratio for WellPointplans overall is 
directionally similar to what I quoted as 
PriceWaterhouseCooper's. But as I also stated, loss ratio is 
just the calculation of premium less claims that are paid. And 
as I also indicated in my testimony, there are a fair amount of 
administrative costs that we pay to help manage chronic care, 
chronic conditions. We pay out of our administrative cost for 
disease management programs for asthma, heart disease, 
diabetes, COPD, to help those 50 percent of Americans that have 
chronic illness manage their costs. And that is typically not 
included in the loss ratio. That is included in administrative 
expense. So if you're looking for a holistic what-do-we-spend, 
it's north of that.
    Mr. Jordan. I understand. I understand.
    Ms. Farrell. Congressman, at Aetna, we spend 84 cents on 
the dollar directly on medical claims. We do spend a fair 
amount on administration relative to innovations in the health 
care industry, making sure that we are providing our members 
and our providers with the most recent tools and technologies 
and information in order to, as you said, give them the tools 
to make them understand what policies they purchased, what is 
in those policies, so that they can make better decisions on 
behalf of themselves and their families.
    Mr. Bloem. Ranking Member Jordan, we paid between 83 and 85 
percent for the last 7 years. Last year was the upper end of 
the range. Around 84.6.
    Mr. Richards. Ranking Member Jordan, for CIGNA last year, 
the number was 89 cents. That number has gone up each of the 
last 5 years.
    Ms. Reitan. Our medical care ratio at HCSC is approximately 
84 percent.
    Mr. Jordan. OK. Let me move to another one.
    According to the Congressional Research Service, each year 
1 billion claims are submitted to Medicare and 10 percent of 
those claims are denied. So 10 percent--that is a lot of claims 
denied, if I got the numbers right when you went through your 
testimony--I just jotted these down.
    United, you have 70 million that you insure; WellPoint 35; 
Aetna 37; Humana, I think had 2 different distinctions, but I 
totaled 16; CIGNA, 46 here and around the world; and HCSC, 12.3 
million.
    So how does your denial rate compare to what the Government 
currently does with the Medicare program?
    Mr. Collins. Congressman, I'm not prepared to answer that 
question today. I really just don't have those numbers 
available, I would like to point out----
    Mr. Jordan. How many claims do you have a year? I'm 
interested in Medicare population, older populations who are 
probably going to be significantly more claims. But 70 million 
people compared to 45 in Medicare--45 million in Medicare. How 
many claims do you get a year?
    Mr. Collins. I don't know exactly. On our primary 
processing platform where the vast majority of our claims are 
processed, as I stated in my testimony, 250 million claims.
    Mr. Jordan. OK.
    Mr. Sassi. Ranking Member Jordan, I don't have the 
percentage of claims that were denied, if that is the question. 
We processed 380 million--we received 380 million claims. The 
number I read was the amount that we processed in 30 days. We 
processed----
    Mr. Jordan. Ninety-seven percent in 30 days. I got that. 
But we heard stories yesterday, so there have to be some that 
are denied.
    Mr. Sassi. Oh, absolutely.
    Mr. Jordan. Do you know what percentage are denied?
    Mr. Sassi. I don't have that.
    Mr. Jordan. Is it more than 10 percent?
    Mr. Sassi. I don't have that number. I'm sorry.
    Mr. Jordan. Ms. Farrell.
    Ms. Farrell. We process approximately 407 million claims 
annually at Aetna. And if you look at the reasons why claims 
are denied, I think what you are trying to get at is the reason 
something might be denied for medical necessity, and at Aetna 
less than one-half of 1 percent of claims are denied because of 
medical reasons.
    Mr. Jordan. Thank you.
    Mr. Bloem. Ranking Member Jordan, I cited the Athena Health 
Study which I commented that we ranked first in terms of the 
lowest denial rate. Our denial rate in that survey was 5.7 
percent. The government, in the government--the Medicare Part B 
program, that had an 8.7 percent denial rate for fifth place.
    Mr. Richards. Ranking Member Jordan, at CIGNA, we have 
about 91 million claims we processed last year, and again 99.9 
first of those were approved for the coverage. So it would have 
been point 1 percent that were not approved for coverage.
    Mr. Jordan. Good.
    Ms. Reitan. HCSC processes 560,000 claims a day, and we 
deny for the medical necessity coverage three-tenths of a 
percent.
    Mr. Jordan. Wonderful.
    Mr. Bloem, in your testimony you talked about some things 
you were doing to make it easier for the folks who you do 
business with, people you insure to deal with--that is one 
thing you hear from folks in our own lives. You get the 
statement of benefits, you try to figure out what the heck it 
says. I think if a lot of Americans are like me, they are 
looking--if it says it's not a bill, they kind of file it away 
and not worry about it too much.
    But you talked about some things you're doing. I would like 
for you to elaborate on that a little bit. Because one of the 
things we hear from health care professionals is they don't 
like the reimbursement rate they get from Medicare and 
Medicaid. But in some ways it's not as cumbersome as some of 
the other things they have to deal with. So I'm curious what 
you are doing to make it easier for people to deal with and 
figure out what is going on, and again getting at this idea to 
empower the patient, which I believe will lower the cost.
    Mr. Bloem. OK. A couple of things I mentioned in my written 
testimony I would just like to quickly summarize. First of all, 
when we talk about the problems that have existed between the 
various constituencies, obviously we have three people 
involved: We have us as the payer, we have the member, and we 
have the provider.
    So to make things simpler, to make things easier, what 
we've done, as in Florida but now throughout the country, is 
come up with a joint venture that we have with a number of 
companies that helps providers get instant adjudication, real-
time adjudication in terms of what a member's responsibilities 
are, what ours are. We are trying to provide certainty against 
all--for all our constituencies.
    Mr. Jordan. So the providers are liking it and the patients 
are liking it?
    Mr. Bloem. Because it's electronic and it basically tells 
people when they go to the doctor, this is what is going to be 
expected of you, this is what Humana is going to pay, this is 
what you are going to pay, this is what the provider is going 
to charge.
    We also--if I could be real brief--we also have a document 
called a ``smart summary'' that we mail to 10 million of the 
10.3 million members that we have, every quarter. And it 
basically tells all the claims that they have had, what those 
claims are for, what doctors, what hospitals they went to, what 
pharmacy, what drugs they are taking. It gives them sort of a 
quick summary of what their situation was for that quarter, 
much like you get with maybe investment accounts you have. I 
would be happy to provide this.
    Mr. Jordan. A quarterly statement?
    Mr. Bloem. Yes. So that people understand that they can 
begin to have the knowledge you're talking about in order to 
take effective control of their health status and their 
insurance. Thank you.
    Mr. Jordan. Ten minutes goes fast, Mr. Chairman. Thank you.
    Mr. Kucinich. I thank my colleague from Ohio.
    We've been joined by two other members. And before we go to 
Mr. Cummings, I will introduce Mr. Schock from Illinois, and 
also the distinguished chairman of the Judiciary, John Conyers, 
who is the author of--he is the author of H.R. 676. I'm always 
pleased to work with him on that. Mr. Conyers, we are honored 
by your presence here, as well as Mr. Schock's presence.
    We are going to go to Mr. Cummings for your questions. Go 
ahead, Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman. I just 
want to know, how many of you--which of you, if any--we will go 
down the line--give bonuses for folks who deny coverage? 
Straight down the line.
    Mr. Collins. We don't issue bonuses for people that deny 
coverage.
    Mr. Cummings. Is it a part of their evaluation? I'm going 
to ask each one of you the same question. Is it part of their 
evaluation--is there any kind of incentives with regard to 
evaluations regarding denial of coverage; that is, claims?
    Mr. Collins. I'm sorry, Congressman. Without going back and 
doing research on that topic, I really could not give you a 
responsive answer to that question.
    Mr. Cummings. You don't know the answer to that question? 
Is that what you are telling me?
    Mr. Collins. Yes, sir.
    Mr. Sassi. I can tell you that WellPoint does not have any 
policies in place to reward people for denying care.
    Mr. Cummings. So there's no policies and you do not do 
that; is that correct?
    Mr. Sassi. My understanding is we do not.
    Mr. Cummings. Or physicians? How about physicians denying 
treatment?
    Mr. Sassi. There are no metrics or anything surrounding 
denial of care.
    Mr. Cummings. Very well. Ms. Farrell.
    Ms. Farrell. Only physicians can deny a claim at Aetna, and 
we have absolutely no incentives, financial incentives, tied to 
that decisionmaking process.
    Mr. Cummings. So employees don't either; is that right? I 
know you said physicians, but what about employees?
    Ms. Farrell. Physicians are the only ones that can 
actually----
    Mr. Cummings. In other words, do they ever?
    Ms. Farrell. Physicians are the only ones who can 
actually----
    Mr. Cummings. Did you ever have that policy of giving 
incentives for denying claims?
    Ms. Farrell. You say ``ever.'' I can't speak for ever.
    Mr. Cummings. To your knowledge, have you?
    Ms. Farrell. To my knowledge, no.
    Mr. Cummings. I see your lawyer is trying to advise you. 
You're welcome to do so because we are going to followup on 
this. Are you finished, Mr. Lawyer?
    Ms. Farrell. To my knowledge, no.
    Mr. Cummings. All right. Mr. Bloem.
    Mr. Bloem. To my knowledge, during my tenure of 8\1/2\ 
years, no.
    Mr. Richards. There are no financial incentives for our 
clinicians to deny coverage.
    Ms. Reitan. At HCSC there are no financial incentives and 
no bonuses paid related to denial of care.
    Mr. Cummings. Then between today and yesterday, there are 
some--apparently there must be some other insurance companies, 
then, because the testimony we got yesterday was just the 
opposite to that. But we will go forward.
    Very interestingly, when you all were answering Mr. 
Jordan's question, you were talking about this whole idea of 
claims. And, Mr. Richards, you in your oral testimony and your 
written testimony seemed--were very proud and I think you 
should be--I think, when you said that over 99 percent of the 
claims that are covered, people are receiving the services that 
the doctor recommended; is that correct?
    Mr. Richards. That's correct.
    Mr. Cummings. Mr. Richards, when you say ``claim,'' what do 
you mean by that?
    Mr. Richards. When I refer to that, I'm talking about the 
determination of whether the particular procedure is covered.
    Mr. Cummings. In other words, those are services that were 
already done; is that right?
    Mr. Richards. Actually, a lot of times a physician, the 
individual's physician would check with us prior to the 
procedure being done under what is called a ``prior 
authorization'' to see if the procedure would be covered.
    Mr. Cummings. So you're including--when you look at this, 
when you're giving us this figure, you're telling us that in 
those cases before services were rendered, you include those, 
and you include those after services were rendered that you 
paid, ``claims.'' Is that what you mean by claims? Because I 
want to make sure that we are going from the same page. Because 
the testimony we got yesterday is that, you know, the industry 
has a definition for claims. And claims means some services 
that have already been rendered. And then you're talking about 
denial. But a lot of the problems that we heard yesterday were 
things leading up to that, where the doctor calls--we had one 
doctor here yesterday that said he literally had to double his 
number of employees just to deal with getting authorization to 
do procedures.
    So just answer my question. When you say 99.9 percent, what 
do you mean?
    Mr. Richards. I mean of the claims that we get, 99.9 
percent of those are approved without any need for appeal. I 
think--first of all, I appreciate, Congressman, the chance to 
clarify this because I don't think it's well understood by the 
public. CIGNA--and I suspect other insurance companies--get 
submitted a lot of claims that are duplicates or are for people 
that are not insured by CIGNA.
    Mr. Cummings. Are those included in this definition?
    Mr. Richards. They are not included. So if, for instance, a 
doctor submitted us a duplicate claim, we had already received 
one----
    Mr. Cummings. OK. I got the duplicate. What else? I want to 
make sure--the definition is changing already.
    Mr. Richards. Well, I understand the committee is 
interested in both what insurance companies are doing relative 
to medical coverage--which is how I was answering the 
question--but I also understand you're very interested in the 
administrative procedures. I'm trying to clarify that.
    Fraud and abuse would be another reason why a claim might 
be denied. And, for instance, I know that that is extremely 
important to Medicare and the Office of the Inspector General. 
So we, for instance, denied--or did not pay 215 million claims 
for fraud and abuse. Again, these would be situations where the 
individual has already received the care but that the doctor or 
provider is inappropriately billing for that.
    Mr. Cummings. When you say a ``duplicate,'' do you mean a 
case where somebody may have been denied and then they try 
again?
    Mr. Richards. No, no. I mean due to a billing error; we 
would have already, for instance, paid the claim and it was 
submitted again. Sometimes things cross in the mail, 
Congressman.
    Mr. Cummings. So is that the only other thing that is--that 
may not be included in your denial rate?
    Mr. Richards. I think those are the major categories. The 
only other thing I might mention is in California, there's a 
fair number of doctors in California who operate under a 
prepayment mechanism where we pay them a certain amount per 
month to cover the care for our customers. So that prepaid--the 
way that prepayment works, we pay them whether the individuals 
seek care from that doctor that month or not. We occasionally--
we sometimes do get claims from those doctors, again 
erroneously, for care that we have already paid under the 
prepayment. In that case, those claims would also not be paid.
    Mr. Cummings. Thank you.
    Mr. Kucinich. The gentleman's time is expired.
    The Chair recognizes the Congressman from Illinois, Mr. 
Schock. You may proceed for 5 minutes.
    Mr. Schock. Thank you, Mr. Chairman. Thank you to our 
distinguished panel for being here. Unfortunately I have half 
the time as the chairman and the ranking member. So I'm going 
to try to make this quick.
    It seems as we discuss health care and the rising costs of 
health care, the focus seems to be on who is paying for it. And 
to me it doesn't matter whether you're a State government 
providing Medicaid or a Federal Government providing Medicare 
or a private business or an individual paying for it privately, 
the issue is the huge rise in costs.
    My question to all of you in the private pay business is 
within your respective organizations--I'm assuming when you 
negotiate with rates to your preferred providers, you ask for 
some justification in costs. And what there seems to be very 
little discussion about is the rise in cost. Some of that is 
true operating costs; in other words, new X-ray, new MRIs, new 
technologies, staff. And some of the rise in cost is also a 
cost shift.
    In other words, the great debate this year is whether or 
not we should cut Medicare rates by 16 percent, and we seem to 
pat ourselves on the back when we leave and we say we staved 
off cuts again this year. We may have staved off cuts, but we 
didn't adequately reimburse the providers for the true increase 
in their costs, therefore requiring them to shift that cost to 
those in the private pay industry.
    So my question to each one of you is: Have any of you 
within your organization looked at the increase in 
reimbursement rates that you all are required to pay and thus 
raising your premium rates? What percent of that is a true cost 
increase in terms of costs to the recipient and what percent of 
that cost increase is because of cost shifting as a result of 
the State and Federal Government not adequately paying for 
their patients?
    Mr. Collins.
    Mr. Collins. Thank you for that question, Congressman. The 
trend in unit costs--so the negotiated rates we have with 
providers and doctors has been running in the range of 4\1/2\ 
to 6 percent for many years now. That is in excess of CPI. I 
don't know the exact percentage of what our costs are due to 
cost shifting. But according to a recent Milliman Study, 
Milliman & Robertson of the accounting firm or the actuarial 
firm, $88 billion a year are cost-shifted from Medicare and 
Medicaid programs to the private sector. The American Hospital 
Association and the AMA have both published statistics that 
show that Medicaid programs on average pay less than 90 percent 
of cost and that Medicare pays less than 100 percent of cost. 
So there is a cost shifting that has been a constant pressure 
on unit costs in the private sector, and it's an ongoing and 
major driver of unit cost inflation in health care on the 
private side.
    Mr. Schock. You said your premiums went up on the average 
of 4 to 6 percent?
    Mr. Collins. Unit cost trend over time in the industry has 
been running around 4 to 6 percent, and that's over a long 
period of time. Annual--just the unit cost. Other components of 
inflation are utilization increases, new technology, those 
sorts of things. But just straight unit costs has been running 
4 to 6 percent.
    Mr. Schock. And have you looked at what percent of that is 
costs of doing business and what percent of it is a shift?
    Mr. Collins. I'm sorry, sir. I couldn't answer that precise 
question. But 88 billion over the private sector is a 
significant amount of money.
    Mr. Schock. Yeah.
    Mr. Sassi. Congressmen, I would agree with Mr. Collins' 
comments. Milliman did publish that study and it estimated that 
88 billion is being cost-shifted to the private sector from 
Medicare and Medicaid, which equates to about an overall 
increase across the board for commercial members of about 10 
percent, or, I believe the study says $1,600 per covered 
member. It would be very difficult for us to identify on a 
facility-by-facility, doctor-by-doctor understanding their 
entire cost structure, what goes into that, to identify at that 
level. But I believe that the Milliman study is credible.
    Mr. Schock. Because I'm tight on time, I'm not going to ask 
anyone to repeat the same thing. Has anyone done--I guess I 
understand provider by provider, it's not possible to do that. 
But I didn't know if you actually looked, did some independent 
study on a sampling pool of preferred providers on what their 
justification of increase in costs is?
    Mr. Richards. Congressman, first of all, I do agree that 
the underpayment by Medicare and Medicaid is absolutely a huge 
problem for hospitals and doctors and it's definitely 
increasing medical inflation. CIGNA has done some analysis of 
the disparity in the rates between Medicare and Medicaid and 
commercial rates. I don't have that with me, but we would be 
happy to provide that analysis of the average rates to the 
committee.
    Mr. Schock. I only have a couple--what is the yellow, 2 
minutes, 1 minute?
    Mr. Kucinich. Go ahead and finish.
    Mr. Schock. OK. One other question, because I'm going to be 
cutoff here. I wish I had more time. It seems to me, again as 
we talk about controlling costs, I found it very interesting, I 
met with the Consulate General of Canada, and he is very much 
supportive of their Canadian health care system. But one thing 
I thought during the discussion was he said, Congressman 
Schock, he said, ``It's still too easy in your country to sue 
doctors.'' And I kind of sat back in my chair and I said, 
``Excuse me?'' He said, ``Well, our health care system in 
Canada would not continue to function if comprehensive tort 
reform were not a part of the health care plan when we passed 
it in our country.''
    My question--obviously my view on this is we shouldn't wait 
for a single-payer system in our country to have comprehensive 
tort reform as a part of reducing not only the premiums that 
the health care community pays but, more importantly, the 
unnecessary medicine that's ordered as a result.
    My question to you, again, is whether or not within your 
respective companies you have looked at the amount of 
reimbursed care that you give through the insured folks, what 
percent of that's done through defensive medicine as a result 
of a fear of these physicians being sued?
    Ms. Reitan. I actually don't have the data with me, but I 
know the BlueCross BlueShield association has done some work on 
this exact issue. So we would be happy to submit that in 
followup.
    Mr. Schock. Could you provide us a copy of that?
    Ms. Reitan. Yes, we would be happy to do that.
    Mr. Schock. Anyone else?
    Mr. Bloem. Tort reform would be very helpful because the 
absence of tort reform increases the intensity of procedures 
that doctors perform, which is one key aspect of utilization 
which you talked about before.
    If I may, I would just like to go back to your question 
about cost shifting with government programs. One of the things 
that happens with Medicare and Medicaid is that they lower 
reimbursement rates in an effort to get more efficiency out of 
the health care system. That, in part, does happen. But when it 
doesn't fully pay for the reimbursements, then what happens is 
there is a cost shift. And the commercial segment, the 
commercial products pay for that shortfall that's not made up 
by efficiency that comes from those reimbursement cuts. And 
that's estimated to be $1,500 for a family of four who has 
private health insurance. That--if you look at the total cost 
of private health insurance, that's a major component it of. 
Thank you.
    Mr. Schock. Thank you. And thank you, Chairman, for your 
generosity.
    Mr. Kucinich. We are glad that you're on this committee and 
we appreciate your participation. The Chair will recognize the 
distinguished chairman of the Judiciary Committee who has 
joined us, Mr. Conyers. You may proceed.
    Mr. Conyers. Thank you for this permission, Chairman 
Kucinich. And I want to thank you for the hearing. These are 
distinguished, experienced members of the health insurance 
industry, and I'm sure their testimony has been very important 
as we work toward a reform of health care.
    And I also want to commend the ranking Republican member, 
Aaron Schock, who is carving out quite a record of distinction 
for himself. I'm glad he is here with us as well.
    Ms. Farrell, what do you think--what is your feeling about 
the public option, and how do you think it fits into health 
care reform as you see it, ma'am?
    Ms. Farrell. My view of the public option is that I think 
we really need to focus our efforts on understanding what 
problems that we are trying to solve around access and quality 
and affordability, and then ask ourselves at the end of that 
whether or not a public plan would actually progress us further 
down the path than some of the bills that have already been put 
in place. I do believe----
    Mr. Conyers. Could you pull the mic just a little closer, 
please?
    Ms. Farrell. One of the things that's concerning about a 
public plan, which Congressman Schock was just referencing, is 
the cost shift. If a public plan were to reimburse at Medicaid 
or Medicare rates, there would be quite a cost shift to the 
commercial segment, which would in turn result in increased 
costs in the commercial sector, and therefore increased 
premiums, which is really antithetical to what we are trying to 
achieve in health care reform.
    Now, Mr. Richards, it was my impression that the public 
option would be designed to save money, not cost more money, 
and that it would provide a choice between citizens as to 
whether they wanted a private insurance plan, of which there 
are literally hundreds, or would they want a public plan. Is 
that your impression?
    Mr. Richards. Congressman, CIGNA supports many of the 
reforms that are being debated in the debate in both the Senate 
and in the House, including personal coverage requirements, 
guaranteed coverage, the elimination of preexisting conditions, 
and the reform of payment mechanisms. We believe if those 
reforms are enacted, then a government-run plan is not 
necessary.
    Mr. Conyers. So, Mr. Sassi, if you agree with that last 
comment, then you don't want any competition in the insurance--
health insurance field, right?
    Mr. Sassi. I think it's our position that there is a lot of 
competition today in the health insurance industry. There are 
over 1,300 health insurers in this country that compete for 
business.
    The challenge is that when the Government could come in and 
have the ability to set reimbursement rates, that it creates an 
unlevel playing field between private industry and the 
Government, and that certainly has the potential to exacerbate 
the cost shift that already occurs between Medicare and 
Medicaid and the private sector.
    We also fear that as a result of that, since we don't 
have--we would not have a level playing field, since insurers 
are subject to taxes and other types of expenses, that lower 
reimbursements, coupled with taxes that we pay, create a 
dramatically unlevel playing field and that could reduce choice 
for the American public.
    Mr. Conyers. Well, Ms. Reitan, with this unanimity against 
the public option, we are putting in a provision that everybody 
has to get insurance, and if you can't afford it, guess who 
will pay for? The Government. And you're talking about the 
public option will cost--someone is talking about it, not you. 
How could one public option destabilize 1,300 private insurance 
companies?
    Ms. Reitan. Our company agrees with the statement that was 
made earlier, that when you implement some of the reforms that 
are being discussed that require insurers to offer coverage to 
all individuals, regardless of their health status, as long as 
they have a requirement to access and carry coverage----
    Mr. Conyers. Could you pull your mic up a little closer?
    Ms. Reitan. We do agree there are people who are lower 
income, often low-income working individuals, who will need 
some subsidy in order to be able to afford health care 
coverage. So we believe if you pass reform with all of those 
elements, we actually will have a more well functioning health 
care system today and have the ability to put in the market 
plans that can be affordable over time.
    Mr. Conyers. Couldn't a public option accomplish that?
    Ms. Reitan. We don't think it's needed in order to 
accomplish that.
    Mr. Conyers. Why not? There are a lot of people advocating 
it.
    Ms. Reitan. Because those reforms that I have described 
have never been in existence in the United States. And so by 
passing them, we think that can significantly improve the 
health insurance system and make coverage both more accessible 
and more affordable.
    Mr. Conyers. Well--surely.
    Mr. Kennedy. We have a public option in the VA. The 
Veterans Administration is essentially a public option. So we 
do have one here in this country.
    Mr. Conyers. What about Medicare? Who do you think runs 
that?
    Mr. Kennedy. Exactly.
    Mr. Conyers. Well, let me--I'm not doing too well on these 
question, Mr. Chairman. Nobody seems to----
    Mr. Kucinich. I would suggest that the Chair is doing very 
well with the questions. It may be the answers that we may be 
having difficulty dealing with here, but your questions are 
just fine.
    Mr. Conyers. Well, let me try Mr. Collins. Have you ever 
heard of a universal single-payer health care system?
    Mr. Collins. Yes, sir, I have heard of the concept.
    Mr. Conyers. And have you developed some feelings about it?
    Mr. Collins. Well, yes, sir, I have--clearly I'm a partisan 
for the--having a private health care, robust private health 
care sector. I believe that the private health care sector 
brings a lot of value to the overall system that we have here, 
and of course we have a robust public system with Medicare, 
Medicaid, VA system, TRICARE. Those are all components of the 
public system.
    I believe the private system is important because it brings 
in innovation, it brings energy, it brings change, it brings 
ideas that are often used in the public sector system as well. 
And I think we can have both a private and public system. We 
can build on what is good in the public system--in the private 
system, and use those things to improve the private system as 
well, sir.
    Mr. Conyers. That's encouraging. Then why not let's try the 
single-payer system, H.R. 676? That's mostly a public system. 
What's wrong with it?
    Mr. Collins. I'm not actually familiar with that bill. If 
it's a single-payer system it would be the end of the private 
system as we know, I believe.
    Mr. Conyers. Is that true, Mr. Bloem? Does that mean that 
the private system goes out if you have a single-payer system?
    Mr. Bloem. I think the primary concern, Congressman, is the 
fact that we mentioned before with respect to the cost shift. 
The Medicare and the government programs, the VA, all of those 
programs have lower rates of reimbursement. So that in the 
entire system, not all of the costs are being covered by--not 
the proportional costs of care that those programs--that those 
programs give are being borne by the Government. So there is a 
shift, as I mentioned to Congressman Schock, of about $1,500 
for a family of four every year.
    And so I think one valid concern would be that if all--
there was a single payer and all of the costs were borne by the 
Government, then there would be none of the innovations that 
the others have discussed. It would be the end of the 
commercial. But then you would have to--the Government would 
then have to absorb all that other cost, and that would make 
it--that would make it more expensive for everyone. There is 
also, I want to remind everybody, what was said to--was said 
about the value of what the private sector provides.
    Mr. Conyers. But what about all the cost increases that the 
health industry is imposing upon people with health care, not 
only in their premiums but also in pharmacy prescriptions that 
are being raised? I mean, you talk about cost shifting; you 
ladies and gentlemen are representing companies that keep 
raising the costs of premiums every single year, and yet you're 
worried about somebody else shifting costs.
    Mr. Kucinich. Mr. Conyers, time has expired. But each one 
of you that wishes to respond to his question, please do so. 
And I would urge any or all of you to do it. Would someone care 
to respond?
    Mr. Conyers. Could we start--Ms. Farrell, could you help me 
understand how I can increase my sympathy for health insurance 
companies?
    Mr. Kucinich. Ms. Farrell.
    Ms. Farrell. Yeah. The way we look at premium increases 
every year and the way they are calculated is based on the 
underlying increase in medical costs. And so----
    Mr. Conyers. So you have to do it. But the profits are 
greater and help--the only people I can think of that make more 
profits than the industry that you six represent is oil and 
pharmacy.
    Mr. Kucinich. The gentleman's time is expired.
    Mr. Conyers. I'm sorry.
    Mr. Kucinich. We are grateful that you're here.
    Mr. Conyers. All right. Thank you very much.
    Mr. Kucinich. And the Chair recognizes Mr. Kennedy. And we 
are grateful that you're here, Mr. Kennedy. And we are grateful 
for your family's lifelong commitment to health care for all 
Americans.
    Mr. Kennedy. Thank you, Mr. Chairman.
    To the panel, as my former colleague was just talking about 
the public option, and given the environment right now in 
Congress with respect to the political liability of a public 
option, I wanted to get to how we are going to implement 
savings in the event that a public option isn't passed. I am in 
strong favor of a public option and want that on the record, 
but I understand that the political reality of what is going on 
right now in Congress shows that that may or may not happen.
    If that doesn't happen, I want to hear today what insurance 
companies are going to do to step up to the plate to make sure 
that we don't waste a lot of time before we get put into place 
what will be the alternative to a public option; that is, 
perhaps a trigger of the public option, which means that we are 
going to have to wait for us to show that insurance companies 
aren't doing their job before a public option then gets kicked 
into place. And, of course, that's an ugly kind of scenario 
because it's basically saying OK, we are going to wait until 
things go wrong before we fix them. And that presupposes things 
are going to go wrong.
    So obviously we don't want things to go wrong. And what I 
would like to hear from you is--we hear a lot of talk about 
different tools in health care that will save money and improve 
quality and efficiency, and we are all familiar with the 
inefficiencies in our current system that lead not only to 
wasted dollars and poor health outcomes for patients, but also 
huge administrative headaches and red tape for patients.
    Health care information technology, as I know, is one of 
the tools we talk about in achieving efficiencies. But another 
area where we could generate savings and quality improvements 
is through a process called improvement tools, such as value 
stream mapping and flat mapping.
    We talk about how to make clinical improvements to improve 
efficiency, so to save money. But what do you see for these as 
potential to save money through the process of administrative 
improvements? And what can be done to incentivize the use of 
these tools in not only making clinical improvements, but also 
making improvements in the whole process of administrative 
making and cutting out a lot of that red tape that everybody 
always acknowledges is a big cumbersome part of your business? 
Could you tell us how do we incentivize in government a way for 
you to do the right thing?
    Mr. Sassi. Congressman, I think there are many things that 
the private sector can work with government on. I think you 
brought up an important element: health information technology. 
I think there--certainly my company, WellPoint, is very 
interested in implementing health insurance technology. 
Examples include e-prescribing and making sure that--making 
available to doctors the ability via a PDA to prescribe--to 
check for drug-to-drug interactions, to get personal health 
information----
    Mr. Kennedy. We know all--we don't have much time. We know 
all about IT and what it can do. But how do we ensure that, you 
know, when you have an IT system that's actually an IT system 
that's working to the maximum effect? We all know IT can work, 
but it doesn't do a lot of good to have IT and say all those 
great buzzwords about keep prescribing and, you know, Doctor, 
you know, supported protocols and all of that stuff. It's not 
going to do well if you don't have a way of monitoring whether 
the system is actually running efficiently.
    And when the doctor says, oh, go out for these five 
referrals, and they go out to the front and the administrative 
clerk only gives them three of the five, who picks up that it 
was only three of the five? How do you measure whether your 
system is working up to speed?
    How do you measure whether your system is working up to 
speed? Who's going to be testing to make sure that you're doing 
the job in terms of getting the most efficiency out of your IT 
system.
    Mr. Sassi. I think each company owns that for their own IT 
areas, but I think it's a shared responsibility.
    Mr. Kennedy. See, that's the problem. See, that's the 
problem, because you can't have all these proprietary systems 
out there. Everybody thinks they've got this new age IT thing 
going, and then, you know, they've all got different systems 
for, oh, we're going to try to do this process more efficiently 
here and this process here, when we don't have standards.
    We have basic metrics for clinical care. Where are the 
metrics for making sure that you're going to do the best 
administratively? I mean, we can do all the protocols in the 
world, when you come into an ER and say, you know, wash your 
hands, get this glove, get that glove, cooperate this way, we 
want this person to be treated so that they don't get an 
infection.
    What I want to know is what you are doing to standardize, 
so no matter what IT system there is and what health system, we 
know that you all are doing, you know, not your own proprietary 
thing, but whatever proprietary thing is doing, it's Good 
Housekeeping Seal of Approval proprietary system that is 
squeezing out every bit of waste and duplication and redundancy 
that there is out there; how do we know that it's really 
working to the best effect that it's supposed to be?
    Mr. Kucinich. The gentleman's time has expired, but the 
witness--one of the witnesses may respond if they care to. 
Anyone? I think that Mr. Kennedy raised some important points. 
In the followup discussions that staff has with the panel, 
we'll explore that. Thank you, Mr. Kennedy.
    We're now going to go to round two of questions. Just a 
little bit of housekeeping here. On the last round of 
questions, I asked Mr. Richards for information about his town 
hall meetings. You know about all of our town hall meetings, we 
want to know about yours. And so you have internal town hall 
meetings. We want your audio tapes as well as copies of all 
minutes of those meetings and all memoranda that was discussed 
at those meetings or actions decided at those meetings. So you 
will be hearing from us in an even more formal way, but just to 
understand that we do want that information, and I just 
announced it from the Chair here.
    Now, I want----
    Mr. Cummings. Will the gentleman yield?
    Mr. Kucinich. The gentleman will yield.
    Mr. Cummings. Just one quick question. We don't know 
whether the others have these types of materials. I just was 
wondering if the gentleman was----
    Mr. Kucinich. At Mr. Cummings request that we will ask, so 
we're not singling you out, Mr. Richards, we will ask everybody 
to produce the same information. You may not call them town 
hall meetings, but we will try to find out what it is you have 
there, try to organize your troops on the issue of cost 
reduction.
    Mr. Cummings. Thank you, Mr. Chairman.
    Mr. Kucinich. I thank the gentleman.
    Mr. Kennedy. Mr. Chairman, in response to the questions I'd 
asked, if all of them could get back to me on actual, tangible 
recommendations as I pointed out to what we can do to 
standardize incentives for them to have widespread standard of 
option of IT to incentivize those savings.
    Mr. Kucinich. I thank Mr. Kennedy. This is not solely an 
investigative subcommittee. We also look for recommendations as 
to how the existing system can be improved. So, as long as we 
have this system, I would imagine you ladies and gentlemen 
probably have some pretty good ideas. So thank you, Mr. 
Kennedy.
    Now, Ms. Farrell, let's talk about Aetna. Aetna's the third 
largest private for-profit insurer, according to Fortune 
magazine, but your current management returned your company to 
profitability by shedding members. You made bigger profits with 
fewer premium payers; isn't that true?
    Ms. Farrell. Are you referring to back in the late nineties 
and early 2000's?
    Mr. Kucinich. That you have made--there is a point at which 
you shed some members, and the profits started to go up; isn't 
that right?
    Ms. Farrell. There was a point in our history where we were 
as an enterprise not profitable, and one of the reasons--the 
big reason why we were not profitable is we had underestimated 
medical costs.
    Mr. Kucinich. I'm sure. That's exactly the point. So how 
many customers did you have to lose in order to return to 
profitability?
    Ms. Farrell. I don't recall. It wasn't looked at in terms 
of how many members we had to lose. It was looked at in terms 
of how--what is the underlying weight of medical costs and how 
are we going to price appropriately for that in the 
marketplace.
    Mr. Kucinich. Forbes magazine said you had to lose about 8 
million. We're going to put that article in the record.
    [The information referred to follows:]

    [GRAPHIC] [TIFF OMITTED] T4918.081
    
    Mr. Kucinich. Does Aetna have an estimate of how much 
expenses the company avoided by shedding those policyholders?
    Ms. Farrell. I don't believe it was looked at that way. It 
was looked at relative to----
    Mr. Kucinich. Can you determine for us, look at your 
internal memoranda, at your actuarials? You should be able to 
figure out how much money you actually saved by shedding 8 
million policyholders?
    Ms. Farrell. I can look at that----
    Mr. Kucinich. I appreciate if you look at that. Also, 
almost all of those 8 million people received their health 
insurance through employers, and they lost their Aetna health 
insurance when Aetna raised prices of the group plans beyond 
what their employers could pay. I mean, isn't that true?
    Ms. Farrell. I say if they left us, it was beyond that 
which they felt was a reasonable premium----
    Mr. Kucinich. Thank you. Now, your CEO has spoken publicly 
about the significant investments in sophisticated information 
technology he authorized at the start of his leadership. I 
assume those IT investments helped Aetna identify employers for 
repricing. So I'm wondering, could you tell the subcommittee if 
Aetna picks employers to shed by, for example, the type of 
occupation, work is performed?
    Ms. Farrell. No, that's not the way we would do that.
    Mr. Kucinich. Age in the plan, the age of the workers?
    Ms. Farrell. You're asking about our underwriting 
practices?
    Mr. Kucinich. Does your IT system identify people by age, 
and do you pick employers to shed by the age of the workers in 
the plan?
    Ms. Farrell. Our IT system does not identify people by age. 
The way it works is that an employer will provide us with a 
list of their employees and, along with that list would be 
other requirements in order to underwrite, age being one of 
those.
    Mr. Kucinich. Can you identify how long someone has been in 
the system?
    Ms. Farrell. It would identify how long they have been a 
member at Aetna, yes.
    Mr. Kucinich. OK. Now, do you pick employers to shed by 
claims histories of the workers in the plan, such as frequency 
of emergency room visits or disease clusters, like cancer?
    Ms. Farrell. Could you repeat your question, I'm sorry?
    Mr. Kucinich. I'm just trying to explore how employers get 
shed. Do you look at claims histories of workers in the plan? 
For example, if somebody visits an emergency room frequently or 
there is a number of people with cancers, do you make decisions 
based on some of those principles? Are any of those programmed 
into your information technology?
    Ms. Farrell. No, we never drop a member because of an 
increase in their medical.
    Mr. Kucinich. Like some, there will be a report that will 
just be spit out that will say, uh oh, cluster of diseases 
here, cancer, high cost, out?
    Ms. Farrell. No.
    Mr. Kucinich. That does not happen?
    Ms. Farrell. That does not happen.
    Mr. Kucinich. And you don't screen by location or ZIP 
codes; or do you? Do you screen by location or ZIP codes?
    Ms. Farrell. One of the ways we price our business is to 
actually look at geography because there are significant cost 
variations by geography across the United States.
    Mr. Kucinich. Are those cost variations determined by, 
among other things, epidemiological factors?
    Ms. Farrell. They are determined by looking at the 
underlying costs by geography, and there can be significant 
variations just towns away from one another. So that's one of 
the things that we do take a look at.
    Mr. Kucinich. My time has expired on this round, but what 
I'd like to do, Ms. Farrell, is so that we can better 
understand the relationship between your information technology 
and how it serves as a tool for decisionmaking, if you could 
provide this subcommittee with a narrative so that we can come 
to an understanding of the relationship between the data that 
you gather and the way that's used as a tool for your 
decisionmaking with respect to your customers and whether they 
will continue to have policies. This would deal with shedding, 
rescissions, even, you know, any use of information technology 
that would use to shed any of those 8 million customers.
    And since we're trying to be fair to each and every one of 
you, this subcommittee's going to ask each and every one of you 
by letter to provide that information, that with the 
information technology that you have, how does it--does it help 
you decide which customers to shed and how does it do that?
    OK. My time has expired. We are going to go to Mr. Schock. 
You have 5 minutes. You may proceed.
    Mr. Schock. Thank you, Mr. Chairman. You know, I guess in 
response to some of the concerns raised, I would only say that, 
you know, I think most of us agree--at least I agree--with the 
comments that were made earlier that health care premium costs 
are a function of reimbursement rates. And so I think it's 
disingenuous to compare a government-run plan to a private plan 
when a private plan cannot control for costs and a government 
plan can.
    In other words, in a truly static system where all 
reimbursement rates are set at a Medicare and Medicaid 
reimbursement level, the system then would be forced to control 
their costs either by reducing quality or reducing options.
    And I think for those of us who share the concern of a 
movement toward a single-payer system, it is clearly focused on 
the quality of the care the patient will receive and continuing 
the progress that this country and its health care system has 
made over those countries with a different plan in terms of the 
innovation and the technology that we have here in our country.
    I can only speak from my experience prior to being in 
Congress, which was in the State legislature in Illinois, and I 
witnessed firsthand what happened in Illinois under then Rob 
Blagojevich's health care proposal, which was All Kids, which 
did similar to what the Majority wants to do here, which was 
basically offer health care, a government plan, for all kids in 
the State of Illinois regardless of income.
    I saw firsthand in my legislative office individuals who 
had children insured, individuals who were duly employed by an 
employer who offered a private health care plan and who opted 
for the savings of anywhere from $50 to $70 a month to take 
their child out of the private plan and enroll them in the All 
Kids Medicaid reimbursement level health care plan.
    Now, it did two things. No. 1, I've got a very poor 
legislative district, 40,000 voters, 20,000 of them on food 
stamps. The people living in poverty who otherwise had access 
to care, their access dried up and went away. Today, there is 
not a dentist in the city of Peoria, Illinois that will take an 
All Kids patient.
    Second, it ballooned the deficit within the State of 
Illinois' Medicaid program, All Kids program. We are now 9 
months late in our reimbursement levels.
    So I would just throw this out there as a case-in-point 
example, a microcosm in our country where we have tried a 
similar option, a competition if you will, against private 
insurers.
    Second, and to that point I just don't--I don't buy the 
concept that the solution to greater quality, greater access, 
and lower costs is the Government.
    To that point, though, I think we need to do a better job 
of providing--if we understand we're trying to control cost, if 
everyone accepts the fact that health care premiums rising are 
making it more difficult for businesses to provide health 
insurance, for individuals to provide health insurance, how do 
we lower the health care premium costs? Are we going to have to 
lower the request for services or the rates that we're paying 
back?
    My question to you would be, how do we give those tools to 
the consumer? Because it's my view right now, as consumers, if 
I have a private-pay health care plan, whether it's provided to 
me as an individual or whether it's provided to me by my 
employer, I don't have the tools necessary--there's not a lot 
of competition. I'm digressing a little bit.
    But there's a lot of talk about health insurance being 
compared to automobile insurance. The biggest difference I see 
in automobile insurance is that if my car gets in a wreck I'm 
going to do one of two things. I'm going to go around and I'm 
going to get probably two or three estimates, not because I'm 
going to pay for out of pocket, but because I know when I turn 
in my automobile expenses, my automobile insurance rates are 
going to go up. That connection doesn't seem to be there--while 
it's true, that connection doesn't seem to be in the mind of 
the patient as he or she accesses the health care system.
    So what tools can you in the insurance industry give to 
consumers, how can we look at maybe reforming the way in which 
people buy their health care, not the premium, not the premium, 
but rather, the actual service, how they buy it--and I 
understand you can't do it in emergency care. But if I go in--I 
live in a relatively large city, 150,000 people. A lot of 
places offer MRIs and each one of those locations charge a 
different rate. Yet that information is not readily available 
to me as a consumer.
    I think that is a part and parcel to us of doing a better 
job of controlling the costs that go and drive up health care 
premiums. So if you could answer that question I would 
appreciate it. What are you doing now and what could we be 
doing to give those tools better to consumers?
    Mr. Kucinich. The gentleman's time has expired, but the 
witnesses can answer the question. Thank you.
    Mr. Sassi. Congressman, I can answer that from my company, 
WellPoint. Several years ago, we embarked on a journey to 
increase the transparency so that consumers could more easily 
compare the prices of commonly used services within their 
geographic area; because you're right, there is a large 
disparity between an MRI in one part of the city and another 
part of the city, a cost for commonly--knee replacements in one 
part of the city versus others.
    So we created Anthem Care Compare, which is a Web site that 
identifies the top 34 elective-type procedures and a member can 
go into that Web site, type in their ZIP code, and it will 
identify different providers within the area and the costs 
associated that would be charged by the different facilities 
for those areas. Plus, we try and tie in as much quality--
publicly available quality information that is available to 
members, so that if you're considering having your knee 
replaced at a certain facility, how often do they do that 
procedure and what is the success rate, what is the readmission 
rate for that?
    We have rolled that out in many of our markets across the 
country, and actually we're now providing that service to many 
BlueCross BlueShield plans across the country. So that's one 
example of how we can increase the transparency.
    Mr. Richards. Congressman, you mentioned MRIs, which is a 
great example. In some geographies the cost of an MRI can vary 
by 100 percent or more depending on where you go. At CIGNA, 
we've provided the cost of MRIs on our Web site so individuals 
can go and look it up. The vast majority of the health care 
providers that work with us allow us to do that. There are some 
that do not allow us to show the transparency, but the vast 
majority do, and it does help.
    The other thing I would say is--along the lines of tools, 
you need to provide the incentives to individuals. One of 
CIGNA's customers is Safeway, and I think they're a marvelous 
example of a company that has worked with CIGNA to both 
increase the cost and quality transparency--because it's not 
cost of areas but quality of areas as well--among their 
employees so they can get the right care, get it at the most 
efficient price. They also incentivize people for appropriate 
behaviors, whether that's not using tobacco or exercising 
because, at the end of the day for Safeway, if you have a 
healthier employee, it's also going to be a lower-cost 
employee.
    Mr. Kucinich. I thank Mr. Schock for his presence here, and 
if you have followup questions, you want to put them in 
writing, we will make sure that they will go through the 
committee. We support your request.
    You know you brought up that issue--I just want as Chair 
just take a little bit of your pointing out that, you know, 
when you brought up the issue about car insurance and compared 
to health insurance, I mean that's one of the debates right 
now. And just what occurs to me is that if you wrecked your 
car, you get a new car. If you wreck your health, you're dead, 
you know, unless you believe in reincarnation.
    Mr. Schock, thank you.
    Mr. Schock. Thank you.
    Mr. Kucinich. The Chair recognizes Mr. Cummings.
    Mr. Cummings. As I was sitting here listening to you all, I 
was saying to myself, boy, they sound real nice, I mean it 
sounds like everything's rosy, and you know, when--it's 
amazing, the people who sat here yesterday made us--I mean said 
some things that were very, I thought, I felt, very damaging to 
the--to what you all do every day. I'm not talking about you 
all individually, of course.
    And the thing I guess that I'm just sort of wondering 
about, they made a big deal of this whole denial of claims. And 
I specifically asked them the question about whether they felt 
that things were worse or better since the Clintons tried to 
get through health care reform, and they said that they were 
far worse with regard to denial of claims.
    And so, Ms. Farrell, I'm going to go to you because I--for 
one reason because you had said something that interests me. 
You had talked a little bit earlier about claims, that there 
were no--there was no one--that only--maybe it was several of 
you who said only doctors deny claims; is that right? So you 
all were telling me that there are no other nonmedical people 
who make decisions that a person cannot get a certain treatment 
paid for; is that what you're telling me?
    Ms. Farrell. Just to clarify, what I said was that there 
are no medical decisions or no medical denials that are made by 
somebody who is not a physician. You can deny a claim for a 
nonmedical reason, and that decision can be made, obviously, by 
a nonclinician.
    Mr. Cummings. And I take it that those kinds of decisions 
are made every day, are they not, by nonmedical people?
    Ms. Farrell. Nonmedical decisions, yes, can be made by 
nonmedical people; but if it's medically related, it is made by 
a physician.
    Mr. Cummings. And so a claim is for services--I just want 
to make sure our definitions are right again--services already 
rendered; is that right? A claim is normally for something--I 
see you shaking your head, Mr. Bloem; is that right?
    Mr. Bloem. I think that we are as a group here struggling 
with what the definition of a denial of a claim is. To me, a 
claim, when I cited what the survey said about us, a claim--
there are basically three kinds of claims, and the first kind 
has been really enunciated here quite well. That's when you get 
a duplicate claim. That's when you've rendered service, as you 
said, and then you get a claim that comes in, and then another 
claim comes in and you probably paid the first one.
    In the denial rate, in the numbers I cited, the 5.7 that we 
have and the 5.4 that we have and the 8.7 that Medicare Part B 
has, in those claims, the biggest cause of that is duplicate 
claims.
    The next kind of claim is for experimental or 
investigational where there wasn't any preauthorization, which 
was also discussed earlier.
    And the last kind is where the employer has not--has 
through the policy terms decided we are not going to cover that 
kind of a claim, that kind of a process, that kind of a 
procedure.
    Now, the other thing that we're struggling--when you are 
asking questions, I believe you're also talking about coverage 
determination; other people have coverage in advance of when 
services are covered.
    Mr. Cummings. Yes, OK. I've got to ask you this. I 
understand a person can have their treatment preauthorized and 
even get a preauthorization number, get treatment and still the 
payment for that same procedure may be denied; is that true?
    Mr. Bloem. In a coverage determination, there's an initial 
decision made about whether this procedure is covered, and 
that, in our company, like in the case of Ms. Farrell's 
company, that's done on a denial of coverage, is only for 
medical reasons, is only done by a licensed board-certified 
medical director.
    Mr. Cummings. And so none of you all, then, nobody up here 
has anyone who denies a person treatment, in other words 
that's--in other words, how many of you all deny folks, if any 
of you have people who you give bonuses to or give financial 
incentive for a denial of treatment? Nobody.
    Mr. Bloem. I answered before, neither, none.
    Mr. Cummings. No, OK. I just think that based upon the 
testimony that we got yesterday, the testimony was clear that 
there are many, many instances where insurance companies are 
basically intentionally--and you may call it coverage, you may 
call it claims, whatever--holding back decisions and literally 
waiting for certain things to happen and, sadly, in some 
instances, death, and then, you know, and the person is denied 
one way or the other. So as the chairman said, here--different 
with an automobile--a person dies, and that's a sad, sad 
situation.
    Mr. Kucinich. The Chair recognizes Mr. Conyers. You may 
proceed for 5 minutes.
    Mr. Conyers. Thank you for your generosity, Chairman 
Kucinich.
    Ms. Farrell, are you aware of the report from Health Care 
for America Now, on July 15th, that reported that profits at 
the 10 largest publicly traded insurance companies was 428 
percent from 2000 to 2007?
    Ms. Farrell. I am not aware of the specific report that 
you're referencing, but Aetna's profits--for every dollar we 
take in, we pay about--we make about 5 cents in profit, pay 
about 84 cents in medical claims.
    Mr. Conyers. Well, what about you, Mr. Richards, are you 
aware of this report?
    Mr. Richards. I'm not aware of that report. I do know that 
if you look at CIGNA's total profits globally, we make about 
$1.66 per customer per month.
    Mr. Conyers. I see. Mr. Sassi, have you ever heard of this 
statement?
    Mr. Sassi. I am not aware of that report either.
    Mr. Conyers. OK. And Ms. Reitan, you must have heard about 
this.
    Ms. Reitan. I have not heard of it, and we wouldn't be in 
there because we're a noninvestor-owned company.
    Mr. Conyers. Well, I know Mr. Collins has.
    Mr. Collins. As a matter of fact, Chairman Conyers, I've 
seen that report in the newspaper and I believe it's just--it's 
somewhat deceptive in the way it's framed. There's been an 
enormous amount of growth among the top companies, and it's 
simply adding up the gross profits of companies as they've 
grown over time. So there's a larger share of profitability 
today in those top companies than there was 10 years ago, but 
that doesn't mean that profits have grown per member, per unit 
of business, per customer. It--one necessarily doesn't flow 
from the other. It's a function of the size.
    Mr. Conyers. Mr. Bloem, you know about this, don't you?
    Mr. Bloem. I'm not familiar with that study, but let me 
comment on my company.
    Mr. Conyers. Wait a minute, I don't want you to comment on 
your company. You're not familiar with the statement?
    Mr. Bloem. I'm not familiar with--I'm not familiar with the 
study or the statement.
    Mr. Conyers. OK. Well, how long have you been in the 
business?
    Mr. Bloem. I've been at my company since the beginning of 
2001.
    Mr. Conyers. OK. Have you ever heard of Health Care for 
America Now?
    Mr. Bloem. No, I've not.
    Mr. Conyers. OK. Well, let me ask you this question. Are 
you familiar with a recent study of the American Medical 
Association that 94 percent of the insurance markets in the 
United States are highly concentrated?
    Mr. Bloem. I'm not. I would----
    Mr. Conyers. You're not familiar?
    Mr. Bloem. I'm not familiar generally with those 
statistics, but it's not an unfamiliar statistic that in terms 
of some markets don't have a lot of competition, but most 
markets have much competition. Excuse me.
    Mr. Conyers. Well, do you contest this finding of the AMA?
    Mr. Bloem. I don't know enough to contest or affirm.
    Mr. Conyers. OK. Well, let's go down the line again then. 
Ms. Farrell, you're a student of the--I know you subscribe to 
AMA journals; you've heard of it.
    Ms. Farrell. I'm not aware of that specific study.
    Mr. Conyers. You've never heard of it. Richards, you never 
heard of it?
    Mr. Richards. No, I have not, Congressman.
    Mr. Conyers. Well, let me just ask to save time: Has 
anybody ever heard of it? Has anybody ever heard of the AMA?
    Mr. Bloem. Yes.
    Mr. Richards. Yes.
    Mr. Sassi. Yes.
    Mr. Conyers. All right. Well, let me--let me ask you about 
this. Have you ever heard of the statement that's been made 
public, and to my knowledge never contested, that the 10 
largest companies in health insurance, the CEOs' compensations 
total $118.6 million, an average of $11.9 million per CEO?
    Now, let's save some time. Anybody ever heard of that 
before? Nobody? Well, do you want a citation for it? Not 
particularly. OK.
    All right. Let me ask you this, Ms. Farrell: What is your 
annual compensation per year?
    Ms. Farrell. My annual compensation is something that is 
very private to me and something that I would be happy to 
submit----
    Mr. Conyers. You don't want to tell me; is that what you're 
saying?
    Ms. Farrell. I'm saying that I consider my compensation to 
be very private and that I would be happy to submit it to the 
committee in writing.
    Mr. Conyers. But you don't want to say it publicly?
    Ms. Farrell. No, because I do consider it to be private.
    Mr. Kucinich. Mr. Conyers, before you came, we asked the 
witnesses to submit information about their compensation in 
writing, if they choose not to answer at this committee 
meeting, but they will present it to us in writing.
    Mr. Conyers. OK.
    Mr. Kucinich. We can still get that information with their 
agreement.
    Mr. Conyers. Last question. Does anybody here--I've never 
had a hearing with six executives of health insurance who were 
all on the same panel. This is a new experience for me. Do any 
of you want to tell me what your annual compensation is, just 
for the record, without having to submit it in writing?
    Mr. Kucinich. If the witnesses care to respond, you can do 
that. If you don't, we certainly want you to submit that in 
writing.
    Mr. Conyers. What do you want to tell me, Ms. Reitan?
    Ms. Reitan. I'll tell you I make $728,000 a year in salary.
    Mr. Conyers. OK. I thank you for that. And what did you 
want to tell me, Mr. Bloem?
    Mr. Bloem. My compensation is $545,000 a year. It's a 
matter of public record.
    Mr. Conyers. Sure, and I thank you for that. And what do 
you want to tell me, Mr. Sassi?
    Mr. Sassi. I'd be happy to provide it in writing but it's a 
privacy issue.
    Mr. Conyers. It's what?
    Mr. Sassi. I consider it a privacy issue, and I'd be happy 
to submit it in writing.
    Mr. Conyers. OK.
    Mr. Kennedy. Would you yield?
    Mr. Kucinich. Before we go to Mr. Kennedy, I just want it 
understood that you have agreed to submit this information to 
the committee. As long as we have that agreement, that's fine. 
You can choose to answer the question now or you can choose to 
answer it in writing. It's really your choice.
    Mr. Kucinich. So, Mr. Conyers. Mr. Kennedy,
    Mr. Kennedy. I just to yield, just to be happy, John was 
bringing up a point. I think folks here just are obviously just 
working in a field that's perfectly legal and set up by our 
society to earn what they're doing and there's nothing wrong 
with that.
    I think what is wrong, as the gentleman's trying to point 
out, is that last year the head of CIGNA earned $11 million. 
Now, if you're going to talk about where that money's coming 
from, it's clearly coming from denied claims. The head of the 
UnitedHealth Group earned $9.4 million. Now, these are public 
records.
    So you don't have to ask. They're nice to--I'm sure they 
love to be called senior executives; but frankly, John, I think 
they hope to be senior executives at those kinds of pay scales, 
but they're I'm sure not at that level yet.
    But the point is, we are trying to make the point that the 
industry is allowing for these kinds of exorbitant pay at the 
very top, which just begs the question, it's an allowable 
industry in our country. But we need to know, you know, kind of 
what is this a matter of where these dollars are coming from 
when people are paying these premiums and people are getting 
rejected for health care, how are these compensations so 
exorbitant?
    So I appreciate the questions you're asking. I also 
understand the fact that these individuals here have every 
right to say or do what they're, you know, doing because 
they're in an industry----
    Mr. Kucinich. If I may, Mr. Conyers' time has expired. 
However, we will now go to you, Mr. Kennedy, if you want to 
yield any time back to Mr. Conyers. You can proceed for 5 
minutes, and we're going to go one more round after that, and 
then we will be done, because I know everyone here is trying to 
catch your planes.
    Mr. Kennedy. Well, I would like, Mr. Chairman, to go back 
to this whole idea of how we're--if insurance has thus far not 
gotten around to figuring out ways to help the government or 
the society change reimbursement reform, if we've known for 
years that our system is upside down, that all we pay is for 
sick care rather than health care, if there are simple ways for 
us to keep people from being frequent flyers in our emergency 
rooms, if we just did X, Y and Z, and that that would lessen 
the pressure on you as insurers to charge your customers 
exorbitant premiums, then why haven't you in your industry 
taken upon yourself to be the biggest advocates for insurance 
reform over the last 20 years?
    And furthermore, what I don't get is that back home, like 
most of my businesses for the most part are passive when it 
comes to their insurance premiums. They let their insurer--
insurance carriers kind of dictate to them. They said, oh, 
here's your premium this year. And in fact, it's the insurance 
companies that work for the company that they are, you know, 
subscribing for and they've been hired to do their policies 
for.
    And so I just don't for the life of me understand why, if 
it's in the interest of their client to reduce premium costs 
and so forth and health--why insurers in this country haven't 
been at the forefront of this health care debate saying, 
listen, we've got--here are the ways we can restructure the 
health care market based upon a capitalist system whereby it 
pays to have better care at reduced costs.
    That's what I can't figure out, Mr. Chairman. If this is 
really about making money, we know there's plenty of money to 
be made. Why can't they build a better mousetrap to make money 
and also save--save money and give us the answers? You know, 
we're just trying to do what I think is consistent with what 
they're trying to do, and that is lower costs and build 
quality. They're the experts. They keep saying they've got all 
the innovation because they're in the private sector. Then why 
aren't they giving it to us?
    Why do I have to sit up here and ask about things that I 
frankly am not all that educated about, because my staff person 
puts it in front of me, and they're going to promise to get 
back to me on value-based streamlining and engineering. That 
cannot apply to health care.
    You know, all of these kinds of things that we're going to 
have to try to put in law so as to enforce insurance companies 
to bring their costs down, why do we have to put that into law? 
I'm sure they don't want to be regulated anymore than they are 
being regulated.
    So tell us why--because we're being pressured to bring our 
deficit down. We've got this enormous deficit. It's going to 
swallow all our future dollars, our taxpayer dollars. Our 
taxpayers are going crazy because they're getting on our tail 
for having a big deficit, and what we are trying to do is 
respond to them and say health care is one of the biggest 
financial nuts our country has going forward.
    So we're asking you to help us because one way or the 
other, money's going to get--have to be streamlined, and it's a 
question of whether it's going to be done at the expense of our 
consumers, which we don't want, or it's going to be done 
efficiently and with quality in mind so that people don't get 
their health care cut just because we haven't been on the 
forefront of making the right decisions policy-wise that allows 
them to continue their health care in the most efficient way 
possible.
    Maybe you could comment on why you don't think--you guys 
have been ahead of the game in terms of getting better 
reimbursement reform prior to this year--why does the 
Government have to do all this incentivizing for health rather 
than sick care? Why are we the ones that have to do this? Why 
haven't you been out there for years doing this stuff?
    Mr. Richards. Congressman, I'd love to respond to your 
question. First of all, I think there are some things that we 
can do individually. Certainly, at CIGNA we do several things 
to improve the health of our customers.
    For instance, we have a gaps-in-care program where we 
monitor for evidence-based care to identify if our customers 
aren't getting the care they need. For instance, somebody who 
has recently had a heart attack, who is not on the proper 
medication, a beta blocker. By mining that data, we can then 
outreach to that individual's doctor and to the individual and 
say, shouldn't this person be on a beta blocker because medical 
evidence would say that for most people that's appropriate and 
if they don't take that drug they're much more likely to have 
an heart attack. So that's an instance where we are using 
technology and our people to actually increase pharmaceutical 
claims for the better health of the individual. That's 
something we can do and do do today.
    Relative to your payment reform question, again, CIGNA is 
working with a variety of health care professionals. I 
referenced Dartmouth-Hitchcock in New Hampshire. We're actually 
working with five other entities around the country for payment 
reform where we have a patient-centered medical home, where a 
primary care doctor can coordinate the care because it is a 
complex system. If somebody is very sick, they tend to need a 
lot of different doctors, and having that primary care person 
look after the care is very important. A lot of primary care 
doctors can't afford to do that today because the reimbursement 
rates that Medicare and private insurance pay them, it's very 
tough for them to be able to do that.
    So medical home is a promising pilot that we're trying 
where we're paying extra money to those primary care physicians 
to allow them the time to help coordinate the care. So I think 
there are things we can do individually. There are thing we can 
do in partnership with health care professionals, the doctors 
and hospitals, and then I think there are things that the 
government needs to help on as well. And CIGNA and the industry 
have definitely supported reforms for a variety of things that 
we mentioned at the committee today.
    We really need government to work with us to help enact 
some reform as well. We look forward to working with you on 
this debate, Congressman Kennedy.
    Mr. Kennedy. My point is that medical home we've known for 
a long time works. Why are we piloting it? I know it's what 
we're piloting in the legislation, but we're only doing it 
because we're slow-walking something that we know works. It's 
been demonstrated over and over again. It makes so much common 
sense. It's like this whole trigger thing. We're doing what is 
inevitable, but it's going to take us an extra 4 or 5 years 
before we take the whole medical home thing to scale, because 
we're just--too many financial interests that we're going to 
have to tiptoe around in order to get this thing implemented.
    But if you guys stood up and said, hey, we all know medical 
homes are about making more efficient, giving the primary care 
doc and gatekeeper more time to help coordinate care because 80 
percent of the dollars are spent on 20 percent of the people. 
They're the chronic users. They're the highest users of health 
care. That's where we can get the most money. Let's do it, 
boom, let's go. What are we slowing down for?
    The reason we're slowing down is because there is this 
inertia out there because everybody is trying to protect their 
piece of the turf, and we wouldn't have that if insurance was 
more proactive. It's in your interest to be more proactive 
because at the end of the day we're going to hit the wall, and 
when we hit the wall, everyone else who is well off is going to 
be fine. It's the people in the middle and the bottom who are 
going to be hurt.
    Mr. Kucinich. The gentleman's time expired quite a while 
ago. But I tell you, I think everyone in this room and everyone 
watching knows how important what you just said is. And they're 
wondering if there's any response to--does industry care to 
respond to what Mr. Kennedy said? Anyway, what he's providing 
is a wake-up call here. Does anyone care to respond? We're 
going to have one more--Mr. Kennedy, we're going to have one 
more round after this and we'll wrap it up. But does anyone 
want to respond to Mr. Kennedy?
    Mr. Collins. Chairman Kucinich, we've submitted--and we'll 
send it for the record--proposals that we circulated with the 
administration and Capitol Hill of $500 billion of potential 
savings. I won't----
    Mr. Kucinich. Over what period of time?
    Mr. Collins. Over a period of time from 2010 to 2019, and 
we'll submit this report to the committee as part of the 
record.
    Mr. Kucinich. How much was that again?
    Mr. Collins. It was $540 billion, sir.
    Mr. Kucinich. OK. That would be helpful, and anyone who 
wants to submit similar information, so ordered, and we 
appreciate you doing that.
    I just want to say that as we go to the final round of 
questions here, I'm sure that the insurance company executives 
who are here recognize that everything's changed with respect 
to health care in America. You are facing a totally new 
environment than when you started your careers in health care: 
47 million people uninsured, another 50 million underinsured.
    As you know, many people are losing everything they have 
because they can't afford to pay their hospital bills, and many 
of those people had insurance. And so today we're talking about 
this business model, but we also have to understand--you get 
respect for your being here, but we also have a great 
understanding of your position and your political power.
    Let me give you an example. The insurance companies are so 
powerful that you were able to take H.R. 676, Medicare for All, 
well off the table right at the beginning of the discussion, 
for either party, not just one party or another. Both parties 
took it off the table. There's 85 Members of Congress that have 
signed on to it. It's a bill that Mr. Conyers and I drafted--
86, thank you.
    But the point is that you are able to exert your influence, 
and some of the reasons you're here today, I mean very clearly 
clashes with your business model. We understand that you're 
very influential here.
    Based on your influence, we're seeing the so-called public 
option which will provide some competition--we understand you 
feel it wouldn't be productive. But based on your influence, 
the public option looks like it is going to be very difficult 
to get into a final bill. And of course, the industry has had 
an influence in shaping issues such as triggers and co-ops.
    What Mr. Kennedy had to say I think is so important, and 
where Mr. Kennedy's comments lead to is that you should be 
thinking about the fact that the business model that you have 
could end up being--could end up killing the goose that laid 
your golden egg. You may be reaching an end point as to how 
much medical loss ratio you can go before people start to say, 
what's going on here? How far can your executives go, making 
millions of dollars a year, while claims are being denied--you 
may say there's no connection, but the public does make a 
connection.
    And look at where we're headed toward. This is where your 
presence here is not a small matter. We could very well be 
headed toward a condition where health care reform in America 
is really a form of a continuation of what I call insurance 
care, whereby the food and well-being of people, according to 
CBO, will potentially be covered by H.R. 3200.
    Without a public option, 32 million people will be pushed 
into private plans. They have to choose among private plans, 
and if they don't do that and they don't choose and they don't 
pay, they could be penalized. Extraordinary. But with that kind 
of power, I would hope you start to think about a different 
model of business and social responsibility. I'm not lecturing 
you. I'm just sharing some thoughts.
    The insurance industry, because of changes in the global 
climate, is due to take enormous hits, particularly in coastal 
areas over the next 40 years. We should all be working 
together, but on health care, you may eventually want to think 
about what it's going to be like when you wind down your health 
care products because, frankly, Mr. Chairman, I think sooner or 
later, whether it's this decade or another decade, you're 
moving toward a condition where more people are going to be 
uninsured, more people will be underinsured. Premiums, copays, 
and deductibles are going to be out of the reach of more and 
more Americans, and they're going to put it on you, and you 
know that.
    And so you know, I didn't call you in front of this 
committee today to embarrass you. That's not my intention at 
all. We need to get information about how your business model 
works, because people really need to understand that. We 
understand you're not charitable organizations. That's not why 
you were formed. You're responsible to shareholders; we 
understand that. If your medical loss ratio changes too 
significantly, Wall Street will punish you; we understand that 
too.
    The question is, is this business model sufficient to 
provide health care to American people at costs that's 
affordable? There's a collision here, and you happen to be at 
that time and place where this collision is happening.
    I'm going to ask one final question as I wrap up my time 
here. Yesterday we received testimony from Erinn Ackley of 
Montana. Erinn's father, William Ackley--and his obituary is 
part of the record--had a request for bone marrow transplant 
and that request was denied coverage on four separate 
occasions, causing a delay of 126 days in his cancer treatment. 
He ended up dying from the cancer.
    Now, Erinn Ackley told this committee that had he been 
enrolled in Medicare he would have received his bone marrow 
transplant right away. And Government-run Medicare provides 
primary health insurance to most senior citizens, has developed 
standardized forms, and standardized fits, with administrative 
costs that are a fraction of yours as percentage of revenues.
    Now, I'd just like to go down the line and answer this 
question. Isn't it true that your reason for not adopting 
Medicare's coverage standards as your own is that you could not 
deny payment for expensive treatments such as the one I just 
referred to? Mr. Collins.
    Mr. Collins. Chairman Kucinich, I can't answer that 
question. I'm not familiar with the Medicare guidelines. That 
would have been something appropriate for our chief medical 
officer to discuss.
    Mr. Kucinich. Mr. Sassi.
    Mr. Sassi. Like Mr. Collins, I am not familiar with it.
    Mr. Kucinich. Ms. Farrell.
    Ms. Farrell. Same, Mr. Chairman, I'm not familiar either.
    Mr. Kucinich. Mr. Bloem.
    Mr. Bloem. Nor myself.
    MR. Kucinich. Mr. Richards, can you answer that?
    Mr. Richards. No. Our chief medical officer actually used 
to be the chief medical officer for CMS, Dr. Jeffrey Kang. Had 
he been here today, I'm sure he could have answered it.
    Mr. Kucinich. Thank you. But I'm glad that you're here 
because I got a chance to ask you about your town hall 
meetings, and I'm really interested in that. So thanks for 
being here, Mr. Richards.
    Ms. Reitan.
    Ms. Reitan. I've got the same problem that everyone else 
mentioned. One of our chief medical officers could have 
answered that question.
    Mr. Kucinich. See, I mean, you know, you may not be as 
familiar with the Medicare standards--and I'll accept that 
answer--but I think you understand why I asked the question; 
and that is, we're trying to get to the genesis of the business 
model here: How do you make money?
    Many Americans believe that insurance companies make money 
not providing health care; that your first obligation is to the 
stockholders or shareholders, and then you have an obligation 
somewhere down the road to the people who are your 
policyholders. You have to have some obligation. You do pay, 
you said you have. You have a pretty good batting average on a 
lot of that. And when you get into the mechanics of analyzing 
it, it will raise some questions which is what we did today.
    Mr. Conyers, you have 5 more minutes for questions, or do 
you wish to----
    Mr. Conyers. I'm so nearly exhausted, Mr. Chairman, I 
hardly have anything else to say, but to thank you for this 
meeting and to thank our witnesses for holding up.
    But you know, it's been made public, but the American 
Medical Association has sort of come out for the Obama 
approach. You all have heard about that, have you? No? Yes, no? 
OK. You don't know if the AMA is with Obama or not?
    What about your companies? Have your companies said 
anything one way or the other about Obama's strategy of health 
reform? Anybody? You don't know? Yes, sir.
    Mr. Richards. Congressman, CIGNA has come out, as have many 
others in the industry, in support of many aspects of the 
President's plan.
    Mr. Conyers. OK. Let me put it more delicately. Are there 
parts of the Obama H.R. 3200 approach that your company is for 
and there are other parts you may not be in full accord with? 
Is that about fair? Everybody shakes their head. There are 
parts you can go along with and some parts--obviously public 
option is not one of your favorite parts of the bill, however 
it may appear, but there may be some other things. But there 
are things you like.
    Mr. Richards. Congressman, there are many things we like, 
yes.
    Mr. Conyers. Pardon?
    Mr. Richards. There are many things we like, yes.
    Mr. Conyers. Well, thank you. Let me just ask you about the 
Baucus bill. You've got a reaction. Did he make a little 
impression on you, or somewhat favorable? How does that 
resonate with your companies?
    Mr. Richards. Congressman, just from CIGNA's standpoint, I 
know that Senator Baucus just came out with it, and we're still 
reviewing the details of that bill.
    Mr. Conyers. Yeah, but so am I. I mean, we all got the news 
at the same time. It's been on television, newspapers, 
commentators, doctors, come on. I mean, how long do you have 
to--how much study----
    Mr. Richards. Congressman, my understanding is there's no 
legislative language actually that's been shared yet; but 
again, we are studying what has been released.
    Mr. Conyers. Really?
    Mr. Richards. That's my understanding, yes.
    Mr. Conyers. He's been preaching about his bill and copying 
headlines all over the place. You say there's been nothing 
specific. There's a bill out that's got the chairman of the 
Finance Committee of the Senate.
    Well, I tell you what, could you--I know you've got a lot 
of assignments coming here today. Could you let me know when 
you--when your companies have examined it sufficiently to let 
me know what you think of it?
    Mr. Collins. Absolutely.
    Mr. Conyers. OK. All right. Thank you very much.
    Now, finally, we had testimony in the Judiciary Committee, 
under subcommittee Chairwoman Linda Sanchez, from doctors that 
there were 1 million medical bankruptcies in the United States; 
that is, personal bankruptcies caused by medical bills. Ever 
heard of that? Nobody's heard of that. OK. Well, I can't--I 
can't ask you to comment on that.
    Let's do it hypothetically. If you heard it and learned 
about that, would that cast some concern on you about the 
problems that individuals are going through when the largest 
cause of individual bankruptcies in the United States are due 
to medical bills that people couldn't afford? You'd be 
concerned? Well, may I send you some things? You're sending us 
a lot of things; can I send you some more information about 
that subject? OK.
    Thank you, Mr. Chairman, for your generosity.
    Mr. Kucinich. I thank the gentleman. Finally, Congressman 
Kennedy, you may proceed for 5 minutes.
    Mr. Kennedy. Thank you, Mr. Chairman. Thank you for holding 
this hearing, Mr. Chairman, appreciate it.
    Thank you all for your patience this afternoon during our 
questions, and looking forward to getting responses to the ones 
I asked earlier.
    I would ask all of you if you would just give me 
affirmative in terms of working with my office in closing a 
loophole that appeared in last year's Wellstone-Domenici Mental 
Health Parity and Addiction Equity Act bill. We applied it to 
all insurers for mental benefits. It seems as though college 
students' health insurance plans do not have--it's not 
applicable to college students' health care plans because 
students are not technically employees of the university. So 
the bill talks about this as covering employee-based health 
insurance plans. So you see the wrinkle there.
    And as a result, since students aren't considered 
employees, they're not subject to the requirement--although the 
insurance companies who insure students aren't subject to the 
requirement for parity and because suicide amongst kids is the 
third largest cause of death, I would ask all of you now, would 
you be willing to work with me to close that loophole in this 
health bill with language that ensures that the spirit of the 
law that's applying to all of you for every other health 
insurance plan is--ensures that kids who need it the most get 
that coverage as mandated under the Wellstone-Domenici parity 
bill.
    Mr. Collins. Yes, sir.
    Mr. Sassi. Yes, sir.
    Ms. Farrell. Yes, sir.
    Mr. Richards. Yes. CIGNA strongly supported the Domenici-
Kennedy bill, and we'd be glad to work with you to close the 
loophole.
    Mr. Kennedy. OK. That would be great. William Gardner in my 
office, if you could be in touch with him. We're just trying to 
make sure we get that facilitated in this bill so that the kids 
don't get, you know, disrupted in their health insurance 
coverage.
    Obviously, I have a lot of other things but want to make 
sure we tidied that up. Thank you, Mr. Chairman.
    Mr. Kucinich. Thank you very much, Mr. Kennedy and Mr. 
Conyers, for remaining.
    This has been a hearing of the Domestic Policy Subcommittee 
of the Oversight and Government Reform Committee. We have gone 
over 3 hours now, and the witnesses have been much appreciated 
and your presence here.
    The title of today's hearing, Between You and Your Doctor: 
The Private Health Insurance Bureaucracy: I feel, as Mr. 
Kennedy just implied, that we barely scratched the surface 
here, but I hope that the witnesses understand and hope that 
you feel that this committee has treated you fairly. There's no 
brow-beating here, there's no trick questions, there's no 
attempt to try to force you to give an answer over something 
that you're not ready to do at this moment, and that's the way 
we're going to continue to proceed.
    We are a fact-finding investigative subcommittee. We're 
going to continue to try to get information from the industry 
so that we can understand your business model a little bit 
better.
    And while I have tried to conduct these hearings in an 
impartial way, away from these hearings I'm a very strong 
advocate of the bill that I wrote with John Conyers, but I 
don't let that interfere with the conduct of this meeting. I 
want to make sure that you're given a chance to put your point 
of view on the record. And so while you're treated fairly here, 
we're hopeful that you're going to treat--treat the American 
people fairly.
    And I think as we move forward this issue of awareness, Mr. 
Conyers is going to send you some information. I think this is 
a time we can become more aware of your business model and you 
can become more aware of why we have such great concerns and 
why there is a national movement right now to really move away 
from the model that you have spent your life building.
    So it's a great time for this debate in the country. Health 
care ends up being a flashpoint, you know this: people losing 
their jobs, their homes, their retirement security, their 
investments. And we're right at the point where it's a 
flashpoint. So let's see if there is a way that we can find to 
best serve the American people. That's why we're in Congress, 
and I hope that's what you'll conclude is a good purpose to be 
in business.
    I'm Congressman Dennis Kucinich, Chairman of the 
subcommittee. This committee stands adjourned.
    [Whereupon, at 5:26 p.m., the subcommittee was adjourned.]
    [Additional information submitted for the hearing record 
follows:]

[GRAPHIC] [TIFF OMITTED] T4918.082

[GRAPHIC] [TIFF OMITTED] T4918.083

[GRAPHIC] [TIFF OMITTED] T4918.084

[GRAPHIC] [TIFF OMITTED] T4918.085

[GRAPHIC] [TIFF OMITTED] T4918.086

[GRAPHIC] [TIFF OMITTED] T4918.087

[GRAPHIC] [TIFF OMITTED] T4918.088

[GRAPHIC] [TIFF OMITTED] T4918.089

[GRAPHIC] [TIFF OMITTED] T4918.090

[GRAPHIC] [TIFF OMITTED] T4918.091

[GRAPHIC] [TIFF OMITTED] T4918.092

[GRAPHIC] [TIFF OMITTED] T4918.093

[GRAPHIC] [TIFF OMITTED] T4918.094

[GRAPHIC] [TIFF OMITTED] T4918.095

[GRAPHIC] [TIFF OMITTED] T4918.096

[GRAPHIC] [TIFF OMITTED] T4918.097

[GRAPHIC] [TIFF OMITTED] T4918.098

[GRAPHIC] [TIFF OMITTED] T4918.099

[GRAPHIC] [TIFF OMITTED] T4918.100

[GRAPHIC] [TIFF OMITTED] T4918.101

[GRAPHIC] [TIFF OMITTED] T4918.102

[GRAPHIC] [TIFF OMITTED] T4918.103

[GRAPHIC] [TIFF OMITTED] T4918.104

[GRAPHIC] [TIFF OMITTED] T4918.105

[GRAPHIC] [TIFF OMITTED] T4918.106

[GRAPHIC] [TIFF OMITTED] T4918.107

[GRAPHIC] [TIFF OMITTED] T4918.108

[GRAPHIC] [TIFF OMITTED] T4918.109

[GRAPHIC] [TIFF OMITTED] T4918.110

[GRAPHIC] [TIFF OMITTED] T4918.111

[GRAPHIC] [TIFF OMITTED] T4918.112

[GRAPHIC] [TIFF OMITTED] T4918.113

[GRAPHIC] [TIFF OMITTED] T4918.114

[GRAPHIC] [TIFF OMITTED] T4918.115

[GRAPHIC] [TIFF OMITTED] T4918.116

[GRAPHIC] [TIFF OMITTED] T4918.117

[GRAPHIC] [TIFF OMITTED] T4918.118

[GRAPHIC] [TIFF OMITTED] T4918.119

[GRAPHIC] [TIFF OMITTED] T4918.120

[GRAPHIC] [TIFF OMITTED] T4918.121

[GRAPHIC] [TIFF OMITTED] T4918.122

[GRAPHIC] [TIFF OMITTED] T4918.123

[GRAPHIC] [TIFF OMITTED] T4918.124

[GRAPHIC] [TIFF OMITTED] T4918.125

[GRAPHIC] [TIFF OMITTED] T4918.126

[GRAPHIC] [TIFF OMITTED] T4918.127

[GRAPHIC] [TIFF OMITTED] T4918.128

[GRAPHIC] [TIFF OMITTED] T4918.129

[GRAPHIC] [TIFF OMITTED] T4918.130

[GRAPHIC] [TIFF OMITTED] T4918.131

[GRAPHIC] [TIFF OMITTED] T4918.132

[GRAPHIC] [TIFF OMITTED] T4918.133

[GRAPHIC] [TIFF OMITTED] T4918.134

[GRAPHIC] [TIFF OMITTED] T4918.135

[GRAPHIC] [TIFF OMITTED] T4918.136

[GRAPHIC] [TIFF OMITTED] T4918.137

[GRAPHIC] [TIFF OMITTED] T4918.138

[GRAPHIC] [TIFF OMITTED] T4918.139

[GRAPHIC] [TIFF OMITTED] T4918.140

[GRAPHIC] [TIFF OMITTED] T4918.141

[GRAPHIC] [TIFF OMITTED] T4918.142

[GRAPHIC] [TIFF OMITTED] T4918.143

[GRAPHIC] [TIFF OMITTED] T4918.144

[GRAPHIC] [TIFF OMITTED] T4918.145

[GRAPHIC] [TIFF OMITTED] T4918.146

[GRAPHIC] [TIFF OMITTED] T4918.147

[GRAPHIC] [TIFF OMITTED] T4918.148

[GRAPHIC] [TIFF OMITTED] T4918.149

[GRAPHIC] [TIFF OMITTED] T4918.150

[GRAPHIC] [TIFF OMITTED] T4918.151

[GRAPHIC] [TIFF OMITTED] T4918.152

[GRAPHIC] [TIFF OMITTED] T4918.153

[GRAPHIC] [TIFF OMITTED] T4918.154

[GRAPHIC] [TIFF OMITTED] T4918.155

[GRAPHIC] [TIFF OMITTED] T4918.156

[GRAPHIC] [TIFF OMITTED] T4918.157

[GRAPHIC] [TIFF OMITTED] T4918.158

[GRAPHIC] [TIFF OMITTED] T4918.159

[GRAPHIC] [TIFF OMITTED] T4918.160

[GRAPHIC] [TIFF OMITTED] T4918.161

[GRAPHIC] [TIFF OMITTED] T4918.162

[GRAPHIC] [TIFF OMITTED] T4918.163

[GRAPHIC] [TIFF OMITTED] T4918.164

[GRAPHIC] [TIFF OMITTED] T4918.165

[GRAPHIC] [TIFF OMITTED] T4918.166

[GRAPHIC] [TIFF OMITTED] T4918.167

[GRAPHIC] [TIFF OMITTED] T4918.168

[GRAPHIC] [TIFF OMITTED] T4918.169

[GRAPHIC] [TIFF OMITTED] T4918.170

[GRAPHIC] [TIFF OMITTED] T4918.171

[GRAPHIC] [TIFF OMITTED] T4918.172

[GRAPHIC] [TIFF OMITTED] T4918.173

[GRAPHIC] [TIFF OMITTED] T4918.174

[GRAPHIC] [TIFF OMITTED] T4918.175

[GRAPHIC] [TIFF OMITTED] T4918.176

[GRAPHIC] [TIFF OMITTED] T4918.177

[GRAPHIC] [TIFF OMITTED] T4918.178

[GRAPHIC] [TIFF OMITTED] T4918.179

[GRAPHIC] [TIFF OMITTED] T4918.180

[GRAPHIC] [TIFF OMITTED] T4918.181

[GRAPHIC] [TIFF OMITTED] T4918.182

[GRAPHIC] [TIFF OMITTED] T4918.183

[GRAPHIC] [TIFF OMITTED] T4918.184

[GRAPHIC] [TIFF OMITTED] T4918.185

[GRAPHIC] [TIFF OMITTED] T4918.186

[GRAPHIC] [TIFF OMITTED] T4918.187

[GRAPHIC] [TIFF OMITTED] T4918.188

[GRAPHIC] [TIFF OMITTED] T4918.189

[GRAPHIC] [TIFF OMITTED] T4918.190

[GRAPHIC] [TIFF OMITTED] T4918.191

[GRAPHIC] [TIFF OMITTED] T4918.192

[GRAPHIC] [TIFF OMITTED] T4918.193

[GRAPHIC] [TIFF OMITTED] T4918.194

[GRAPHIC] [TIFF OMITTED] T4918.195

[GRAPHIC] [TIFF OMITTED] T4918.196

[GRAPHIC] [TIFF OMITTED] T4918.197

[GRAPHIC] [TIFF OMITTED] T4918.198

[GRAPHIC] [TIFF OMITTED] T4918.199

[GRAPHIC] [TIFF OMITTED] T4918.200

[GRAPHIC] [TIFF OMITTED] T4918.201

[GRAPHIC] [TIFF OMITTED] T4918.202

[GRAPHIC] [TIFF OMITTED] T4918.203

[GRAPHIC] [TIFF OMITTED] T4918.204

[GRAPHIC] [TIFF OMITTED] T4918.205

[GRAPHIC] [TIFF OMITTED] T4918.206

[GRAPHIC] [TIFF OMITTED] T4918.207

[GRAPHIC] [TIFF OMITTED] T4918.208

[GRAPHIC] [TIFF OMITTED] T4918.209

[GRAPHIC] [TIFF OMITTED] T4918.210

[GRAPHIC] [TIFF OMITTED] T4918.211

[GRAPHIC] [TIFF OMITTED] T4918.212

[GRAPHIC] [TIFF OMITTED] T4918.213

[GRAPHIC] [TIFF OMITTED] T4918.214

[GRAPHIC] [TIFF OMITTED] T4918.215

[GRAPHIC] [TIFF OMITTED] T4918.216

[GRAPHIC] [TIFF OMITTED] T4918.217

[GRAPHIC] [TIFF OMITTED] T4918.218

[GRAPHIC] [TIFF OMITTED] T4918.219

[GRAPHIC] [TIFF OMITTED] T4918.220

[GRAPHIC] [TIFF OMITTED] T4918.221

[GRAPHIC] [TIFF OMITTED] T4918.222

[GRAPHIC] [TIFF OMITTED] T4918.223

[GRAPHIC] [TIFF OMITTED] T4918.224

[GRAPHIC] [TIFF OMITTED] T4918.225

[GRAPHIC] [TIFF OMITTED] T4918.226

[GRAPHIC] [TIFF OMITTED] T4918.227

[GRAPHIC] [TIFF OMITTED] T4918.228

[GRAPHIC] [TIFF OMITTED] T4918.229

[GRAPHIC] [TIFF OMITTED] T4918.230

[GRAPHIC] [TIFF OMITTED] T4918.231

[GRAPHIC] [TIFF OMITTED] T4918.232

[GRAPHIC] [TIFF OMITTED] T4918.233

[GRAPHIC] [TIFF OMITTED] T4918.234

[GRAPHIC] [TIFF OMITTED] T4918.235

[GRAPHIC] [TIFF OMITTED] T4918.236

[GRAPHIC] [TIFF OMITTED] T4918.237

[GRAPHIC] [TIFF OMITTED] T4918.238

[GRAPHIC] [TIFF OMITTED] T4918.239

[GRAPHIC] [TIFF OMITTED] T4918.240

[GRAPHIC] [TIFF OMITTED] T4918.241

[GRAPHIC] [TIFF OMITTED] T4918.242

[GRAPHIC] [TIFF OMITTED] T4918.243

[GRAPHIC] [TIFF OMITTED] T4918.244

[GRAPHIC] [TIFF OMITTED] T4918.245

[GRAPHIC] [TIFF OMITTED] T4918.246

[GRAPHIC] [TIFF OMITTED] T4918.247

[GRAPHIC] [TIFF OMITTED] T4918.248

[GRAPHIC] [TIFF OMITTED] T4918.249

[GRAPHIC] [TIFF OMITTED] T4918.250

[GRAPHIC] [TIFF OMITTED] T4918.251

[GRAPHIC] [TIFF OMITTED] T4918.252

[GRAPHIC] [TIFF OMITTED] T4918.253

[GRAPHIC] [TIFF OMITTED] T4918.254

[GRAPHIC] [TIFF OMITTED] T4918.255

[GRAPHIC] [TIFF OMITTED] T4918.256

[GRAPHIC] [TIFF OMITTED] T4918.257

[GRAPHIC] [TIFF OMITTED] T4918.258

[GRAPHIC] [TIFF OMITTED] T4918.259

[GRAPHIC] [TIFF OMITTED] T4918.260

[GRAPHIC] [TIFF OMITTED] T4918.261

[GRAPHIC] [TIFF OMITTED] T4918.262

[GRAPHIC] [TIFF OMITTED] T4918.263

[GRAPHIC] [TIFF OMITTED] T4918.264

[GRAPHIC] [TIFF OMITTED] T4918.265

[GRAPHIC] [TIFF OMITTED] T4918.266

[GRAPHIC] [TIFF OMITTED] T4918.267

[GRAPHIC] [TIFF OMITTED] T4918.268

[GRAPHIC] [TIFF OMITTED] T4918.269

[GRAPHIC] [TIFF OMITTED] T4918.270

[GRAPHIC] [TIFF OMITTED] T4918.271

[GRAPHIC] [TIFF OMITTED] T4918.272

[GRAPHIC] [TIFF OMITTED] T4918.273

[GRAPHIC] [TIFF OMITTED] T4918.274

[GRAPHIC] [TIFF OMITTED] T4918.275

[GRAPHIC] [TIFF OMITTED] T4918.276

[GRAPHIC] [TIFF OMITTED] T4918.277

[GRAPHIC] [TIFF OMITTED] T4918.278

[GRAPHIC] [TIFF OMITTED] T4918.279

[GRAPHIC] [TIFF OMITTED] T4918.280

[GRAPHIC] [TIFF OMITTED] T4918.281

[GRAPHIC] [TIFF OMITTED] T4918.282

[GRAPHIC] [TIFF OMITTED] T4918.283

[GRAPHIC] [TIFF OMITTED] T4918.284

[GRAPHIC] [TIFF OMITTED] T4918.285

[GRAPHIC] [TIFF OMITTED] T4918.286

[GRAPHIC] [TIFF OMITTED] T4918.287

[GRAPHIC] [TIFF OMITTED] T4918.288

[GRAPHIC] [TIFF OMITTED] T4918.289

[GRAPHIC] [TIFF OMITTED] T4918.290

[GRAPHIC] [TIFF OMITTED] T4918.291

[GRAPHIC] [TIFF OMITTED] T4918.292

[GRAPHIC] [TIFF OMITTED] T4918.293

[GRAPHIC] [TIFF OMITTED] T4918.294

[GRAPHIC] [TIFF OMITTED] T4918.295

[GRAPHIC] [TIFF OMITTED] T4918.296

[GRAPHIC] [TIFF OMITTED] T4918.297

[GRAPHIC] [TIFF OMITTED] T4918.298

[GRAPHIC] [TIFF OMITTED] T4918.299

[GRAPHIC] [TIFF OMITTED] T4918.300

[GRAPHIC] [TIFF OMITTED] T4918.301

[GRAPHIC] [TIFF OMITTED] T4918.302

[GRAPHIC] [TIFF OMITTED] T4918.303

[GRAPHIC] [TIFF OMITTED] T4918.304

[GRAPHIC] [TIFF OMITTED] T4918.305

[GRAPHIC] [TIFF OMITTED] T4918.306

[GRAPHIC] [TIFF OMITTED] T4918.307

[GRAPHIC] [TIFF OMITTED] T4918.308

[GRAPHIC] [TIFF OMITTED] T4918.309

[GRAPHIC] [TIFF OMITTED] T4918.310

[GRAPHIC] [TIFF OMITTED] T4918.311

[GRAPHIC] [TIFF OMITTED] T4918.312

[GRAPHIC] [TIFF OMITTED] T4918.313

[GRAPHIC] [TIFF OMITTED] T4918.314

[GRAPHIC] [TIFF OMITTED] T4918.315

[GRAPHIC] [TIFF OMITTED] T4918.316

[GRAPHIC] [TIFF OMITTED] T4918.317

[GRAPHIC] [TIFF OMITTED] T4918.318

[GRAPHIC] [TIFF OMITTED] T4918.319

[GRAPHIC] [TIFF OMITTED] T4918.320

[GRAPHIC] [TIFF OMITTED] T4918.321

[GRAPHIC] [TIFF OMITTED] T4918.322

[GRAPHIC] [TIFF OMITTED] T4918.323

[GRAPHIC] [TIFF OMITTED] T4918.324

[GRAPHIC] [TIFF OMITTED] T4918.325

[GRAPHIC] [TIFF OMITTED] T4918.326

[GRAPHIC] [TIFF OMITTED] T4918.327

[GRAPHIC] [TIFF OMITTED] T4918.328

[GRAPHIC] [TIFF OMITTED] T4918.329

[GRAPHIC] [TIFF OMITTED] T4918.330

[GRAPHIC] [TIFF OMITTED] T4918.331

[GRAPHIC] [TIFF OMITTED] T4918.332

[GRAPHIC] [TIFF OMITTED] T4918.333

[GRAPHIC] [TIFF OMITTED] T4918.334

[GRAPHIC] [TIFF OMITTED] T4918.335

[GRAPHIC] [TIFF OMITTED] T4918.336

[GRAPHIC] [TIFF OMITTED] T4918.337

[GRAPHIC] [TIFF OMITTED] T4918.338

[GRAPHIC] [TIFF OMITTED] T4918.339

[GRAPHIC] [TIFF OMITTED] T4918.340

[GRAPHIC] [TIFF OMITTED] T4918.341

[GRAPHIC] [TIFF OMITTED] T4918.342

[GRAPHIC] [TIFF OMITTED] T4918.343

[GRAPHIC] [TIFF OMITTED] T4918.344

[GRAPHIC] [TIFF OMITTED] T4918.345

[GRAPHIC] [TIFF OMITTED] T4918.346

[GRAPHIC] [TIFF OMITTED] T4918.347

[GRAPHIC] [TIFF OMITTED] T4918.348

[GRAPHIC] [TIFF OMITTED] T4918.349

[GRAPHIC] [TIFF OMITTED] T4918.350

[GRAPHIC] [TIFF OMITTED] T4918.351

[GRAPHIC] [TIFF OMITTED] T4918.352

[GRAPHIC] [TIFF OMITTED] T4918.353

[GRAPHIC] [TIFF OMITTED] T4918.354

[GRAPHIC] [TIFF OMITTED] T4918.355

[GRAPHIC] [TIFF OMITTED] T4918.356

[GRAPHIC] [TIFF OMITTED] T4918.357

[GRAPHIC] [TIFF OMITTED] T4918.358

[GRAPHIC] [TIFF OMITTED] T4918.359

[GRAPHIC] [TIFF OMITTED] T4918.360

[GRAPHIC] [TIFF OMITTED] T4918.361

[GRAPHIC] [TIFF OMITTED] T4918.362

[GRAPHIC] [TIFF OMITTED] T4918.363

[GRAPHIC] [TIFF OMITTED] T4918.364

[GRAPHIC] [TIFF OMITTED] T4918.365

[GRAPHIC] [TIFF OMITTED] T4918.366

[GRAPHIC] [TIFF OMITTED] T4918.367

[GRAPHIC] [TIFF OMITTED] T4918.368

[GRAPHIC] [TIFF OMITTED] T4918.369

[GRAPHIC] [TIFF OMITTED] T4918.370

[GRAPHIC] [TIFF OMITTED] T4918.371

[GRAPHIC] [TIFF OMITTED] T4918.372

[GRAPHIC] [TIFF OMITTED] T4918.373

[GRAPHIC] [TIFF OMITTED] T4918.374

[GRAPHIC] [TIFF OMITTED] T4918.375

[GRAPHIC] [TIFF OMITTED] T4918.376

[GRAPHIC] [TIFF OMITTED] T4918.377

[GRAPHIC] [TIFF OMITTED] T4918.378

[GRAPHIC] [TIFF OMITTED] T4918.379

[GRAPHIC] [TIFF OMITTED] T4918.380

[GRAPHIC] [TIFF OMITTED] T4918.381

[GRAPHIC] [TIFF OMITTED] T4918.382

[GRAPHIC] [TIFF OMITTED] T4918.383

[GRAPHIC] [TIFF OMITTED] T4918.384

[GRAPHIC] [TIFF OMITTED] T4918.385

[GRAPHIC] [TIFF OMITTED] T4918.386

[GRAPHIC] [TIFF OMITTED] T4918.387

[GRAPHIC] [TIFF OMITTED] T4918.388

[GRAPHIC] [TIFF OMITTED] T4918.389

[GRAPHIC] [TIFF OMITTED] T4918.390

[GRAPHIC] [TIFF OMITTED] T4918.391

[GRAPHIC] [TIFF OMITTED] T4918.392

[GRAPHIC] [TIFF OMITTED] T4918.393

[GRAPHIC] [TIFF OMITTED] T4918.394

[GRAPHIC] [TIFF OMITTED] T4918.395

[GRAPHIC] [TIFF OMITTED] T4918.396

[GRAPHIC] [TIFF OMITTED] T4918.397

[GRAPHIC] [TIFF OMITTED] T4918.398

[GRAPHIC] [TIFF OMITTED] T4918.399

[GRAPHIC] [TIFF OMITTED] T4918.400

[GRAPHIC] [TIFF OMITTED] T4918.401

[GRAPHIC] [TIFF OMITTED] T4918.402

[GRAPHIC] [TIFF OMITTED] T4918.403

[GRAPHIC] [TIFF OMITTED] T4918.404

[GRAPHIC] [TIFF OMITTED] T4918.405

[GRAPHIC] [TIFF OMITTED] T4918.406

[GRAPHIC] [TIFF OMITTED] T4918.407

[GRAPHIC] [TIFF OMITTED] T4918.408

[GRAPHIC] [TIFF OMITTED] T4918.409

[GRAPHIC] [TIFF OMITTED] T4918.410

[GRAPHIC] [TIFF OMITTED] T4918.411

[GRAPHIC] [TIFF OMITTED] T4918.412

[GRAPHIC] [TIFF OMITTED] T4918.413

[GRAPHIC] [TIFF OMITTED] T4918.414

[GRAPHIC] [TIFF OMITTED] T4918.415

[GRAPHIC] [TIFF OMITTED] T4918.416

[GRAPHIC] [TIFF OMITTED] T4918.417

[GRAPHIC] [TIFF OMITTED] T4918.418

[GRAPHIC] [TIFF OMITTED] T4918.419

[GRAPHIC] [TIFF OMITTED] T4918.420

[GRAPHIC] [TIFF OMITTED] T4918.421

[GRAPHIC] [TIFF OMITTED] T4918.422

[GRAPHIC] [TIFF OMITTED] T4918.423

[GRAPHIC] [TIFF OMITTED] T4918.424

[GRAPHIC] [TIFF OMITTED] T4918.425

[GRAPHIC] [TIFF OMITTED] T4918.426

[GRAPHIC] [TIFF OMITTED] T4918.427

[GRAPHIC] [TIFF OMITTED] T4918.428

[GRAPHIC] [TIFF OMITTED] T4918.429

[GRAPHIC] [TIFF OMITTED] T4918.430

[GRAPHIC] [TIFF OMITTED] T4918.431

[GRAPHIC] [TIFF OMITTED] T4918.432

[GRAPHIC] [TIFF OMITTED] T4918.433

[GRAPHIC] [TIFF OMITTED] T4918.434

[GRAPHIC] [TIFF OMITTED] T4918.435

[GRAPHIC] [TIFF OMITTED] T4918.436

[GRAPHIC] [TIFF OMITTED] T4918.437

[GRAPHIC] [TIFF OMITTED] T4918.438

[GRAPHIC] [TIFF OMITTED] T4918.439

[GRAPHIC] [TIFF OMITTED] T4918.440

[GRAPHIC] [TIFF OMITTED] T4918.441

[GRAPHIC] [TIFF OMITTED] T4918.442

[GRAPHIC] [TIFF OMITTED] T4918.443

[GRAPHIC] [TIFF OMITTED] T4918.444

[GRAPHIC] [TIFF OMITTED] T4918.445

[GRAPHIC] [TIFF OMITTED] T4918.446

[GRAPHIC] [TIFF OMITTED] T4918.447

[GRAPHIC] [TIFF OMITTED] T4918.448

[GRAPHIC] [TIFF OMITTED] T4918.449

[GRAPHIC] [TIFF OMITTED] T4918.450

[GRAPHIC] [TIFF OMITTED] T4918.451

[GRAPHIC] [TIFF OMITTED] T4918.452

[GRAPHIC] [TIFF OMITTED] T4918.453

[GRAPHIC] [TIFF OMITTED] T4918.454

[GRAPHIC] [TIFF OMITTED] T4918.455

[GRAPHIC] [TIFF OMITTED] T4918.456

[GRAPHIC] [TIFF OMITTED] T4918.457

[GRAPHIC] [TIFF OMITTED] T4918.458

[GRAPHIC] [TIFF OMITTED] T4918.459

[GRAPHIC] [TIFF OMITTED] T4918.460

[GRAPHIC] [TIFF OMITTED] T4918.461

[GRAPHIC] [TIFF OMITTED] T4918.462

[GRAPHIC] [TIFF OMITTED] T4918.463

[GRAPHIC] [TIFF OMITTED] T4918.464

[GRAPHIC] [TIFF OMITTED] T4918.465

[GRAPHIC] [TIFF OMITTED] T4918.466

[GRAPHIC] [TIFF OMITTED] T4918.467

[GRAPHIC] [TIFF OMITTED] T4918.468

[GRAPHIC] [TIFF OMITTED] T4918.469

[GRAPHIC] [TIFF OMITTED] T4918.470

[GRAPHIC] [TIFF OMITTED] T4918.471

[GRAPHIC] [TIFF OMITTED] T4918.472

[GRAPHIC] [TIFF OMITTED] T4918.473

[GRAPHIC] [TIFF OMITTED] T4918.474

[GRAPHIC] [TIFF OMITTED] T4918.475

[GRAPHIC] [TIFF OMITTED] T4918.476

[GRAPHIC] [TIFF OMITTED] T4918.477

[GRAPHIC] [TIFF OMITTED] T4918.478

[GRAPHIC] [TIFF OMITTED] T4918.479

[GRAPHIC] [TIFF OMITTED] T4918.480

                                 
