Physician Schedules Count

Physician Schedules Count 

By NU ONLINE NEWS SERVICE

Published 3/30/2011 

A health care system that is affordable and appears to offer high-quality care may not do much good if patients cannot actually get in to see the doctors.  

Karen Davis, president of the Commonwealth Fund, New York, makes that case in a report on accountable care organizations (ACO) and patient-centered medical homes put out by Health2 Resources, Washington.

Health2 Resources brought together experts from many employer, health care and health insurance organizations, including UnitedHealth Group Inc., Minnetonka, Minn. (NYSE:UNH), and Humana Inc., Louisville, Ky. (NYSE:HUM), and they had a hard time coming up with concrete, specific proposals for how to promote ACO efforts and similar efforts. They mostly agreed that compensation programs ought to be different and than patients should somehow be involved in developing the new system.

Davis, who represents a health policy research group, came up with more concrete suggestions based on her own experience with sitting in an emergency room simply because her own doctor was available.

Davis suggested that health care organizations that want to be genuinely accountable and genuinely patient-centered ought to make urgent care providers available in the evening and on weekends, rather than forcing patients who need immediate care for conditions that are not life-threatening emergencies to go to emergency rooms, according to a Health2 Resources account of the “national thought leaders’” efforts.

Similarly, primary care physicians ought to provide same-day or next-day access, and patients should have a reasonable chance of getting in to see their own personal primary care providers, Davis said.

To make the U.S. health care system work for patients, policymakers must “actively support federal funding of primary care workforce training efforts across the full spectrum of primary care team members in order to ensure an adequate and well-trained primary care workforce,” Davis said.

Policymakers also ensure that policies and initiatives that promote ACOs and patient-centered medical homes ensure superb patient access to care, including off-hours care, same-day or next-day care, and telephone and electronic consultations, Davis said.

- Allison Bell

IRS Releases W-2 Group Health Guidelines

IRS Releases W-2 Group Health Guidelines 

By ALLISON BELL

Published 3/30/2011 

Most employers that send out more than 250 W-2 wage tax withholding forms in 2012 will have to provide information about how much they spend on the employees' group health coverage.

Bush administration officials had suggested that employers ought to put group health expenditure information on W-2 forms, and Congress included the requirement in Section 9002 of the Patient Protection and Affordable Care Act (PPACA), a component of the Affordable Care Act. PPACA Section 9002 added Section 6051(a)(14) – the group health W-2 reporting requirement – to the Internal Revenue Code.

“Nothing in Section 6051(a)(14), this notice, or the additional guidance that is contemplated under § 6051(a)(14), causes or will cause otherwise excludable employer-provided health care coverage to become taxable,” IRS officials say in an announcement of the 2012 W-2 group health reporting guidelines, which are described in IRS Notice 2011-28.

But U.S. Treasury Department officials have been noting since the days of the Bush administration that group health “tax expenditures” – federal income tax revenue foregone as a result of the group health tax exclusion – cost the federal government more than $100 billion per year.

An Affordable Care Act provision is supposed to impose a “Cadillac plan” excise tax on some high-cost plans starting in 2018.

The new Section 6051(a)(14) will apply to insured employers that send more than 250 W-2 forms and to employers with self-funded plans that are subject to COBRA benefits continuation requirements, IRS officials say.

Employers can report group health expenditures this year, on the 2011 W-2 forms, on a voluntary basis.

The IRS has provided a list of questions and answers employers and their benefits and tax advisors can use to provide the required group health cost information for 2012.

The group health cost figure will not include contributions for multiemployer plan coverage or for expenditures on health reimbursement arrangement contributions or health savings account contributions. The figure would include dental or vision coverage costs only if dental or vision coverage were integrated into the group medical coverage.

The cost figure could include some health flexible spending account (FSA) contributions, if “the amount of the health FSA for the plan year exceeds the salary reduction elected by the employee for the plan year,” officials say.

In that case, the FSA amount included in the “aggregate reportable cost” would be “the amount of that employee’s health FSA minus the employee’s salary reduction election for the health FSA,” officials say.

HealthSpring Completes Offering

HealthSpring Completes Offering 

·         By NU ONLINE NEWS SERVICE

Published 3/30/2011 

HealthSpring Inc. says it has raised about $301 million by selling 7.5 million shares of common stock to the public and 1.125 million shares to the offering underwriters.  

HealthSpring, Nashville, Tenn. (NYSE:HS), a company that runs Medicare Advantage managed care plans with about 300,000 enrollees, says it will use about half of the offering proceeds to pay off debts and about half for “general corporate purposes, which may include acquisitions of similar or complementary businesses.”

The underwriters sold the HealthSpring stock at a price of $35.95 per share, the company says.

- Allison Bell

This would get you out of the Medicare market...

Don't be so nice

by Michael Boyette on March 30, 2011 · 0 Comments and 0 Reactions
Posted in: Top Sales Dog | Email

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I think I know what’s wrong with salespeople:

They’re too darn nice.

Lots of people think salespeople are overbearing, pushy, hard-charging egomaniacs. But I know the truth.

You’re a bunch of puppy dogs. Warm, friendly and eager to please.

Take the buyer who just can’t seem to give you a yes-or-no answer. In the real world, busy people won’t put up with the runaround. They get irritated. Demand an answer. Maybe even raise their voice.

In the puppy-dog world of sales, however, these fence-sitters get nothing but love, love, love. “I understand,” the salesperson says soothingly. “Take all the time you need. Don’t even worry about how much of my time you’ve wasted or the fact that I’ve done everything you asked. What can I do to help?”

Here’s what you can do to help: Find out whether the two of you are just wasting your time on a sale that’s never gonna happen. Or if it might happen, what’s slowing things down? Or if it’s close to happening, what else do you have to do to get it nailed down?

In other words, sometimes you have to nip at the buyer’s heels to get them moving. Just try not to bite too hard.

3 steps to developing a successful referral system

3 steps to developing a successful referral system 

Words from the Wise 

Larry Klein

Published 3/22/2011 

Most producers get referrals by asking their clients for the names of any acquaintances who may need their services. But when the producer calls the acquaintances, they don’t know who he is, they don’t know what he does, they don’t know why he is calling, and they don’t know how he got their names.

If the producer follows the process I describe below, the referral will be expecting his call and will know who he is.

Step 1: The personal introduction. The producer should prepare an endorsement letter about himself, which the client will send to the referral. This letter basically says, “I’m working with Larry, and he’s done a great job for me. I think it would be worth your while to meet him.” At the bottom of the letter, the producers should add a sentence, “If you don’t want me to give your name to Larry, let me know.” This gives the prospect the opportunity to opt out. The producer does not want to waste his time on people who aren’t interested in what he has to offer.

The producer should prepare these letters before the business development meeting so that the client can sign them. With the client’s permission, the producer then can print envelopes for the letters, adding the client’s return address. When the note arrives at the referral’s home, it appears to have been sent from the client’s home.

Step 2: Drip marketing. Now that the producer has been introduced, he must build the prospect’s trust to improve the odds that he will get the prospect’s business. I usually make two additional mail contacts before attempting to call for an appointment.

A few weeks after the initial introduction, the producer should follow up with another passive form of contact. He might send a copy of his newsletter or a booklet the prospect might find useful. The producer might attach a personal note or Post-It.

The third contact should be a personal letter from the producer. This is where the producer introduces himself and describes what he does. This letter should mention, “I got your name from so-and-so. If you have any questions about me, fell free to call so-and-so before I call you next week.”

Step 3: The telephone call. The producer should follow up with a telephone call the next week, as promised. This call is to set an appointment.

Yes, it really can be this simple to increase the number of referrals that the producer converts into clients. The secret is to use a systematic approach to obtain and process referrals.

Editor’s Note: The preceding is an excerpt from “Developing Referral Systems That Work” by Larry Klein, CPA, CSA, an article that originally ran in the July 2004 issue of Life Insurance Selling. To read the full story, click here.

Master the B2B Sale

by Romy Ribitzky

Mar 28 2011

Positioning your company to be a market leader in the B2B space takes more than just engaging clients on an emotional level. You must prove how you'll drive growth, success, profits, and minimize risk.

The Apple of Business' Eye

Consumer-favorite Apple becomes the dominant player in the business-to-business space, knocking down two-year leader Southwest Airlines as the top B2B brand for 2011, according a Business Journals survey of small- to mid-sized business owners. Read More

Each year, The Business Journals surveys 1,800 business owners, CEOs, and presidents of companies who employ less than 500 workers and asks them to rate specific brands that have a clear business-to-business appeal. Click through to explore the top 25 B2B brands for 2011.

Building a successful and respected brand takes work. A look at the companies that are winning the brand game by focusing on value, innovation, leadership, relevance, momentum, customer service, and ethics.

Marketing to companies, versus the American consumer, hasn’t been a sexy or flashy side of business. Companies like Apple, this year’s top business-to-business brand as judged by a new survey of small- and midsized business owners and executives, opts to quietly talk about its business arm in-store rather than going with a full-blown media push. But as startups and entrepreneurial ventures continue to drive the recovery, appealing to the needs of this fast-growing sector of the economy is key for companies looking to capitalize on the boom of the nation’s emerging business.

 “With the ‘consumerization of IT,’ we’re seeing a convergence in B2B and B2C marketing, especially for technology products,” says Amy Bermar, president of public relations firm Corporate Ink, based in Newton, Massachusetts.

Bermar explains that while at face-value B2B marketing and B2C efforts have much in common, companies targeting businesses as consumers need to consider the following: “The buyers, the price points, risks, and expectations, are very different. At the core, when companies adopt a new product of technology, there’s a substantial risk and the need for tangible rewards is essential,” she says. But with return-on-investment being difficult for many startups and smaller companies to track, companies need to make it incredibly clear how their offerings can change a client’s business, she adds.

John Luginbill, CEO of Indianapolis marketing and branding firm The Heavyweights, agrees. “While B2C marketing and sales generally engage the emotions of the buyer based on status, desire, and pricing, with B2B marketing you must make the rational economic case and engage the emotions surrounding joy of success, dangers of failure, and the safety of your relationship.”

Reliability, besides a constant drive for innovation and new products, is key to developing a B2B marketing strategy. Companies marketing to other businesses need to prove that they are solving problems for them in an efficient way that will ultimately lead to higher profits, says Luginbill.

Adds Bermar, “Businesses need to see that you can drive growth, deftly manage organizational change—and above all else, minimize risk. The wrong decision made by a purchasing manager could cost the organization hundreds of thousands of dollars—and jobs,” she says.

How can companies prove their worth to new clients and potential customers? “Define the cost of saying no,” Luginbill says. “If a prospect doesn’t want to do business with you immediately, you have to clearly explain the negative consequences they would incur.”

Once you’ve gotten to "yes," develop a sales price strategy that consistently communicates next steps, Luginbill adds. “First, clearly define what is next, and who has to do what in order for the client to engage you. Then, outline each step in the process and explain your initial timeline for delivery. There must always be a clearly defined future of a B2B sale to have any chance of moving forward.”

Rely on past clients and current customers to spread the word. Just like the consumer market, customers are always your best advocates, says Bermar. “Those who love you will actively promote you—and often are just waiting to be asked. Have a strategy in place to identify and connect with them, and let them help you sell.” Monitor customer service complaints and stay up-to-date with comments on social media platforms that can alert you to any potential problem. “If people don’t love you, find out why not and fix it,” says Bermar. “People love to talk about companies they love. So make them love you.”

http://www.portfolio.com/resources/2011/03/28/developing-and-maintaining-a-strong-b2b-marketing-strategy#ixzz1I0FhM1GW

Workers Are Seething

Workers Are Seething 

By ALLISON BELL

Published 3/28/2011 

The workers that employers have left may be more productive, but they are also angrier.

The percentage of U.S. employers who say they feel a very strong sense of loyalty to their employees has held steady at 57%, and the percentage who say workplace satisfaction is high increased to 44% in 2010, from 43% in 2008,.

But the percentage of employees who say they feel a very strong sense of loyalty to their employers has fallen to 47%, from 59% in 2008, and the percentage who say their companies have a very strong sense of loyalty to them has fallen to 33%, from 41%.

About 36% of current employees say they would like to be working somewhere else by the end of the year.

Researchers commissioned by a unit of MetLife Inc., New York (NYSE:MET), have published those figures in a summary of results from one survey of 1,508 benefits decision makers at U.S. employers with at least 2 employees and a second survey of 1,412 full-time U.S. employees ages 21 and older at companies with at least 2 employees.

A few years ago, the job market was hot, and employers were focusing on keeping good employees. Now, employers are telling MetLife that controlling health and welfare benefits costs is a more pressing concern than employee retention.

About 39% of the employers told MetLife they have increased employee productivity in the past 12 months.

“But these productivity gains were not viewed as favorably by employees, and they could begin to wane if employees head out the door once the economy recovers,” the researchers note.

About 40% of the employees surveyed said they have been working harder in the past 12 months, and 25% said they feel even less secure in their jobs this year than they did a year ago, the researchers say.

In Wisconsin, a battle between state employees and a budget-cutting governor nearly shut down the state government, as the governor has been trying to tackle health and pension costs by eliminating collective bargaining.

Building a strong benefits program can help increase worker loyalty, but that may be more challenging in the next few years, as employers decide whether to drop health coverage, pay a penalty and have workers buy coverage through the new health insurance exchanges, or continue to “play” and offer traditional group health benefits, the researchers say.

As many employers deemphasize their role as the group health plan sponsor, other benefits, such as life insurance, disability insurance and retirement benefits, may get more attention, the researchers say.

Important Texas Legislative Information!

Important Texas Legislative Information!

The opportunity to file bills for consideration in the 82nd session of the Texas Legislature has passed   Your Legislative Council has reviewed the list and want you to know about bills we are watching.

The most important legislation to our industry certainly is a bill that creates a Texas Exchange.  There are 4 bills filed.

• HB636 (Zerwas) creates a Texas Health Insurance Connector and has been heard in      hearing.  TAHU and our coalition partners testified at the hearing on      February 28 about the importance of the involvement of agents and the preservation of plan design and compensation.  We are watching this      bill VERY closely.
• HB3402 (Coleman)   also creates a state health insurance exchanges and was referred to House Insurance last Friday.  It has not yet been posted on the committee's agenda.
• SB1510 (West) is   virtually identical to the Zerwas bill and has not yet been referred to      committee for hearing
• SB1782 (Ellis) is    very similar Representative Coleman's bill and is at the same status as Senator West's proposed legislation
•  

Two bills have been filed in the House to allow for H S A qualified plans to be offered to employees of the State.  You'll remember that this has been attempted for the last several sessions.

• HB1766 (Crownover)     has been referred to Pension & Investments and is scheduled for a     public hearing on March 22.  TAHU has long supported this legislation     and will continue to do so.
• HB1362 (Laubenberg)      was referred to House Insurance on March 1, but has not been set for      hearing.  The language in this bill is significantly different from      HB1766 in that it creates no savings to the state budget.

 One bill has been filed in each house on TDI sunset.  You'll recall the last session where a stopgap of another 2 years was granted.  This year we have a very clean bill that is expected to be approved without difficulty.

• SB644 (Heger) was    referred to the Committee on Government Organization and is to be heard in    committee on March 21.
• HB1952 (Taylor) has      been referred to House Insurance and is not yet set for hearing.

Other House bills on our watch list include

HB1534 (Eiland) regarding "silent PPO networks

HB2430 (Kolkhorst) regarding price transparency

HB2576 (Truitt) regarding pricing of charges for inpatient and outpatient care

HB3087 (Smithee) addresses facility based physician charges and how to resolve conflicts, including notification that a higher than usual and customary charge prior to service.

And in the senate we are watching

SB554 (Corona) regarding limitations on a fees charged for dental services not covered by the insurance contract.

This is a lot for you to read, and we cannot keep you all up to speed each and every day.  So, if you have special interest in any of these pieces of legislation, please to go http://www.capitol.state.tx.us/ and search by bill number

Innovations.cms.gov – a new Web site for a new approach to healthcare

Announcing:  Innovations.cms.gov – a new Web site for a new approach to healthcare

 

Today, the Center for Medicare and Medicaid Innovation (the Innovation Center) re-launched its website: Innovations.cms.gov. Along with providing information about the Center’s mission and operating process, the website provides ways for the Center to gather new ideas to improve the health care system for Medicare, Medicaid and CHIP beneficiaries.

Additionally, the Innovation Center is hosting a stakeholder call TODAY at 3pm ET March 21^st, to discuss the launch of this site, and answer any immediate questions.  The call in number is (877) 251 – 0301. Because of anticipated interest in the topic, we suggest you call in 15 minutes prior to the start time.

We look forward to having you on the call and hope you will share your ideas with us through the new website: innovations.cms.gov

Thank you,

Susie Butler
Director, Provider Relations Group

About the Innovation Center:

Established under the Affordable Care Act, the Innovation Center’s mission is to help transform the American health care system by delivering better health and better healthcare for Medicare, Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, and to reduce costs through improvement.  The Center will accomplish these goals by being a constructive and trustworthy partner in identifying, testing and spreading successful new models of care and payment.

Share your ideas:

Clinicians, health systems and community leaders throughout the country are developing new models that provide better health and better health care at lower costs.  We want to partner with these innovators to help them succeed.  Share your ideas for creating the next generation of health care delivery and payment models.  The Innovation Center wants your input for building the Center, and for ways to deliver and pay for care that save money while improving health and health care for Medicare, Medicaid and CHIP beneficiaries.   

Visit Innovations.cms.gov to learn more. 

You're never too old to tweet

You're never too old to tweet 

 

·         BY Ginny Kipling

Published 9/14/2010   

A Pew Research survey shows older generations are increasingly logging in, connecting with, posting on and tweeting about.

88 percent growth in the number of adults aged 50-64 who use social networking sites, such as Facebook and Linkedin, between April 2009 and May 2010.

100 percent-plus growth among adults who are 64 and older who use social networking sites, such as Facebook and Linkedin, between April 2009 and May 2010.

42 percent of those aged 50-64 consume their news online compared with 44 percent of users ages 18-29 and 45 percent of users ages 30-49.

34 percent of those in the 64-plus age category read their news online.

Two-times rate increase, from 22 percent to 42 percent, in the number of adults 50-plus who use social networks in 2010.

47 percent of adults ages 50-64 and 26 percent of adults ages 65 and older have their own accounts on social networking sites.

6 percent increase in adults 50-64 who have used Twitter between 2009 and 2010.

Source: Pew Research

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A New Resource Directory for www.Medicare.org.

Medicare Information Source is pleased to announce a New Resource Directory for www.Medicare.org.

Since 1996, Medicare.org (brochure) has educated and served seniors and Medicare beneficiaries. Now, an average of 100,000 people visit Medicare.org each month for our articles, newsletters, health library, and online resources. 

These seniors research online, but frequently want to purchase locally.  The Resource Directory helps seniors find local organizations like yours.  The directory will...

Position Your Organization:
We’ve become a national resource for seniors since 1996.  Adding your organization to our Senior Resource Directory allows you to borrow our credibility.  Click the following links for examples:
    Hart Insurance
    Dave Ramsey National ELP

Help Seniors Find Your Organization:
Seniors will find your organization through a variety of ways:

• Links within Medicare.org's main menu,
• Medicare.org's State resource pages, and
• Generally, increased Google search rankings

Register, Create your own ad, and then decide if you want to “Go Public” and pay the $150 per year for the listing. 

Medicare Information Source
www.Medicare.org

GOP Plan to Challenge Mandatory Spending Could Affect Exchanges, Prevention Fund

Reprinted from AIS's HEALTH REFORM WEEK, the nation’s leading publication on the business implications of the massive changes for the health industry mandated by reform.

 

By Jennifer Lubell, Editor

March 14, 2011Volume 2Issue 8

State health insurance exchanges and the new prevention fund could falter under a proposal by House Republicans to eliminate mandatory funding provisions in the health reform law — although its chances of success depend upon acceptance by the Senate, and that’s unlikely, health care observers say.

Given the necessity of reaching some kind of budget agreement, one health care consultant suggests that there may be more leverage in making smaller changes around defunding or reducing funding for certain aspects of the law. This would be more politically feasible than total defunding, “because they need to pass budget resolutions to fund the government,” David Tuomala, director of actuarial consulting at Ingenix Consulting, tells HRW.

Bipartisan solutions were nowhere in sight, however, at a March 9 hearing of the House Energy and Commerce Committee’s Subcommittee on Health. Its chairman, Rep. Joseph Pitts (R-Pa.), has sights set on introducing legislation, possibly a series of bills, to convert the spending for at least five health reform provisions from mandatory to discretionary funds. Discretionary funds are subject to congressional appropriation, and therefore can be reduced or eliminated.

A spokesperson for Pitts didn’t specify a date for introducing the legislation, although sources tell HRW that the chairman plans a markup in the health subcommittee by the end of March.

GOP Plan Could Affect Exchanges

In setting fiscal priorities in health care funding, the subcommittee “must assess and prioritize all of the things that we need to do and would like to do and then make difficult funding decisions with limited amounts of money,” Pitts said during the hearing.

A March 7 internal memorandum obtained by HRW identified the provisions the GOP wants to transform into discretionary funds, including the law’s $17.75 billion Prevention and Public Health Fund, grants for state-based health insurance exchanges, funds relating to teaching health centers or school-based health centers, and other health education programs.

The reform law “was unusual in the sense that it provided mandatory spending for numerous newly created or established programs that would be normally considered discretionary in nature. This funding process weakens congressional oversight by bypassing the annual appropriations process where Congress is forced to weigh the relative value of discretionary programs,” according to the memo.

The law, in particular, outlines “unlimited” mandatory spending for the exchanges, meaning that HHS can determine the amount of spending, and then use those funds without further congressional action, the memo stated. Grants under this language can be used to “facilitate enrollment,” yet the term is undefined in the statute — meaning the funds could go to any activity HHS determines as facilitating enrollment, it said.
Unlimited mandatory spending is problematic, says Don Garlitz, benefits consultant with insurance broker FirstWest Benefit Solutions, who assisted in setting up Utah’s insurance exchange. In his view, providing HHS with a blank check with no congressional oversight isn’t a reasonable approach.

States that want to build their own exchanges for 2014 “will certainly be looking for help given how state budgets are looking. Yet, we have been surprised by the size of some of the ‘early adopter’ exchange grants recently awarded to several states,” Garlitz tells HRW. HHS on Feb. 16 awarded $241 million in these grants to several states to develop information technology needed to operate their health insurance exchanges (HRW 2/21/11, p. 4).

A plan to reduce the exchange funding that goes to the states, however, “certainly has ramifications,” Tuomala acknowledges.

“I know a lot of states have been putting out RFPs [i.e., requests for proposals], asking for assistance with outside entities for the designing of exchanges. So, if that spigot of money gets turned off, particularly where states are in their own budgets crises,” that could create a lot of challenges for states to implement the exchanges, he says, as “there’s not a lot of excess money floating around if the feds aren’t going to fund it.”

Joseph Vitale, a Democrat who serves in the New Jersey Senate and testified before the House panel, cautioned that defunding the insurance exchanges would serve only to eliminate state flexibility, “paving the way for a single federally based health insurance exchange.”

The irony of the Republicans’ proposal “is that it is coming from those who are typically opposed to the expansion of federal government in favor of greater state autonomy,” said Vitale, whose state received a $1 million planning grant to help develop its insurance exchange (HRW 10/11/10, p. 5).

Pitts Attacks Public Health Fund

Pitts during the hearing targeted the law’s Prevention and Public Health Fund as another area where spending could skyrocket out of control. “There is no doubt that we must focus on preventing disease,” he said, referring to the $1.3 billion disbursed to the fund since June 2010.

And yet, the $1.3 billion is “over and above the amount” that Congress slated for these activities, Pitts said. In his opening statement, he noted that the law authorizes the appropriation of only $1.25 billion for prevention fund activities in fiscal years 2010 and 2011.

The GOP’s discussion draft recommends repealing what Pitts called a “slush fund” that HHS can spend from, without any congressional oversight or approval. “By eliminating this fund, we are not cutting any specific program or activity. We are reclaiming our oversight role of how federal taxpayer dollars should be used,” Pitts said.

House Democrats countered that Pitts’ proposal was yet another effort to defund and dismantle health care reform. The Republicans are continuing their “round the clock complaints” about the law “without a glimmer of substance or innovation” on their end, said Rep. Frank Pallone (D-N.J.), the health subcommittee’s ranking minority member, during the hearing. Pallone referenced the GOP-sponsored Medicare Modernization Act of 2003, which was “chock full of mandatory goodies,” and accused the GOP of being hypocritical in its complaints.

Alexander Vachon, Ph.D., a health care consultant with Hamilton PPB, opines that Republicans held the hearing and issued this proposal to advertise their priorities to the public. Pitts “is making a list and checking it twice” on what he wants eliminated from the law, Vachon tells HRW. The caveat is “the Senate has to sign off on it, and the president, too.”