minnesota, and we have significant opportunity to have quality and to have a tremendous amount of access as a result of that so you can see that the fairview system, and mayo, all of these institutions as well as children's hospitals and a number of other institutions provide outstanding care for the folks in minnesota, and this is really an important issue. .. that we have learned a lot of lessons about where should we collaborate, and where should we compete? and the system needs to take some lessons from some of that example, and i'll touch on that as we move through this discussion. certainly working on payment reform, i don't need to repeat a lot of what you've heard already today, but i agree with the premise that has been put out

here, if you pay for volume, you get volume. and we have seen that largely across our systems, across the united states. in minnesota, we have medical homes and what we call baskets of care, that are actually part of public policy that are actually part of public policy and are being piloted in a variety of places said these are some measures that we think are important in the system as it evolves but we also think that global payment is going to be a very important and significant feature of how health care gets funded in our state. it will be important as the private-sector in combination with our health systems move towards more globally oriented payments that a move that way with medicare moving that way as well so i agree with the comments that have been made about medicare and payment reform. is going to be important to have

critical mass as a move through that. a variety of other instruments have been put into play to get at the cost issue because there isn't one flavor that suits everyone and you have to have lot of the approaches so certainly have done things two-tier networks so some of the smaller employers who are making more costs related joyces are making them around what delivery system works for them. we have done work around centers of excellence. minnesota happens to have 16 designated centers of excellence within the blue cross system so kiss us loss of opportunities there. we profile providers on their quality and use that data and made that data transparent in our market and that has been important. has it taken on the full flavor i think it will in the future? no, but it has been information out there and will become

increasingly more information -- in. as information becomes more robust. we have also worked to what we have called peer comparison tool which allows the consumer easy access to move through the various forms of treatment they be looking at to compare chatman patterns and also look at cost so it is an important part of the equation when talking about how do we get the consumer and immigration. the consumer needs to understand we need to be more transparent as an industry about sharing information about cost so people can make informed decisions and the scare comparison to is one of the vehicles forgetting that done. changing the care model obviously we need to take fee-for-service type of reimbursement out of the system where ever we can and i think that will be an important part of the transition to a new health-care system of cross.

and will also be important to consent the right kennedy haters and the benefits we put out there so one of the benefit plans we see taking on a lot of interest are benefit plans where the consumer can have a reduction in their premium by managing their numbers and when i say their numbers being aware of your blood pressure and your cholesterol, being aware of your body mass index and make that available through a number of other employers today and those set benchmarks and then as you move toward improving those numbers and demonstrating move and improving you get a premium reduction. those are incentive based in our imports into this overall reform effort talking about. some of the things we've tried to do is certainly minnesota one of the year leaders and retell clinics and we actually wave copays if you use the retell

clinics so try to put incentives in the benefit package to use the right place for people to be accessing care briefing at quality and get a lower cost so it is about having the benefit lineup with where we like to take the system. one of the other things that has been a viable conversation going on is one that involves all the ceo's of the various health plans in town and the large health systems in town. i mentioned at the pump for large systems before but it includes the children's hospital's underwriters. we have made open to anyone who wants to be in that dialogue but we are as a group of leaders every couple of weeks talking about how do we as a private sector reform the system and do the things necessary to deliver the quality and out comes that are expected of us and should be

expected by each and every person in our state so we have said some very aggressive for amateurs for ourselves. we want to live out the trend line, we want to make that less than it cpi if we can and what all of the health systems have come forth and said is they are interested in global payment, they would like to engage those dialogues so we're not as far along as experiment have kept global payment but we are moving down that path and the providers of care see that as an important vehicle they are actually asking for. we think with that foundation we have in minnesota and the change payment reform that we can be a model for the nation and would very much like to step up to that challenge. one look at some of the collaboration i mentioned before understanding where to collaborate, where to compete be as a community have moved to a number of different

organizations. one called the institute for political system improvement referred to in the organization is already looking at evidence base care and best practices in establishing those for the community, not health plan or institution but for the community, and valuable asset. minnesota and in the measurement is looking at data and the patterns emerging in our community and publishing those so you as a consumer can look at minnesota canoe is a measurement and see the results from one clinic to the next so that is a valuable piece of information and in the other part is physicians can see where they stand versus their positions and that has been a good motivator as well. we have the exchange which is setting the parameters for how the various organizations including the stake of minnesota will exchange information some

rather than operating in your own world the system obviously needs to be more integrated and these are a panicle community assets that are moving us toward that type of integration. an example out of a the group is established 48 -- lines, one around diabetes care. so as you move down this list living in each of the elements of how diabetes should be treated and scoring that and then the minnesota committed to measurement making that visible to the consumer on-line or you can go and see how one clinic for says another is performing and this is just a quick depiction of what that looks like given presenting in washington d.c. but literally you can go and break -- the names are on there and you can see how one compares to the next through an element called helms' court and this is just a valuable piece of data for the

reform of the system. winfrey look at minnesota and think about it as a model for the country a lot of it is built around how integrated the delivery system is so hospitals in the twin cities in particular have the physicians employed by the hospital, ancillary services employ the hospitals and these are very tightly integrated systems so they're in position to take on a global payment and to manage that much more actively than perhaps would have been the case and number of years ago some and we talked about this feels like something we have tried before a thing this system is in a different place and is a different dialogue with the system leaders are asking those of us on my side of the table to bring that type of payment to them. i think the last time we can all admit the health insurers were bringing that to the system and it wasn't quite ready to take on that kind of change.

the other large integrated delivery systems is they have made the capital investments in electronic records so we have a lot of data, is there more opportunity to use that? and absolutely but the infrastructure is there and i think that sets a model that a lot of other people would aspire to. we have worked with a large provider group around quality payments paying for performance in standardizing practices of care so one of the great examples in this space is the minneapolis heart institute. it was able to reduce by half of the incidents of a mortality related to am i, not by enrolling new technology, they did it by bringing together nurses emergency staff and cardiologists.

everybody who touches the treatment of cardiac event they brought them together and remount the process, every mapped the protocols and words collaborative lee in a very different way than uc in a lot of other communities around the country. now that protocol they have established is 100 different places around the country but it comes from that ethic around collaborating in getting outside your walls and thinking more holistic we about the delivery of care. i am going to switch the focus to second and look at access because it is also a very important part about what we're talking about when covering the uninsured population in the country. in minnesota today recover 92% of our citizens so we have a percent uninsured it with a country is average i believe around 15%. of the 8% 4% and chile have access and have not availed

themselves of coverage entitled to so we need to do a better job there but we really have programs available to 96 percent of the people and our state. we absolutely are not happy with that and we need to close that gap and we would like to have everybody covered the part of this is making sure you that availability to everyone and i think we've done a pretty good job of making that happen. some of the vehicles is what we call the minnesota comprehensive health association or someone who has not covered now and doesn't qualify for coverage is covered as results of a pool which is a cooperative between the health insurance in the state. and, of course, of the schip program so we have lost apprenticeship to attain a the same and between private insurers to get people covered so there is an example of how

you get access and how you get people covered. we're working that already and we feel like we have got very good partnership with government to make that happen. the blue cross plan it that i belong to has just also launched a series of what we call instant care product in -- products so people injured for a brief time we have now wash products that are 30 days, 60 days and 90 day duration for somebody who knows the have a specified time of gap. we have made that available and is creating a lot of interest in the marketplace. i have touched a bit already on public-private partnerships and obviously we have those in medicaid and medicare within our state or working probably with government. probably no secret that i see this cooperative arrangement and this partnership as a way to go as opposed to having government as a competitor to u.s..

i think we have demonstrated we can have access and deliver quality and can address the cost problem particularly when they get the payment reform that we need so when we look at minnesota with in the medicare product minnesota stands out because it is in the high as quantum for quality in the low squadrons for cost. we believe we aren't getting the job done, we think there is more to be done but we have laid out a map for how we think we are going to accomplish that. i mentioned before thinking about our company as a health company and literally step back with my team and a strategy session and then about our industry and its migration, we grew up as an insurance industry and pay claims, were there to cover the loss of finance and then health plans, delivering to employers and trenton manage the costs for employers. i believe the next generation is really about health company.

how do we create prevention, wellness, better outcomes, how to recreate the partnerships and the market place to deliver that. how are we an agent of the consumer. that doesn't mean we don't still pay claims and are involved with employers but i think is we take care of consumers we take care of employers because of our commitment to the consumer. that is a difference in how we think about ourselves and we think our primary jobs are. as a health company what is our focus? is encouraging refracts -- best practice and evidence based madison, critical to help company focus. change the incentive to promote better care so let's get out of the fee-for-service trap. transparency and power of consumers and providers, and giving them the data but when you get the data is a double edged sword with responsibility on the consumer side as well.

coverage for everyone. we absolutely believe everyone should be covered and we're working to make that happen in minnesota. promoting health and wellness. we believe these are critical. if you look at the growing tide of cost coming to the health-care system is not going to be changed by taking one player out of the mix are making small changes around the fringes. it is going to be changed because we did in and get to the issue is creating a major cost bobble coming out of this country. driving this cost is tobacco and dying in inactivity so we cut this differently and opposed to the things people are doing that are driving cost. we have to be serious about taking on these challenges. these are preventable issues so have we think about this in minnesota? we think about this and a comprehensive line. i will start with how do we

address the individual. when we look at the individuals we have health risk assessments in place to get a better handle on what each consumer needs and the risk profile and we are dedicated to stopping smoking. i'll give you did it in a minute. we have online coaching of our members, and actively involved in reaching out to folks as we see the markers that tell us folks need to be engaged very directly and we have to prevent benefits so engaging people with premium discounts when you are managing your numbers i think is a very active way in to draw the engagement of the consumer into the equation. when we look beyond the ring of the individual is the family. everyone who has a health issue has a family of some kind around them that are critical to the support system that delivers to that individual sinking more

holistic we not just about the person that you cover want to think about the whole family even if we don't cover the whole family so we think more about the community and how we reach out to the community. this is a critical part of our care. when we look at the worksite we are engaging the cafeteria's at the have to make recommendations about what food should be there, how they should subsidize the items they serve their. what kind of many machines to have in place. this is not about having a single bullet but is being comprehensive in how you think about care. and we think about the community we do things that are unusual for health insurance company. we were the major advocate for smoking cessation in our state. we beat tobacco and how that back into taking this smoking rates down. we do things like complete streets every advocate for

sidewalks, bypass, a safe crossing guards and things that i held company would think about as opposed to an insurance company. when you look at the social determinants of how these things that are driving cost. this is social connectedness, this is how people think about child development before the age of five. are foundation has been actively involved in this work for over 20 years. this is an imprint distinctive about how we think about health care. the next slide is to shoot it's not easy to change culture or gnomes and you notice the palm tree in the corner, this is not minnesota. [laughter] we understand it is difficult to change norms so had we know it is working? we know because we have saved over $25 billion in smoking cessation benefits so we know that the thousand dollars in change for every person who stops smoking to the bottom line of the health care delivery back

to the of we're delivering that care so it absolutely has a return and is critical. minnesota has 17 percent smoking rate among the country has 22 percent smoking rate, blue cross blue shield as a 10.9 percent smoking rate. we are dedicated to this. we know it works and there is a return on the bottom line. when we look in excess risk if you look at the next slide it tells you that talking about somebody with normal risk profile is at $2,200. click sign-up for each of the risk profiles elements that come into the pit to give patients profile so it is critical these preventive situations are down on a preventive basis and make a change in the way that is delivered. i want to touch on innovation. innovation in said minnesota has

been one of the hallmark features of that community. certainly with retail clinics coming out of their, with consumer directed health care coming out of minnesota. lots of things have been launched there and have been valuable. our new piven model is going to be one of those things as well but we have recently announced the cross blue shield of minnesota are going to be paying for online care. online care is honoring the physicians' time. a position talks to you on the phone, walks through a situation and they get paid nothing for that. they are paid in a show up at the office: we look at this we are going to be paying for that online interaction. we have a partnership with an american wow and it will be an ideal setting through the web can exchange with the position but we think this has a world of potential. if you think about situations like chronic mesa interaction inouye know how you are going to

be treated and go twice a year every time it is the same thing. they bring into the office because that is where they get paid for syria. if they told you this they don't get paid. online caris says you have that interaction on-line with the physician. they order the prescription the never show up. they spend their time on something important and is been a time on something more important, your employer is happy and there is a win for interactions that there in the system. it is not for everything but it absolutely can help take some of the expense of the system. and this is just a quick screen shot of what that looks like. we're talking about a video transmission from the patient and the opposition. we think it has a lot of application for the rural parts of our state, think about being interactive on the phone line. there is lots of opportunity for

that to take off. in summary we have been tackling cost and looking at improving the care to collaboration. we see ourselves as a health company. i went to this quickly that we are committed and passionate about what we're doing there and a lasting only be with is a couple of comments for this process in washington d.c.. payment reform and medicare critical. this is where we should be spending our time and effort. individual mandate in exchange for guaranteed issue, absolutely on board with that. medical malpractice reform should be a bigger part of this discussion here defensive medicine happens because the malpractice situation in our country. leadership on and of life is a place for that discussion can happen. advance directives part of that discussion but there is so much expense is not something getting a lot of attention.

guidelines and certainly quality requirements are an absolute rule of the federal government. i'll leave you with minnesota has been a vader, looks to be a leader in the quality of care being delivered in this country. this is too big an issue to be a partisan political issue. this is about delivery of quality care for every single american and are committed to it -- thank you. [applause] >> thank you, pat, it's great to see that even though minnesota so far ahead they continue to work hard to improve their delivery model. now i like to introduce martha who i'm sure is well known to all of you. he is the director of the annenberg center at brookings where he draws on his public sector experience having led both cms and fda and, of course, brings his background as a physician and an economist to that role.

mark most recently has been playing a key role in the development of the bill baker daschle plan and an important bipartisan agreement on health care reform and he will describe some of the multi care initiatives that he's involved in that concern as a model for health-care reform. >> thank you. it is great to be here this morning with all of you. how are we doing on the slides coming up fykes okay. this is a very distinguished panel and i'm glad someone had taken time to be here and we're seeing some discussion at around payment from an improving how it works. i'm going to talk about that as nancy mentioned focusing on things like accountable care and multi stakeholder approaches to doing this. but it is very refreshing to see how much of an emphasis there is on getting these kinds of ideas into legislation. this is something that can be

bipartisan. a lot of congressional staff are working hard to turn these concept and the legislation that improves benefits and care and is paid for. that is really hard. nancy mention the efforts that we have been providing technical support for at brookings by bipartisan policy center made up of former majority leaders and the u.s. senate so senator dole, senator -- well, senator baker and george mitchell working with us to the guy new job working middle east peace. and again for to asking which is more difficult, but in that ever there was a major set of proposals related to health care delivery form which fits with a lot of discussion we have had here today. this is not the right presentation -- soaring. the me see if i can talk all we are getting the right one up there. it should be identified in for nihcm but the point is pretty basic. what i want to emphasize is that

as part of bipartisan health care reform there is an emphasis on getting better information for using health i.t. to developing better evidence on what works for a particular patients of what kind of policies work best for decision making. those are important policy steps but in themselves are not going to be enough. they are enablers and not going to be enough and so all of this emphasis hearing today on reforming payments to providers and moving toward paying for what we really want, better health, lower-cost as opposed to fee-for-service is also extremely important. a third key element is consumers and involving patients to been a reform and we talked about that as well. i've heard about that in the last presentation and you can think of the reforms being considered on coverage sitting in the school as well. insurance market reforms make sure everyone has access to a range of choices and competition

among health plans based on each patient better and not by selecting healthier individuals. we talk about the insurance market reforms. tax reforms and things like having the health insurance exclusion from coverage. maybe not the first nine people would like to do, it is a limit on the subsidies from the government but another step toward making consumers and people more cost conscious about their health care decisions. they're being focused on reforming health care delivery and bipartisan health care reform are elements of this comprehensive bipartisan policy center proposal which i encourage you to take a look at. there are some lessons moving directly into my piece of this about payment reform and what can work. there are some lessons from examples brown the country about the fact of the ways to reform payments and promote these

delivery system reforms. one is to put greater accountability onto pawlenty and cost so instead of paying for more services there is another point on here move from rewarding intensity to increasing value and that does mean more responsibility for providers, patience on getting better results. you heard about that from the other speakers as well. there have been a lot of discussions about this is going to save money and accountability and payment reform can save money. when some of the proposals are doing to get the support of the congressional budget office that are likely to lead to savings as building in the kinds of traditional approaches to saving money in medicare and public programs by reducing update rates by giving provider somewhat smaller payment increases by getting an opportunity to not have to d