care, so as you move down this list, looking at each of the elements of how diabetes should be treated and scoring that and then through minnesota community measurement, making that visible to the consumer on line, where you can go and see how one clinic versus another is performing.

and this is just a quick depiction of what that would look like, given that i'm presenting in washington, d.c., i didn't put anybody's name on this, but literally in minnesota, you can go and look and the names of the clinics are on there and you can see how one compares to the next through an element called health score and this is just a valuable piece of data for the reform of the system. when we look at minnesota and think about it as a model, a potential model for the country, a lot of it is built around how integrated the delivery system is, so the hospitals in the twin cities in particular, have the physicians are employed by the hospitals, ancillary services employed by 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 effectively than perhaps would have been the case a number of years ago. so when we talked about hey, this feels like something we may have tried before, i think of

the system is in a different place. it is a very different dialogue when the system leaders are asking those of us on my shied of the table to bring that type of payment to them. i think the last time we can all admit, that the health insurers were bringing that to the system, and the system wasn't quite ready to take on that kind of change. the other thing about having large integrated delivery systems is they've made of the capital investments in electronic records. so we have a lot of data moving in the system, in a much more effective way. is there more opportunity to use that data? absolutely. but the foundation and the infrastructure is there, and i think that sets a model that a lot of other people would aspire to. we've also worked with a lot of large provider groups around quality payments, paying for performance, and standardizing practices of care. so one of the great examples in this space, is the minneapolis heart institute.

of the minneapolis heart institute was able to reduce by half the incidence of mortality related to m.i. and they did that not by involving new technology. they did it by bringing together nurses, emergency staff, cardiologists, everybody who touches the treatment of cardiac event. they brought them all together, remapped the process, remapped the protocols, and worked collaboratively in a very different way than you see in a lot of other communities around the country. now that protocol that they've established is in 100 different places around the country, but it comes from thattest i can around collaborating and -- that ethic around collaborating and getting outside your walls. i'm going to look at access because access is also a very important part of what we're talking about when we talk about

covering the uninsured population in the country. in minnesota today, we cover 92% of our citizens. so we have 8% uninsured, where the country has averaged out i believe around 15%. of the 8%, 4% of those folks actually have access and haven't availed themselves of coverage they're entitled to. so we need to do a better job there, but we really have programs available to 96% of the people in our state. we absolutely are not happy with that. we have need to close that gap. we'd like to have everybody covered. but part of this is making sure that you've got availability to everyone and i think we've done a pretty good job of making that happen. some of the vehicles for doing that is what we call the minnesota comprehensive health association, this is where someone who is not covered now, who doesn't qualify for coverage, is covered as a result of a pool which is a cooperative

between the health insurers and the state. it's a very effective way for expanding coverage. minnesota care is the expansion of medicaid coverage within our state, and of course, the chip program, so we have lots of partnerships between the state and between private insurers, to get people covered. so there is an example of how do you get access and how do you get people covered? we're working that already in minnesota, and we feel like we've got very good partnership with government to make that happen. the blue cross plan that i belong to has just also launched a series of what we call nstaa care products. we've launched products that are 30 day, 60 day, 90 day coverage for people who have a gap in

coverage. i've talked a bit on public-private partnerships. we have those in medicare and medicaid, within our state, where we're working cooperatessively with government. probably no secret that i see this cooperative arrangement and this partnership as the wave to go, as opposed to having government as a competitor, i think we've demonstrated, we can have access, we can deliver quality, and we can address the cost problem, particularly when we get the payment reform that we need. so when we look at minnesota, within the medicare product, minnesota stands out because it's in the highest quadrant for quality, and the lowest quadrant for cost. so we believe we're getting the job done. we think there's more to be done, but we've laid out a map for how we think we're going to accomplish that. i mentioned before, thinking about our company as a health company. i literally stepped back with my

team and we did a strategy session and thought about our industry and its migration. we grew up as an insurance industry, we paved claims, we were there to cover the loss, the large financial loss. we then were health plans. we were delivering to employers, and we were trying to manage the cost for employers. i believe the next generation really about health company. how do we create prevention, wellness, better outcomes, how do we create the partnerships in the marketplace to deliver that. how are we an agent of the consumer. that doesn't mean we don't still pay claims and still are involved with employers, but i think as we take care of consumers, we then take care of employers because of our commitment to the consumer. so that is th a difference in hw we think about ourselves and what we think our primary jobs are. so as a health company, what's our focus? it's encouraging research on what works? so best practice and

evidence-based medicine, critical to a health company's focus. change of the incentive to promote better care. so let's get out of the fee for service trap that we've been in. empowering consumers and providers, giving them the data. but with you get the data, it's a double edged sword. there's a responsibility on the consumer's side as well. coverage for everyone. we have absolutely believe that everyone should be covered and we're working to make that happen in minnesota. promoting health and wellness. we think these are critical. if you look at the growing tide of cost, coming through the health care system, it's not going to be changed by taking one player out of the mix, or making small changes around the fringes. it's going to be changed because we did in and get to the issues that are creating the major cost bubble that is coming at us in this country. so if we look at what are the things that are driving costs, tobacco, number one, and diet

and inactivity, number two. so we cut this differently as opposed to disease states. these are the things that people are doing that are driving costs. we have to be serious about taking on these challenges. these are preventable issues. so how do we think about this in minnesota? we think about this in a very comprehensive wave. i'll start with how do we address of the individual. when we look at the individuals, we have health risk assessments in place, to try and get a better handle on what each consumer needs in their risk profile. we are absolutely dedicated to stopping smoking. i'll give you some data in just a minute. we have on-line coaching of our members. we're actively involved in reaching out to folks as we see the markers that tell us that folks need to be engaged very directly. and we have of the preventive benefits that i talked about before. so engaging people with premium discounts when you are managing your numbers, i think is a very

effective wave to draw engagement of the consumer into the equation. when we look beyond the ring of the vivid, it's the family. -- the individual, it's 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. so thinking more holistically, not just thinking about the person that you cover, we want to think about that whole family, even if we don't cover that whole family. so we think more about the community, and how we reach out to the community. and this is a very critical part of our care. when we look at the worksite, we're engaging the employers that we cover to look at the cafeterias that they have. to make recommendations about what foods should be there, how they should subsidize the items that they serve there. what kind of vending machines do they have in place? this is not about having a single bullet. this is about being very comprehensive in how you think about care. when we think about the

community, we do things that are unusual for health insurance company. we were the major advocate for smoking cessation in hour state. we have beat tobacco, we took that money and plowed that back into taking the smoking rates down. we also do things like complete streets, where we advocate for sidewalks, bike paths, safe crossing guards, things that a health company would think about as opposed to perhaps an insurance company. :

>> and back to the employer who is delivering that care. so it absolutely has a return, and it's absolutely critical. minnesota has a 17% smoking rate. the country has a 22% smoking rate. blue cross blue shield of minnesota has a 10.9% smoking rate. we are dedicated to this. we know it works. there is a return on the bottom line. when we look at excess risk in the system, if you go to this next slide, it tells you that if you are talking about somebody with normal risk profile, it's

at $2200. it goes on for each of the risk profile elements that come up to that particular patient's profile. so it's critical that these preventive situations are dealt with on a preventive basis and that we get out and make a change in the way that care is being deliberate. i next want to touch on innovation. innovation inside of minnesota has been one of the hallmark features of that community. certainly with the retail clinics coming out of their, with consumer directed health care coming out of minnesota. lots of things have been launched there and have invaluable. our new payment model was going to be one of those things as well, but we have recently announced that blue cross blue shield of minnesota that we're going to be paying for ongoing care. on line care is honoring the physicians time. a physician talk to you on the phone, watching through a situation, they get paid nothing for that. they are paid when you show up at the office.

so when we look at us, we are going to be paying for that on line interaction. we have a partnership with american well it it will be an ideal setting to a webcam exchange with a physician, but we think this has a world of potential there if you think about situations like you have a chronic nasal infection, you know exactly how you're going to be treated. you go twice a year. every time it's the same thing. deposition tells you they've been into the office because that's where they get paid for sinew. if they tell you over the phone and send the prescription and they don't get paid. on line you have the interaction on line it takes 10 minutes. you never show up in their office. they spend their time on something more important. you spend your time on something more important. your employer is happy. there's a win here for lots of interactions that happen in the system. for everything, it's not that it absolutely can help take some of the expense out of the system.

so this is just a quick screenshot of what that looks like. we're actually talking about a video transmission from the patient and the physician. we think it has a lot of applications for the rural parts ! individual mandate in exchange for guaranteed issue, we are absolutely onboard with that. medical malpractice reform

should be a bigger part of this discussion. defensive medicine happens because the malpractice situation we have in our country your leadership on end-of-life care, this is a place where that discussion can happen. advance directives is a minimum part of the discussion but there is so much expense there and it's not something that's been getting a lot of attention. guidelines and certainly quality requirements are an absolute role of the federal government. i'll leave you with minnesota has been a leader, is a leader, looks to be a leader in the quality of care via delivered in this country. this is too big an issue to be a partisan political issue. this is a doubt delivery quality of care for every single american and we are committed to. thank you. [applause] >> thank you, pat. it's great to see that even though minnesota is so far ahead they continue to work so hard to

improve their delivery model. now i'd like to introduce mark mcclellan who i'm sure is also well known to all of you. he is the director of the ingle brooks center at brookings where he draws on his public-sector experience having led both cms and fda. of course he also 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 dolby girt daschle plan, and important bipartisan agreement on health care reform. markle described some of the multi-payer initiatives that he's involved in that also can serve as a model for health care reform. >> thanks, nancy. it's great to be here this morning with all of you. how are we doing on slides? coming up. okay. like i said, this is a very distinguished panel. i'm so glad people are taking time to be here and that we are seeing so much discussion around payment reform and improving health care works as part of

health care reform. i am going to talk about that, as nancy mentioned, focusing on things like accountable care and multi-stakeholder approaches to doing this. that it is very refreshing to see how much and emphasis there is on getting these kinds of ideas into legislation. this is something i think can be very bipartisan. i see a lot of congressional staff. i know you're all working hard to actually improves a benefit, improve care and is paid for. and that's really hard. nancy mentioned the efforts that we've been providing technical support for at brookings by a book called made up of former majority leaders in the u.s. senate so senator dole, senator daschle, senator baker, senator george mitchell is working with is also. enough that a new job and is doing middle east peace and i am looking forward to asking which one is more difficult. but in that effort there was a major set of proposals related

to health care delivery form which fits with a lot of the discussion that we've had here today, and this is not the right presentation, sorry. let me see if i can talk while we are getting the right one of there. it should be identified for nihcm, but the points are pretty basic. what i want to emphasize is that as part of bipartisan health care reform there's a lot of emphasis on getting better information through using health it to support decision-making, through developing better evidence on what works for particular patients and what kinds of policy work best for decision-making. those are important policy steps that in themselves are not going to be enough. they are tools, they are enablers but they are not going to be enough. to all of this that you have been hearing about today on reforming payments to providers and moving towards paying for what we really want, better health, lower costs, as opposed to fee-for-service is also

extremely important. third key element is consumer and involving patients through benefit reforms. we've talked some about that as well. i've heard about that in the last presentation. you can think a lot of the reforms are being considered on coverage fitting into this goal as well. insurance market reforms are making sure everyone has access to a range of choices of health plans, the competition among health plan is based on treating each patient better, lower cost that are out, not by selecting healthier individuals. we talked about the insurance market reforms and we need to get there. tax reforms. things like having to health insurance, exclusion from employer-provided coverage. maybe not the first thing that people would like to do. is a limit on the government but it is another step towards making consumers, making people more conscious about their health care decision. so a big focus on delivery and bipartisan health care reform and all of those are elements of

this comprehensive bipartisan policy center proposal which i encourage you to take a look at. there are some lessons now moving more towards correcting my piece of this discussion about payment reform and what can work. there are some lessons from examples that are taking place around the country. some of what you are a heard about today about effective ways reform payments and to promote these kinds of delivery system reform. one is to put greater accountability on to quality and cost. so instead of paying for more services, more intensity, there's another point on your. to increasing value and that does mean more responsibility for providers, or patients on getting better results. you heard about that from some of your other speakers as well. there have been a lot of discussions about whether this is really going to save money, whether this kind of accountability and payment reform can really save money. i want to come back to that. what some of the proposals are

doing to get the support of the congressional budget office, that they really are likely to lead to savings is building in some other kind of traditional approaches to saving money and medicare and other public programs by reducing update rates, by giving providers somewhat smaller payment increases from year to year. but giving them an opportunity to not have to deal with that just any traditional way, despite dealing with a lower payment rate per service by increasing volume or seeing more patients, things that don't really do anything to improve health care. moving another way forward to get to those achievable, at least savings that many people think are achievable in bending the curve on health care cost. again, very important part to make sure that consumers can get involved and we have a very diverse health care systems of these reforms need to be able to work with a wide range of practice settings ranging from some other pre-advanced integrates systems that you just heard about from patrick to solo practitioners working on their own and rural america.

this slide talks about different, a way of maybe putting some of these different kind of payment reforms proposals together. we were working on this, not only in alphabet soup but a whole range of different kinds of ideas. all of which have the same goal of getting better quality and avoiding unnecessary costs. and i want to highlight again getting to accountability is the key part of this so there are some proposals out there that really are about supporting better performance, and probably will have an impact. things like paying for reporting. something medicare does not. many private payers do not. that gives us better information, gives providers better information on opportunities to improve care, focus his efforts and can lead to improved specific aspects of care. payment for better coordination services. paying for things we don't pay for now to help people stay healthy and get better care, like medical homes where we don't have any payments now for

answering e-mails or using records to track a patient and how well they are doing and filling their prescription and providing those kind of medical home services. you can go further to actually pay for better performance in some dimension. the so-called pay for performance or p. for p. elements that have been demonstrated and medicare in the private sector do show an impact not just reporting. paying for when you get better compliance with diabetes medications for better results and other specific aspects of care. the challenge with these though is that there are so many dimensions of important dates so many dimensions of important quality care even if you get improvement in some specific area it still can be hard to have an impact on overall cost and overall health outcome for a population. so in many of these demonstrations will we have seen it you have an impact on a specific aspect of quality of care that are measured, but maybe less an impact on overall

cost, additional payments you make for improved performance offset some of the savings that might occur because you got improved performance. that's more of an emphasis on trying to bring cost, reducing unnecessary costs directly into these performance incentives. a lot of effort is underway now to implement episode payments where there is a payment based on a particular procedure like a bypass operation, you know, everything is included with a hostile care, the physician services or maybe a case based payment for diabetes and all these might be adjusted for the severity of illness of the patient. the idea is you get paid the same amount or maybe more if you deliver better quality of care in this episode. those payments take those kind of measures and those kind of payment reforms can be very important in getting the better quality. the challenges that one way of improving health and reducing costs is to avoid many of these episodes in the first place. maybe by avoiding the bypass

operation, or reducing the level of complexity of diabetes or preventing it in the first place, it might be a better way to get the better health and lower cost. if you just focus on episode not going to incorporate that. very important element of getting to higher value in health care. so some efforts are focusing more directly on paying for higher value. i'm going to spend a few minutes talking about accountable care organizations and accountability for getting this goal met, getting better outcomes for a population of patient, better health for population of patients at a lower overall cost. and that can be done through a shared savings, so this can be added into current payment systems without radical change to give providers an opportunity to share in the savings that they create when they take steps. they currently are reimbursed or not enough or are being reimbursed exactly for the right patient. whatever it takes to get better outcomes and reduced the average cost of the patients they are treating, should provide better support. it should be channeled back into better support for those

providers. and even further along this senator, i does moving in the section to be distinguish what he is doing in massachusetts have capitated payments. very important difference is there but the basic idea is putting more weight on an overall goal of meeting our cost target while improving quality and putting less weight on the traditional ways of paying, such as fee-for-service. in the extreme you put no weight on fee-for-service and all the weight on capitated payment that's adjusted for quality and for severity of illness of the patient. for a long string but definiteldefinitely where a lot of organizations, a lot of payment reforms are aiming. now accountable care organizations as a concept we've been working on. by the way, i should play in the headers on the slide so you can see it. this is a joint, reflection and joint work by us at engelbert at brookings and the dartmouth institute for clinical services,

or for health policy and clinical practice. collaborative effort. the idea behind accountable care organizations is that we want to support providers that are organized in a way that they can manage the whole continuum of care. the whole set of care for patients. maybe not very formal organization at least having accountability, have the payments be on the result or a population of payments. not for a specific service or even a specific episode but for a population of patients. this requires the care organizations to be large enough to support comprehensive measurement of performance, and provide a critical mass for the kinds of targets support services that can benefit particular patients within this population. and there also needs to be enough organizations in these accountable care organizations to be able to plan ahead, be able to take steps that aren't going to actually improve care and reduce cost. lots of different ways that an acl could format a lot of these are big considered an legislation right now.

what should the requirements be. my own view is that it's probably best to provide some flexibility here given that there are lots of different practice settings in which these kinds of accountable care steps may occur. he might have an organization that is very integrated between primary care providers, especially providers and hospitals. on the other hand, these kind of support or better results for population of patients with a lower cost could occur at a regional level, could occur with a loose or virtual relationship or informal relationship between providers that might be spread out more geographically. maybe including a hospital, maybe not. it's important to consider that there are other elements that get brought in when you think about changing payments that focus on better outcomes and lower costs. mental health services, home health services, other elements of the overall delivery of care. and even things that are traditional health care like community based services and wellness programs that may be the most cost-effective way for some p