e watching at home. as you know, we're committed, and president obama is committed to enacting health reform this year. [inaudible] primary care is really important. right now, we all know that high costs makes it difficult for patients to afford adequate

insurance and comply with treatment recommendations and there's one thing we know for sure, quality is uneven across the system. we need to do something about that because too many patients don't receive the recommended care. so our goal and the thing that many of you have been working toward, vermont, good to see you again, and other places around the country is to try to improve that and address the challenges we want to working with congress and all of you, including physicians and state health leaders who have been engaged in some of these reforms. this is going to require changing the way we deliver health care so we're really gratified that some of you have already been engaged in that difficult work. we need to focus on improving the quality of outcomes, making sure we're providing better care, coordnating care for patients with chronic diseases. all those are things that

primary care has a critical role to play in doing and driving the transformation of our delivery system we know we need. today we've gathered experts in the field and some of you who have been working to do this around the country to discuss only advanced models of primary care that can meet the challenges of our health care system. we believe that the reform that we're talking about offered a major opportunity to improve the quality and coordination of care leading to improved patient health and experience, but also low in cost and i'm looking forward to hearing what some of you have to say about your experience in doing that. we're joined by health care leaders who have been developing advanced models of primary care that address these challenges. we have representatives from state medicaid programs, health plans, integrated delivery systems and physician societies. we're also joined by academic experts and we appreciate your willingness to come and share your perspectives and expertise on how to improve and expand

these advanced primary care models. we have people here from all over the country and people who traveled a long way and we appreciate your taking the time to do that. . >> i'm barbara smith, special counsel in the office of health reform, nhhf. >> i'm ibm's general manager for

global healthcare and life sciences responsibility. >> i'm dan fields, i work at the national economic council on healthcare. >> bob phillips, director of the robert graham center, part of the american academy of family physicians. >> i'm the policy director for the medicare program. >> i'm ken thorpe, professor of public policy at emory university and the executive director of partnership of iconic disease. >> -- chief of staff, the first lady -- also part of the healthcare reform team from the white house counsel's office. >> my name is elizabeth session and i work on the national economic council on healthcare policy. >> i'm kevin grumback and i partner -- >> i'm mark dug began senior economist at the -- >> i'm phyllis torda, chief executive for the national

committee for. >> paul grundy, d dtor of healthcare transformation forfom corporation -- representing about 400,000 physicians on primary care and most of the fortune 500 to really drive transformation and change in the covenant in the way we buy care and deliver care around a model of care, patient center primary care. >> i'm john tucker. c.e.o. of the american -- an internist. >> i'm executive director of the national association of public hospitals and healthcare systems and will emphasize the health systems part in this meeting. >> i'm a family practitioner. previously -- [indiscernible] >> craig jones, i'm the director for the vermont blueprint for health and a pediatrician as well.

>> and i'm michael soman, a family physician who practiced for 17 years at group health -- now i'm the president of a medical group and medical director of the owned and operated delivery system. >> barbara walters, senior medical director at dartmouth hitchcock chicago and -- [indiscernible] and here today with -- [indiscernible] >> i'm dick salmon, family physician and national medical director for performance improvement for significant that health. >> my name is sue williamson, deputy director of the colorado department of healthcare partnership and financing. our agency administers our public health insurance programs like medicaid and our s-chip program. >> i'm david dorr, a practicing inearnist and medical -- at oregon health and sciences university. ly explain that. i work on a model called care

management plus. >> i'm allen dobson, a family physician with carolina healthcare system now. i'm the chair of the community care of north carolina and formerly the medicaid director and secretary of health. >> and my name is bob koch, i work with the national economic council. i want to thank everybody for coming. we are thrilled to have a tremendous cross-section of innovative practices and experts who think about primary care. i want to take a few minutes and talk to you a bit about the opportunity to do advanced primary care and frame a discussion that we'll have going forward. if you, i would like to do that. >> nancy-ann said we are thrilled that this year we will be talking about healthcare reform in ways that reduces the cost and cost growth for americans families and businesses that improve the quality of care and expands access and choice to millions of

people. today's discussion is going to be all about improving the quality of car. around the table we have folks who have done amazing things to improve the way patients receive care and -- it is only going to accelerate the improvement in care. i want to talk a bit about the changes in quality that we foresee coming which many of you embody in the delivery system. the first is we're going to address quality. a theme we're going to hear today is all about ordering quality of care and think about ways we can align the incentives to practice in ways like you have. -- it is not done because of costs. the we're going to make sure that health plans cover that and make that accessible to everybody. because that actually reduces costs and improve quality and is the right thing to do for shoe. coordination is going to be something that all of you have thought a lot about and going to think a lot about how to coordinate care with such that patients who have multiple diseases get the right care for

their combination of diseases and each disease and that the care team will know who's in charge and who's doing what and what need to happen. there's a lot that goes into. that that has to be improved. making sure the patients get the right clinically recommended treatment. too often we fall short on delivering evidence-based care. there are lots of reasons why that may happen. but your practices have all come up with ways tone sure that evidence-based care benefits more often the patients and figures out when it's not happening to remedy that and get patients back on the right treatments. -- is something that's chronic in our healthcare system. and you've all thought through ways of organizing the care to avoid duplication and even thicks that are unnecessary and those that are not done. and finally the connection of community. we have a system of clumsy handoffs between hospitals, specialists, primary practices,

community for families and patients. clearly it's costly. again today going to talk about ways to ensure that community and families and patients are much more likely to be informed and cooperative in the care. and finally, reform will expand access to millions of people who don't have access today. we talk about primary care today because primary care is something that too often isn't in place for enough patients. primary care, what we refer to when we say primary care, what what we mean is a doctor and a practice and homefully a carry team who is responsible for ensuring that a patient working with them gets the proper care. that a patient knows who to call, that they call them back, that if you have questions you have somebody who can answer, you have concerns about accessing specialists or what to do that there's a practice that actually serves those needs for you. and many of us in the room experience that, most of you deliver those types of care to your patients. but it's too often not the case. the and so in the care system of

the future we will absolutely have a much more robust primary care system that will more like what we talk about today. next i want to point out that around the table is incredible impact. we have seven systems who have all taken primary care in different ways but all with similarly impressive results. we're going to hear stories today about how north carolina saved $400 million already taking better care of medicare patients. -- across a really set of patients who are different and complicated in different ways than the population that allen is going to talk about. how colorado has really improved pediatric care and had remarkable improvement in compliance in state metrics. how group health has very quickly avoided a lot of emergency room says visits that would have led to both -- outcomes, frustration and expense for families and how

geisinger has -- we have really compelling stories today. what's amazing about these stories is we have talked to these groups andland more about them is it's things that can be done widely in many places. these are not limited examples. these are examples that all could be scaled. in today's discussion we'll talk some about how we can actually scale these so more patients get more of the benefit we're going to hear about today. as we go through, there are going to be 2004 elements. so i said there are many difference. there are four things that are common to all these practices. the first is the notion of carry coordination. so it's not left to chance what happens after a patient see. whether there's a followup process to ensure that whatever has to happen patients are reminded, physicians are reminded. it involves not just information technology but teams to take care of patient. because there's no one person in charge, there's jobs that need to be done by a full team. there's a much more patient

engagement in these practices than in a typical practice. so patients know what to do. they're followed up in some cases so the patients are rewarded for doing the right thing. but they're much more education that goes into the care of patients in these practices than in many around the country. easier access. so in these practices when you call them they answer. and you're likely to hear a phone call answered on the first phone call. that's not typical in many practices. so they've come up with ways to make it much easier to interact. in some cases the practices are open nights and weekends, there's alternatives to emergency rooms and it's much much simpler to communicate, sometimes by e-mail and other ways to make it easy for patients. and finally they're data driven. so each of these practices utilizes information technology to ensure the practices are reminded which patients are high risk, that the interventions can be taken before -- need age-appropriate screenings so if the appointment is not scheduled

it's scheduled and happens. so we're going to hear a lot about how information technology makes care better. so i'm thrilled that we're going to get these stories and that there are similarities but also tailoring that's happened in each of these practices that it leads to better care for the patients. allen is going to go first. in the interest of having a spirited round table discussion we're going try to be disciplined about five minutes. we're going to hold up a sign that says one minute warning. and i have to cut you off when you go over which makes me very anxious. so i'm hoping we'll stick to that. because the discussion you know about your practices more than others. so we don't want to go into great detail but talk about what you did and what happened and all of you have data to share in that regard. i'm going to have allen lead off. we'll hold the questions untilled end and then we can use the round table for questions. >> i appreciate being here and talking about primary care in north carolina. it clearly is now time for reform. and we really must -- to be

economically sustainable we have to overhaul a fragmented system. and i think the first must be an investment in primary care. and i think the values and principles outlined in the joint principles of patient-centered primary care is outlined is a pretty good first fundamental step for reform. community care is an example of the value of just such an investment. we started about 10 years ago with this project. community care is a public-private partnership between the state of north carolina and 14 not for profit networks that are comprised of the majority of the local healthcare providers in the state. and it's built around primary care. it also includes all the other physicians, local healthcare providers and in particular our hospitals, our academic medical centers, public hospital systems, health departments, social services and other safety net organizations.

this partnership delivers the patients that are primary care to medicaid and s-chip recipients and other low income adults and children in our state. and our networks have now grown to over 4500 primary care physicians, the majority of primary care physicians in the state and 1360 locations covering all of north carolina, all 1 hundreds counties and manages a little over 1 million patients. and next slide. and this is what the math looks like of how the providers have self-organized themselves. community care delivers improved quality care to our patients and cost savings to our state using -- primary care physicians serve as a medical home or personal physician for our patients. second, local not for profit networks decree -- are created as a virtual integrated healthcare system that links the primary care physicians and patients to the rest of the

local healthcare system and support agencies. it's like the glue in the communities. these networks provide the needed physician leadership and local collaboration in order to create a local solution to improve care management and quality. this provides a flexible structure that has proved to us to be adaptable in the rural areas as well as our largest areas including our largest academic health systems. third the state funds the primary care physicians through an additional blended monthly fee and also fund the network to provide additional local resources to the patients and the primary care doctors such as case managers, care coordinators, pharmacists, medical directors and some local quality improvement infrastructure to make sure that we improve the care. this assures that optimal support is provided to patients and the results are achieved locally. community care has demonstrated quality improvement and cost

savings and obviously phenomenal growth since it's now statewide. and has documented significant savings exceeding $100 million a year since 2003. and in short, north carolina has successfully managed the cost of its medicaid program mainly through a clinical management strategy rather than just a price reductions and regulatory control mechanism. so community care is now kind of the centerpiece of healthcare strategy in north carolina, is enthusiastically accepted by both patients and providers. again it's a value-added proposition. and it's in the community. legislature has mandated its expansion to s-chip and inclusion of mental health. and community care is now working with c.m.s. on a medicare demo that will allow us to continue to care for the sickest medicare fully eligible and at risk medicare. we believe north carolina's model serves as an important national model for health reform.

local infrastructural work both in urban and rural areas as well as public and private systems. the path for our reform efforts i think can be really informed by a lot of folks around this table and a really high-functioning health system. but the problem is that most of our healthcare delivery system isn't in the system at all. and so i think some of the lessons learned from north carolina show the value of investing in patients in primary care and a road map for organizing local communities regardless of size or quality and improvement of quality. so some of my suggestions for improvement would be making sure we adequately reimburse p.c.p.'s. a blended payment to support those activities, making sure we have enough primary care doctors to meet the needs of our folks. also aligning -- we were able to

align some policy and payment decisions to get certain access in comprehensiveness equation like after hours clinics. we need to fund additional care coordination strategies both at the practice and community level and provide the ability for flexible ability for primary care physicians and other providers to link together outside of a risk model. the big thing we learned was that you have to reinvest the savings to get growth in strengthening local systems and get meaningful and lasting growth. and there's a need for preventative services. and clearly there's a need for technical support for primary care physicians to undergo this transformation, maybe through an ag extension model or model in the local community to support primary care efforts. appreciate the opportunity to be here and participate in the discussion. >> thank you. david? >> great, thank you. as i said, i am an internist and i practice infomatics as well.

we study the way -- i like to do this in the context of a patient. so i'm going to talk about our care management plus pilot that we've done at intermountain healthcare and our subsequent dissemination at oregon health and sciences. gloria is 75, she's seen at mountain. i'll show you her picture with her permission in a little bill. she's active. she says her health is fairly good. she lives at home. she's doing pretty well but she has five chronic conditions that kind of accumulated. diabetes, she had a little bit of depression, she had cardiovascular disease and she's having memory difficulties. and so we know just from that that she'll probably see an average of 13 providers a year. she'll fill 50 prescriptions. she has 90 times the risk of hospitalization versus somebody with no chronic conditions. and the 5% of medicare patients like her account for about 42% of the costs. and so at intermountain where

this was developed these were the patients who really wanted to target in primary care to keep them healthy and at home. and so the model is simple. it's a care manager in a primary care team that has specific health information technology to help them. and we use that to help do care coordination, education, motivation and other tasks. we've seen some successes around hospitalizations reduced, improvement in mortality, improvement in quality and efficiency. so a little bit about the background. we started doing this in 2001. and in seven clinics versus six controls, we basically built this system with the help of a care manager. they saw about 70,000 patients in those clinics, the care managers saw about 4700. and we compared these seven to six control clinics in cost, quality and utilization. our patient population was

really focused on patients like gloria although they could refer whomever they wanted. and we've since in the last few years done dissemination in 75 teams at ohsu. so the model is simple. gloria would be referred by her primary care provider to the care manager, actually usually the care manager comes to the room and joins the visit. and then they work out together what gloria and her family need to stay healthy. and so the care managers receive specific training to do assessment and cocreate a plan, and then they have technology to really back up that plan and make sure it happens reliablely. and so the clinics were very similar to clinics. intermountain is a large integrated delivery network but they had multiple payers. most of their pay did not come from special pay for performance. a small portion. so the care coordinators did this because the primary care

providers in the system thought it was a good idea for satisfaction overall. the care managers saw about 350 active patients on average in the pilot. and the health i.t. really helped them to do care coordination tracking, to never lose track of a population or a patient who's at risk, a person who's at risk. and had a centralized reminder system that had protocols that also had kind of the ongoing task around social and other needs that these patients so often face. so scheduling and access was improved as well as a connection to the community through the i. t. and the evaluations were regular in the program. the health plans initially was done by the medical group, but since then we've worked with several health plans and different payment models which i'll discuss at the end. and we've been working with federally qualified health centerrers in our dissemination as well as medicaid. so what are the results? i hit them at the beginning. i will discuss them.

we reduced hospital admissions 20 to 40% and we improved guide line compliance about the same. we reduced mortality. so the patients in these intervention clinics were living longer. people with multiple chronic conditions are at high risk of an exacerbation of their illness that could lead to death. all of this led to significant savings which led intermountain to double the size of the program in the medical group and per patient what we saw about 640 to $1,650 per patient per year savings. we also saw the clinics were more efficient and people were much happier. the patients and their families called this a life saver. they really felt like they couldn't live without it. and the fizz eggses really felt they could work smarter and the pressure on their primary care was -- the hamster treadmill that many primary care physicians phil they're on with 20 to 30 visits a day was lessened. the care managers even told us that computer tools were an

absolute god send which is obviously near to my heart. [laughter] >> so we really felt like that was successful. and what we've done since nen is rolled this out starting at ohsu at more than 75 clinics across the country. and a lot of what i'm going to say for the summary is really going to be focused on what those clinics told us. so next slide. first of all we found that care manager role was essential. most of our dissemination clinics had a thursday but didn't have a care manager. we found nurses and social workers were great at this, although some small clinics needed a combination team that did the care management together. training was essential. it was a new role for many of our care managers and care coordinators. we really had these competencies to be worked on. health information technology was essential. every one of our initial practices and most of our dissemination had electronic health record systems but they

needed more. and so we helped them to enhance what they had, to use it better, but also to use additional functions around population management and care planning. we found that our technical assistance was really helpful to them and was critical for them to be successful but they could do it. and we found that most of them came back to us very excited about it but since they were paying for this mostly themselves really were talking to -- they needed changes in the payment that they got. we call this pay for pro-active care for care coordination, for goal setting and motivational interviewing for behavioral change and education. many of them also find that per member per month is helpful, although selecting populations is really helpful to see some cost savings and the clinics really needed to be able to refer whoever they could -- that they saw the need for, into the program to make it work, to make

that efficiency work. so that's really what i had to say. thank you again for having me. >> thank you. sue, take us to colorado. >> thank you. it's my pleasure to talk about the medicaid medical homes for children pilot that we initiated a couple of years ago. and i'd like to share somerief background to put it into context. when governor bill ritter came into office in 2007, healthcare was a top priority of his administration. and there was really a deliberate decision to focus on children's coverage and health access issues. and while we have a couple of excellent managed care plans that participate in the medicaid program, the vast majority of our medicaid clients' children are seen in a fee for service model. and for us, that raised some serious concerns or questions about the sustainability and

increased costs associated with that fee for service model. it also raised some questions about the extent to which children were receiving preventative care, getting their immunizations, -- having care coordination. it raised serious questions about access. at that time, only 20% of our private pediatricians and family practice physicians participated in the medicaid program. and of course, you know, at the top of the list for not participating is the lack of reimbursement. but when you really dig down a little deeper, there are a variety of barriers that primary care physicians list as barriers to taking medicaid and s-chip kids. for example, there is a very high incidence of missed appointments. and we know why there are missed appointments. because this population

sometimes have challenges accessing transportation to get to medical appointments. we know that there are social supports that are needed to support these families that there are a lot of things that need to happen in that family's life other than just accessing healthcare. there are housing issues and economic job-related issues. and so we had all of these concerns. and also in 2007 legislation was passed. medical home for children's legislation that mandated the department implement systems and standards for medical homes for children so that -- to maximize the in many of children that had medical homes. and that was all supposed to be done in 12 months. so in government, that's a very short period of time to implement something. and so we had to work quickly

and we had to work smart. and our approach was really to leverage the existing programs, resources that were already in place to create our pilot program. fortunately for us, we were well-positioned to do this. our sister agency, the department of public health and environment, their title v program had been involved with dr. carl coolly's learning labs and learning about medical homes. and out of that work, two passionate pediatricians, dr. steve pool and dr. james todd, created a nonprofit association called the colorado children's health access plan which was really designed to recruit more private primary care physicians to accept medicaid and chip and then to provide support services for

those practices. and we also have a very robust e.p.s. opinion p.t. outreach in case management program. we have outreach workers situated throughout the state that have been helping families value and use healthcare and they really serve as that -- in that health educator role. so we liken this to creating a reese's peanut butter cup. we've researched all the best aspects of what we were doing in the public sector and join them with what the good work that was being done in the private sector and created our medical home pilot. our pilot design, we had 28 c-chap practices that included about 11,000 medicaid children. c-chap, the nonprofit association, provided 14 support services to the families and practices.

and then the department, we reimbursed a fee to the c-chap practices and we aligned the payments to preventative care. so we tried to innocent advise behavior. -- incentivize behavior. we gave $10 per preventative care visit birth to four years old and from five years to 19 years, $40 per preventative care visit. and we used existing codes to provide that enhanced reimbursement. now, that doesn't sound like a lot of money, but it was enough money to get us going and in the right direction. here you can see our e.p.s.-p.t. outreach. they are really serving as the care coordinator role. they are sort of again approaching it from the holistic

viewpoint of the client looking at the life cycle of the client, everything that has to happen in order for a family to access healthcare services. they work in the community, identify resources and link those families to those community resources. because this pilot is focused on children, colorado has a very unique sort of philosophy. we are very much family-centered. i know there's a lot of talk about patient-centered. but when you're working with children, you really have to look at the whole family. and so we have a very -- we have a family-centered medical home model. and then our c-chap physicians serve in the primary role of providing care and helping do the care coordination. the c-chap continues to provide the support services,

interpretation services, linkages to mental health services, again looking at the whole child. so what are the results of our pilot? as mentioned earlier, 74% of our medicaid children in this pilot had a well child visit during the 12-month observation period compared to 56%. we saw reduced costs of care per child, improved health outcomes, increased immunization rates. in 2006, colorado was ranked 49th in the rate of childhood immunizations for our medicaid kids. we have raised that. we're 26th now in just a very short period of time. and we believe our medical home pilot and our work in this area has been a big contributing factor. preventative care visits

increased as previously mentioned. emergency care visits and hospitalization rates have also decreased. now, it says there on the slide that we are collecting baseline data too. but miraculously over the weekend i was able to obtain some data on the physician and client experience. c-chap surveys the providers participate 0% satisfaction rate. -- 90% satisfaction rate. i think it's significant. my favorite story about a private practice is that dr. pool went to a high-end pediatric private practice, never took medicaid or s-chip kids. he led one of the fizz eggs to the window and said, "look out that window. did you know that 33% of the children that live in this neighborhood are eligible for

medicaid and s-chip and you don't see a single one of those kids "? that exchange, that dialogue, that communication was a turning point. i don't know if it was guilt. sometimes guilt works very well. but that pediatric practice started taking medicaid patients. and again, i think physicians say they're willing to see our kids. they just need some help with some of the barriers. and working with vulnerable populations. the family experience, one parent quoted the medical home is building relationships. 96% of our families feel their child's provider creates a medical home for their child, 100% feel the provider values the child, and the child's family, and 100% feel the provider meets the needs -- family's cultural differences. >> sue, why don't we move to

significant that and you can chime in the conversation? >> did i go over? i tried so hard? >> your enthusiasm is -- -- you have a couple good thoughts for how to scale it. maybe we'll bring this into the conversation. i want to make sure everybody gets team and we have the discussion. so barbara and richard, if you could talk to us about what you're launching up at dartmouth. >> i'll go ahead and start. i'm dick salmon with signa healthcare and i'm joined by barbara walters. we're please today share with you the partnership that we have developed over the last several years that really resulted from a challenge our senior leadership gave to us 18 months ago to accelerate the improvement in both quality and affordability of the individuals that we served in common. at baseline, dartmouth hitchcock, as all of you know, has superb clinical reputation.

over 1,000 physicians who provide excellent care in both urban, rural, and academic settings. and parallel to that we have cigna healthcare who over recent years has developed robust health advocatesy services, both teletonnic and internet based case management, disease management and wellness services as well as pretty significant health infomat ex services to guide the improvement in care. we had two problems. first of all, these clinical efforts were not ideally connected. so two systems running in parallel and we weren't getting the synergy we wanted ou out of connecting those two systems. the second was that our primary interaction to exaggerate the point was a periodic no, over fee schedules every couple of years and it was not an interaction where we sat down together and said, how do we improve fundamental value?

how do we improve both quality and affordability, and how does the plan reward dartmouth for doing that? so we developed a new program together that has the key concepts outlined there. and i want to emphasize just a few of them. one is we said that program had to operate in the open fee for service environment. that is this has to be a program that didn't require people to work through their primary care physician, but rather provided incentives to members to work with their primary care physicians because the physicians offered enhanced access and enhanced care coordination. so it was improving the care coordination delivered by primary care physicians, not by forcing people to work with their primary care physicians but by provide such excellent service that that's what people wanted to do. the second is the rewards for the program had to be based on an improvement of both quality and affordability.

it wasn't just about quality and it certainly wasn't just about affordability. both had time prove in order to provide rewards. and we need to administer those rewards through a different payment mechanism. instead of just increasing the fee for service payment, pay the rewards to a periodic care management payment. the third was we wand to obtain synergy. so leverage the strength of dartmouth's direct face-to-face clinical programs with cigna's teletonnic and internet-based programs and with our advanced analytic and health information services to identify patients who are at risk and identify gaps in care or care improvement opportunities. so with those three fundamental concepts we began designing our program in january of '08. we implemented it about a year ago. and we'll have our first level of results later on this fall in about november.

at this point what i'd like to do is to turn it over to barbara who will tell you about the real important aspects of the program, and that is how it affects individual patients. >> thanks, dick. as i mentioned earlier, dartmouth hitchcock participated in the medicare physician group practice demonstration project, and we were able to show increased quality compared to benchmark and national targets as well as savings through the our three years of participation in the program. and we were absolutely delighted and looking for a commercial partner to see if the same thing that is we had designed that are listed up there under practice resources would be applicable to a commercial population. because it really is a different patient population. so i'm just going to tell you a very brief story about one of our patients that i hope illustrates that we believe that we're on the right track here. so i want to talk about mary. mary is your next door neighbor. my next door neighbor, could be my sister, could be any one of our sisters.

she is married. she's been married for about 30 years. her husband works. he's fully employed. he's insured by cigna. he is a tradesman. they have a company of kids, a couple of grandkids. mary loves to cook and she really likes to scratch book. her husband is a hunter and a fisherman, live in a small town in new hampshire. mary has insulin dependent diabetes and she's a cancer sur. she was referred to one of our care managers by one of her primary care docks who she sees most often because he just thought she was depressed and she wasn't getting better. no matter what he did, he really couldn't make her mood improve. and our care manager was asked to do what care managers do, get to know her and make a referral to a local mental health provider. at the time that our care coordinator contacted mary, and i think dr. kocher earlier said

you can call and get answered by the first time. we actually call our patients before they call us which i think is really good sometimes. and we do a screening tool for all of our patients in primary care. the personal health questionnaire nine which is a score for depression. her score was 22 which is very, very severely depressed and perhaps suicidal. our care coordinator was able to at least connect with mary and began speaking with her on the phone every week. they set small goals. sometimes they met the goals, sometimes they didn't meet the goals. she learned that mary grew up in an orphanage. and through the most of mary's life she was scared, she was shy, she felt invisible. she was frightened to get involved with people. and she was the actually barrier to going to a mental health visit, not her husband as she had previously reported. and in fact, she started telling us that her husband was so worried about her he began taking time off work to stay around the house with her so

that she wouldn't do anything to harm herself. so we're also losing employed time from the employer's perspective here. she said that when her husband was in the house the thing that kept her going was thinking about her grandkids. one of the things that our care managers do all the time, and i'm sure they do it all the places we're talking about is medication reconciliation. so she would take the medication list that she thought may was on and the medications that mary thought she was on and tried to make sure they agreed on the same medication lists. the and it just wasn't working. we've got this really spiff if i medical electronic records you can print out a patient's medication list. the we mailed it off to mary because they weren't getting the words right. called again. and lo and behold, mary admitted that she really couldn't read very well. so she really didn't know what our spiff if i patient friendly medical reconciliation list said. so our care manager scheduled a visit, brought her in.

her husband came in as well. and god bless this woman. she sat down and color-coded and drew pictures on every single bottle of medication and on our spiff if i medication list that patient couldn't read. she put a frowny face for the antidepressant medication. she put a heart for her medication for her hypertension. and she did something with food for her cholesterol medication. and at the same time, we were interacting with cigna and cigna shared with us that mary hadn't in fact filled her antidepressant medication in over a year. it's really hard to get better from a medication if get it filled. we involved the community, her church, the visiting nurse es association. mary is taking all of her medication. her husband hasn't missed a day at work in over i think about six months the last time that we looked. her score, her depression score is down to 9 so she's in contr

control. so i think that's the core of what we're trying to do. we're trying to work with people living real lives doing real things, fully employed, getting information from cigna that they have that we don't have, getting information from our care manager. we have a doc who knew something wasn't right, we had a care manager who wouldn't give up and we had some information from cigna that really put this all together. and that what we think we're trying to do in this clinical collaboration. and i'm going to get my slides and close on. that i hope that we can spread. this and we do it in urban communities. we do it in all communities. we do it in large communities. and we think that this is what advanced primary care practice is all about. the docs love it. it takes off the burden of the paperwork. they get a patient who's ready to talk to them. the nurses love it. they're being able to practice nursing the way they want to practice nursing and what they went to nursing school for. and patients are like, oh, my

gosh, you called me. i didn't even have to call you. so i think that's what we're hoping for. thank you. >> bob, we had a slide that showed the payment ail ga rhythm. that was before this one. but i guess it actually got left out. so i can just speak to one -- >> the mary story was one that i'm glad that you shared. how does it work? >> ok. so again to make all of that work we have to align the incentives. and so what we do together with dartmouth is agree is that we will track both -- we will require both improvement in quality and improvement in affordability, and affordability is measured by total medical cost and the trend in total medical costs compared to the market average so they're measured against their peers. the improvement in affordability essentially funds the bonus pool. and then how much of the bonus pool dartmouth gets depends on

how much they not only improve affordability but also improve quality. and that payment is made through a periodic care management payment onto the go. code system rather than as a modification for the fee service. so we feel by getting the reward system lined up, synergy in the infomat ex, synergy in the working together between dartmouth and cigna that we're able to drive a much better outcome. >> thank you. we're hearing wonderful patient stories. thank you for sharing mary. michael? >> i'm dr. michael soman, president of group health physicians. like all of you we seek better care at lower costs. and we found that one year a 29% reductions in emergency room and urgent care visits in our pilot paid for itself. our practice has 900 physicians, 250 primary care practices and cares for about 400,000 patients

in the state of washington. we have made a strategic long-term commitment to effective primary care to apply to all of our clinics. first we ran a two-year pilot. and we learned from that pilot many things that helped us identify the elements to apply everywhere we were now about actually two-thirds of the way through using leanrocesses. in short we learned that upfront investments in primary care lead to better quality, better patient and staff satisfaction and stabilized the medical costs trend. so what this really is about if i can have the next slide is putting the patient-physician relationship at the core of all we do. and then supporting that relationship with high-quality information, strong teams, and great access. this allows the teams to address each patient's acute chronic and prevention needs. that's it in a nutshell. so what did we do? first we invest in our primary care teams. we added 30% of staffing.

physicians, nurses, mid levels, pharmacists. then we decreased the number of patients that each physician is responsible for, from 2300 to 1800. increased the visit time on a template from 20 minutes to 30 minutes. and then we hit on real goals. we finally figured out how to really leverage our electronic medical record or e.m. r. and i have a key point about this. that it's not really about the convenience that these records allow for both patients and clip eggses, though that convenience is huge and can't be overstated. the real power in these systems comes because they allow us to know or patients so that we can pro actively address their care needs. that's what makes them really work. and we can address these care needs through a variety of processes from focused, outreached complex patients to simply knowing every patient's

prevention needs at every visit and delivering on them. this of course increases our quality scores which is nice. but more importantly it allows us to know what to do for each patient at every visit. we can also address populations of patients. example: 2007 we put in a new process to care for our 7,000 patients on blood thinners. we shortly decreased clots and bleeds 26%, saving over $3 million while giving better care. last point about e.m.r.'s, clinicses through the our system are adding to the evolving story about each patient. this kind of collaboration deepens our understanding and makes it pretty easy, actually, to give up-to-date, seamless evidence-based care. about access, we changed the paradigm. we said patients, you're in charge. you tell us what access works

for you. group visit, traditional face-to-face visit, e-mail, security message, phone visit. what works? you're in charge. we found that we could often resolve their concerns with a phone message or secure message, saving them time, cost and convenience. patients also can access their records, e-mail their doctor, order medications and make appointments online. this engages them in their health, strengthens the bond between them and their doctor, and ultimately puts them right where they belong at the center of their care experience. the results of one year, if i can have the next slide, are gratifying, at two years they're even better. i need to point out the error. the first line under cost productivity says we added 29%. that's wrong. we addedded system for all of it, which was about 8% in primary care. so at one year as i said we saw 29%, that's where the number

came from, reductions in e.r. visits and urgent care visits. we also found 11% reductions in am blah story care sensitive hospital admissions, the kind that do well with good am blah story care. the reductions in utilization actually paid for the pilot for one year. we didn't expect. that i had a briefing last week about the two-year results and it's even more come pelling. i can tell you this much. it saves money, lots of money. also improve health outcomes like cholesterol management and people with core on air artery disease or diabetes. it enhanced work satisfaction, decreased burnout, increased patient satisfaction. we now have 12 applicants for every physician we post in primary care. think about that given the primary care shortage nationally and in our state. so based on this findings we're rolling it out to all 26 medical centerrers, about two-thirds of the way there. we identified the key ingredients for our system. we think these elements can be translated to different practices with different payment

mechanisms and lesser levels of integration, and m'scaps need to be supported by reform. example, we need innovative payment mechanisms that allow quality, integrated electronic medical records, more development of medical homes, collaboration between providers. that allows teams to for the whole patient across the continue up of care. that's how you get the benefits. most important of yours is the experience of patients so i want to close with the words of a delightful 80-year-old woman. not only today but continually, no matter when we come, we are treated promptly, courteously, cheerfully and efficiently. in recent visits we are aware of an extended time with the doctor, no longer a sense of rush. to everyone from the front door to the end of our visit, thank you. keep up the great work. thank you. >> thank you. great story.

craig. talk to us about sure. first off i want to thank nancy-ann, and bob, thank you both for being able to be here for the benefit of the state of vermont. one thing that drew me to vermont two years ago was the environment there and the commitment, the willingness of the leadership in the state, the governor and the legislature, to really take on healthcare reform and do it in as comprehensive a way as you could imagine. and it's really visionary leadership. and i think that's where this starts, when you have in our case a bipartisan willingness to come together and to work on complete healthcare reform the. and that's what's led to us where we are as a state right now with our healthcare reform models. and i would just summarize it by saying what the state really wants to do is build this coordinated, well-integrated, high-quality system of health. and where we started from, we're starting from a typical tapestry like the rest of america with independent practices, some big, some small, some affiliated with

hospitals, some federally qualified health centers, poor areas, more dense and urban areas. we're starting with the same tapestry. how do you turn it into a coordinated system of health? so if we start off with the first slide, it's a summary of the timeline. and we're in the midst of our first pilot. and really working on testing this out across this mow sayic, this -- mosaic of healthcare environment. we're working on three different communities. we hope to have about 60,000 patients enrolled in the pilots testing this new approach to healthcare. you can see the timeline on the bottom of the slide. we started planning this in 2007. that meant negotiating the financial reform, designing a payment model that could really support high-quality care, it meant designing the health information technologies that would be so critical for this. it meant putting in place the community health teams. and so we spent about a year getting the design, the strategies up.

and then in july of last year we started with the first pilot community october 2nd. and we're now getting ready to gear up the third pilot community. just as a brief summary of this, the uptake has been tremendous as we've heard from the other participants with the docs, with the patients, with the families, and even with some surprising the hospital c.e.o.s, the uptake of this and the engagement of this, the acceptance of this has been fairly rapid and so much so that actually this year, starting this summer, working on statewide readiness for expansion of the model. much faster than we would have anticipated. so if i go to the next slide i can just give you a key breakdown of what the components of the healthcare model is. it really does foe into being able to operate with just high-quality delivery. and so it starts with the payment reform. and the payment reform that

we've negotiated is with all of our insurers involved. i want to stress that. it's really critical to have all the insurers involved in this. so our major commercial ensures and medicaid, they're all paying the same way. and what happens is the practices get scored based on national standards. our mcqa standards. this drives based on the quality of care, how thorough the care is, the great access, the practices get enhanced payment. it's on top of their normal fee for service. what are we doing here? we're beginning to balance out the pressures, the incentives for volume against incentives for quality. beginning to balance out that scale where it was all volume before. but that part of the payment isn't all it's limited to. it also includes our insurers sharing the costers for what we call community health teams. and these teams are a critical component. so the teams are made up of a whole mix of profession also. they include nurse coordinators, social workers, mental health counselors, dieticians. the people you really need to make thorough, high-quality

healthcare work. now, the idea of having all our insurers involved and the idea of having a health team not limited to a practice is, how do you scale this? how do you work in a world where you have a small, independent, single practitioner versus large group practices? where you have some practices that are spread out in rural areas, others that are in more dense urban areas? how do you build a model that can work across this whole setting? so that's the idea of the community health teams and of having the insurers share the costs that these teams can be expanded, scaled, include the number of people, the right mix of people that they need to serve a collection of primary care practices, not just one. and then the primary care practices are paid for delivering thorough care. and what we've seen emerge out of this is an incredible approach to well-coordinated care. because we start with a team of five people in the community health team. but that's the new people that are put in place. what happens is they do such an effective job of linking to

social services and other services in the community, the functional team is much bigger than the five. and we're seeing it translate into tremendous case examples. and i was listening just thinking of one i asked one of our docs for case examples today. and one classic example, very similar to what you described, is a 62-year-old woman living in a poorer area in vermont, lower socioeconomic area. came in to see her primary care doctor maybe once every two years. she's got diabetes. came in last spring. turned out she had an elevated depression score, never really engaged in her treatment plan or getting control of her disease. turned out that she was more worried about the rest of the people in her house, being able to get to their healthcare. the doc was able to attach her to the community health team, the nurse coordinator, the mental health counselor. they began to work with her, connected her to social services that got her transportation to the practices. in july, just a few months later, she now has really solid

control of her diabetes, she's had tremendous improvement in the mental health issues. and this is a classic example of a patient that was going to be ripe for the worst possible health outcomes of chronic disease with depression. she was going to be sick, she was going to have terrible outcomes. she was going to cost the health system a large amount of money in terms of hospitalizations. and within a few months the teamworking with the primary care doctor was able to turn that around. and those type of experiences have really led to rapid uptake in adoption of the model in the state and the desire to expand this statewide. the health i.t. is part of this. the information technology is a core part of this. but it should live quietly behind the scenes, helping deliver, helping drive great care. it shouldn't be the focus of it. it should be the architecture that supports it. so we have electronic medical records where they have been connected through the registries with the health information

exchange so information can pass back and forth and the core information is where it needs to be for the community health team members and for the practices and the people working within the practices. . >> on the slide, our hospital

ceos had unanimously agreed to work with us -- we are statewide recognized and we're beginning to ordinary -- coordination for primary care practices. should we be able to expand as, they will be able to do that quickly. moving on to the next slide, thinking about evaluation, we have a core set of measures to evaluate this. looking at the quality of health care -- you improve the quality and you have a new payment reform, information technology, if you have this new environment this changes the way the quality of care is delivered. if it does, patients get more screening test and assessments that they need. they get more of the assessments and they stay engaged and come back on a regular basis, all the rest is

changing the health of this population. they shift to more preventive care. if all that happens, what happens financially on health care costs? and to that extent, we have put in place of robust set of databases and we will look carefully at all these layers. the last thing about one mentioned, what we really need for this to work -- we need have more complete present occasion of all our insurers. we need to work closely -- we need them working closely with this to expand this throughout the state. thank you for this opportunity. >> thank you for the opportunity to be here today. and in the greatest system in teaching hospitals and insurance

companies -- we are not mutually exclusive. other ensure networks use other community providers. in 2006, which included that we needed to develop a new care model to develop models for our medicare patients. our objectives were to improve the quality, care, and experience of the patients. we also believe that that health care financing was a zero sum game. we had to do this without increasing the total cost of care. the navigator model was the result of this. we introduced it to one pilot practice in 2006 and rapidly expanded it to 35 hospitals. the model was built as a partnership between our primary

care physicians an hour in currency -- and our insurance companies. the strategy was to provide 24/27, 360 degree care and guidance for our patients. at the center of our redesign effort, we've delivered a system to deliver high care system -- high-quality care whenever and wherever it was needed. it included a case manager in the office and in the specialist office, in a nursing home or hospital. next slide, please. a similar system was a foundation of this effort. we expanded access, and nurses provided many routine services, from our electronic health registry.

the nurses were reminded to order to -- order the -- the nurse is reminded her to order the proper tests. when she is not home, see can be monitored. we moved our population management plans to the pc peake -- pcp offices. manages used our predicted modeling tools. it helped them develop an end of the july care plan. when she finds her condition worsening, she can call her case manager using a dedicated phone line to get immediate advice. when she is hospitalized, she can arrange to be seen in seven days.

it would improve the services provided outside the primary- care practice. but all is to identify ancillary providers to help with this valuable mission. it would also optimized systems. under our program, each practice would have quality and dissidents targeted on improving joint quality metrics. the teams meet monthly to review their progress on these goals as well as goals related to that member experience and cost of care. during these meetings, they also discuss individual cases, trying to identify opportunities to improve care. the value reimbursement program at a news stipends for decisions in practice as well as a shared savings incentive model to our pre-existing performance

programs. all payments are best -- based on quality targets. we believe that the improvements and the total cost of care woud cover it. we found that care coordination demonstrated positive results quickly. within three months, and reduced admissions within six months. the next slide, please. this is also been positive for our first 11,000 members. these results were measured across the entire population. there is no regression to the meaning. we believe that these results can be projected over our entire medicare population. one health status, we scored significant improvement in our metric for measuring compliance with outcomes for diabetes.

coronary artery disease, as well as a preventative care services. readmission is decreased 25%. total emissions decrease 15%. total cost of medical care was 70% debt and our medicare population. the next light. in conclusion, we learned that it is possible to deliver more value for our members. this model is strong. there was a two to one return on investment. we're currently in the process of designing and implementing a multi payer program in northeast pennsylvania. care management is essential. they had been resources for managing individual patients and providing a focus for our efforts. the partnership approach was important because a group from

the really big -- a group from the realization that no one could do this alone. he needed to be a partnership. both sides have strengths and ordered a successful. electronic health records were helpful but not essential. the most essential aspect of the model is to establish a context that drives the practice and caucuses on delivering high value in comes to individual patients and their populations. realign the proper -- but we're delivering these outcomes. we found that get doctors are reason to deliver an pursuit value for their patience and we support their practices for operational and harassment, and the care team would deliver in the short term. thank you very much for the opportunity. i look forward to the discussion.

>> this has been fascinating. i should have said at the beginning that what is great that is all of these@@@@@ "d"rr done so it's not like we're just talking, you know, in academic circles here. this is already happening and congress has taken note and trying to move it forward. do you have a way --

>> well -- >> i don't have a lot of time. >> i'll dive right in, i think one of the things that would be interesting for us to hear from you is with these great examples and models that we have, how do we take that to a larger scale, like to a national scale. what are the things that we need to consider and the ways in which we can go about doing it? >> i can dive in just for collaboration. we have at least 102 pilots that are rolling out across the country. you've heard from seven. and what we've seen is really anywhere from 17% per member per month savings. it's quite phenomenal. but i would stress from the standpoint of the 600 members of the healthcare collaborative that we firmly agree on a set of principles that we give to you as a gift. we've got all of organized

primary care that's signed onto the principles. and it's more than just chronic care management. it's more than just care coordination. it's comprehensive primary care for all of our patients. that's got to be foundational for all of us on this. there's no other civilized nation on the face of the earth that's delivered healthcare value without that kind of fundamental foundational understanding of healthcare. my members are my patients one. they want access. they want convenience. they want to be able to use tools like emails to communicate with their doctors and the doctors to be paid for that. that's fundamental and foundational. so the current bills that you talk about that are on the hill, they're great and we support them but they focus narrowly on the stuff like end of life and chronic disease and when you do that the system is designed for

everybody. it's great, comprehensive primary care for everybody is foundational for each. thank you. >> well, let's try to catch around it counter-clockwise. >> just a couple of points pointed together some themes from the discussions. what can we do to really move this forward? first of all, the health i.t., i think there's an opportunity with our measures of meaningful use and other efforts underway to really send a signal to the h.r. industry that there are some standardized ways that these systems need to support the practices because right now too many practices have to figure out on their own to make the systems work for them to provide a medical home so there's an opportunity to make that easier for those going forward. secondly, the idea of the regional centers which is really kevin's thing, but we've heard a

lot from relatively big systems around the table, and some systems -- [inaudible] >> and they really need what we call -- come to call extension centers to support them. and then finally interactive. again, you can achieve a lot of coordination of care within an integrated system but it's really hard to achieve right now without the kind of interoperability where different systems can talk to each other. >> ken? >> i first want to thank the presenters for providing the data. it's important for people to understand there's a lot more information out there other than the medicaid demonstrations. if you haven't published the data i would encourage you to get it out and published because this is a real important body of work. on scaling and replicating -- you know, i focus on the functions and i heard some real common themes across-the-board here in terms of what are the key functions that really seem to be effective in driving these

results? one was integration with the care coordination. we learned that from the medicare demonstrations. we also learned it from work in north carolina, vermont, and some of the other models as well. that's essential. second is building a transitional care component. this is critical in the medicaid program. we've got 20% of patients readmitted within 30 days. we can reduce the results by 30 to 50% if you have a program that's put in there that's targeting those. targeting the right patients and measuring progress on it also important. i think we learned that on how not to do that in the medicaid demonstrations and we've seen the demonstrations and we've seen how to do it in these programs. the fourth piece that would be population-based primary prevention. disease aversion. we talk a lot about prevention in terms of detecting disease. that's important. but averting disease in the first place is as important and we have some proven results of how to do that and i think that's in a population-based way got to be a core part of what we do here.

the role of data in measurement in evaluation about how well we're doing and providing that information organically to the systems i think is critical as well and the final point i'd make is payment reforms. i guess i'm thinking more specifically for fee for service medicaid and making sure you align financial incentives and payment incentives with some of these structural changes i think is an important part. i would target those functionalities because if you target the functions, we can scale this. we've seen this in vermont and in north carolina. i think it's the direction to go. the current congressional bills are on the right path. i guess the issue is can we improve on those? can we keep pushing? i hope so. i guess i'd make the final point is that certainly what they put in those bills is better than what we're doing now so we're going in the right direction. and i think there's a lot of lessons learned here about how to improve what we're doing in this current discussion. >> bob and then dan.

>> well, i really appreciate ken going before me 'cause he saved half my talk. >> okay. well, keep doing that. >> it allows me to say something else. what ken is pointing out is very important. all these groups have very common functionalities, very common vision and goals. and have gotten there with some variation that i think actually they could learn from each other. that's fantastic. that says that you have a model that's scalable. a model that's implementable. where i wanted to talk to is -- the agency for healthcare research and quality has asked us to do an evaluation of a primary care stand-alone network in texas that took 15 years to get there and that really is the variation and scalibility. that without payment reform, without facilitation, without leadership and vision and getting there, without getting all the payors involved this goes from a two-year process to a 15-year process. so it really takes some organization and some work to help practices get there,

particularly, as craig was saying in areas where you have one or two or three-person practices as phyllis was saying you need to facilitate those people getting there and help get the payment reform, the community care teams, the public health integration set up for them and get them involved in the process. that will take you from a two-year to a fifteen-year process or fifteen on two-year depending on how you set it up. >> thank you. >> i have five really quick thoughts. one is education, communication, what this is and what it's not. and i think that the american public would just be really excited to hear what this is versus what it's not. so i think, one, communication, these types of sessions and taking us out on a broader platform would be certainly helpful. common theme leadership, bring all the governors together. share these stories. and you hear a common theme about leadership. we get a chance to spend a lot of time with the state leaders

and the governors are looking for ideas like this that can start to get a cost and quality and i think they would be very receptive to you sponsoring something to bring in these kinds of ideas. third area, incentives. we need to bring the health plans in this conversation. it's great to have cigna part of this conversation, the health plans can play a very important role in creating the right kind of incentives systems independent of the change that's going. if they want to come bring them into the conversation. i think it's a very healthy one. primary care education, we need to have a resurgence of primary care physicians. we need to look at the team care models. you heard about care management. start calling that out. start encouraging people to build build new medical schools that have primary care as a foundation, new care management. i think that would be very helpful, again, your voice heard there would go a long way. last but not least, encourage the level of incubation. figure out a way to fund these projects whether it's type of

rapid learning networks within primary care. any monies that you have to continue to drive this, we can shorten that time of fifteen years to two years based on the experience. those are the five things, communication, leadership, incentives, primary care education, and then continue to find a way to fund these kinds of projects that are making a difference. >> i'll be hard about comments, maybe just john and chris. okay. all right. two more. >> well, again, congratulations and i think it's remarkable how the functions around primary care have been satisfied in each of these projects. the first contact, continuing comprehensive care and the fact that everybody has held onto the key elements of the wagner chronic care model updated as ken mentioned and the information management systems,

those are all key elements that everybody has. where i think we need to think about now more is think about this more from a patient's point of view. it's one thing to have a patient experienced through an integrated health system. it's another thing to have a series of silos in a community where the patient has to go from the practice to the hospital to wherever now. from the point of view of state-based initiatives such as allen and craig mentioned and susan compared to the integrated health systems, how we can turn this around and think from a patient's point of view through the healthcare system that they will expect and get the same quality of care and cost reduction across a community of care as opposed to each individual silo of care. >> okay, thanks so much. i just wanted to say very briefly, i think one of our goals is better coordinated care. it's also that we not have the uninsured in this country. as you're looking at primary

care, i'd urge you to look at the system that they have in richmond, virginia, with the vcu system coordinated care for the uninsured that give all of them a medical home. give them a primary care network. and these are all people who do not have access to health insurance today. and i think you need to look -- i they're doing some of that in north carolina also. i think there's a couple of very good models out there for the uninsured out there. >> he's unusually quiet. >> i shocked you -- >> it's usually not the case. >> i must not be feeling well. i appreciate everybody sharing their experiences. look, folks, i think there's got to be a vision here and i think this is partly in your lap. we talked a little bit before, bob. this is about a vision for what healthcare in this country should look like and it's getting beyond that it's just coverage. absolutely, we need to cover everybody in this country. that's just the first start of a transformation of what healthcare should be. and we're not doing a good enough job.

for many people, even those who are insured it's good but it's not great and it's not the level of superb country that everybody should be getting in this country. you hear pockets of where that's happening, where any one of us would love to go to group health and say that's the care. we should be saying that's the care every american should be getting today. that they should be getting accessible, whole person, patient-centered care that is built on a solid foundation of primary care. and, you know, that is not the governing ethos of this healthcare system right now. it's about how much high tech can you pour into it? how much subspecialization can you get? how many new hospitals can you build? that's where every incentive to the medicaid system. and have a vision that's not buying us high quality patient-centered accountable sustainable healthcare. we need a new vision and that

the white house is willing to articulate a new vision that is really built around whole person patient-centered care and it's got to be centered around the primary care. and the emergency is the foundation is crumbling under our feet right now. we have half as many people going into family medicine as they were a decade ago. it's happening with physician assistants. you know, every model you've heard of is built on a foundation not just of physicians but a core primary care clinicians of other team members and if we don't reverse that trajectory right away, we will not have the capacity to achieve this vision. so i would like to hear that articulated. i think the public would get that. that this is why every american has a stake in healthcare reform because it's a better type of care they will be getting that works for them, and i think we really need to look across-the-board at what we're delegate do to rebuild that primary care foundation that undergirds this entire system. >> that summed it up well. >> a great conclusion. and i think you heard that vision here today, kevin in

manifesting of what's going on around the country. i guess i'm a glass half full person 'cause i was thrilled to see that there was as much dissemination of this model as there is. i didn't know group health was doing it as many places and other things are doing the same thing. a new -- one location, i didn't realize you were spending it out so much. i talked to governor douglas in vermont, who is a great sort of spokesperson for the cause and i think he does talk about the other governors as well. so i think that is what we're aspiring to hear and with the work of everybody in this room we can make it a reality. >> i'm half full too and i agree there are really good elements in the bills moving forward and i think we need to assure that they stay there and are strengthened. >> we do. thanks, everybody. >> thank you. >> thanks, everyone. >> thank you. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009]

>> president obama hosts town hall and health care and support new hampshire. that is live at 1:00 eastern. >> this fall, and to the home to america's highest court from the grand public places to those only accessible by the nine justicees, the supreme court, coming the first sunday in october on c-span.

>> now the discussion on how to increase health care access and a look at the current legislation before congress. you will hear remarks from the editor-in-chief of health affairs magazine and the president of texas a&m's health science center. this is almost an hour and a half. >> i want to welcome you to this program. my name is ed howard with the alliance for health reform, thanks for braving hot weather in washington to come to this program. you probably remember how old you were last time you were here. and you probably thought that was a great idea, to spend the august afternoon in the air-conditioned comfort of the columbus club. but that is not your going to get for your money. you are going to have one of the

best programs you will have a chance to be part of, on the extent to which efforts to reform the health-care system will affect the access to healthcare. our board of directors, you have a chance, the board of directors directly. i turned 65 a while back. and became eligible for medicare. i knew that getting that card, i was going to have to find a primary-care doctor because my previous one did not affect medicare. i got a fine primary care physician and appreciate your concern, but the point is having

insurance is very important big to getting access. the institute of medicine estimates that 18,000 americans die every year who want, if they had insurance. there are other factors beyond holding an insurance card that affect whether you actually get the care you need and we are here to talk about those factors. we know, for example, that there need to be enough primary care doctors and other providers if people are going to have adequate primary care access, and a lot of young professionals are not going into primary care in our mid schools and associated schools and we know relative to specialists primary-care providers have substantially lower incomes, and the way they are reimbursed, the way most physicians are reimbursed, that is to say, a fee for a service, offers no incentives for caring for patients in the most efficient,

high-quality, effective way. our partner and co-sponsor in this enterprise has strong interest in this topic, they self identified as working to help americans who beat healthier lives and get the care they need, so we are pleased to have their involvement in the formulation and execution of this forum. i want to thank david colby and their colleagues at the foundation for their interest and support. a couple of quick logistical items. there will be a web cast available tomorrow on kaiser family foundation's website, you will find copies of the materials in your kids and the biographical background in our speakers, i have the time to

take, to give you today. you will find all of that material on our web site, allhealth.org. if you are watching on c-span, everything the people have in front of them on paper is on our web site, health.org. even with the presentations, the power point presentations, if that is what you want. at the appropriate time, those of you who are in the room can fill out the green question cards that are in your packets and hold them up and ask the questions we can get to. there are microphones at the front and back of the room that you can use to ask your question yourself and at the end of the briefing i appreciate you filling out blue evaluation forms so we can improve these briefings for your usefulness. let me get to the program. we have a terrific group of panelists today, nationally

respected analysts, people working on the ground to improve access, we will give you a brief access and then turn to discussion including your questions and we will start with susan dentzer. susan dentzer, is the editor-in-chief of health affairs, the preeminent health policy journal in america. as well as an on-air analyst on health issues for the news hour with jim lehrer. they know her pretty well since she spent a decade leading reporting unit focusing on health care and health policy and social security. if you rely on health affairs as i do for health policy in sight you have a sense of the breadth and depth of susan dentzer's expertise. we asked her to bring us up-to-date on what is actually in the major reform plans being worked on capitol hill in the relevant areas. thank you for joining us, glad to have you with us. >> thank you very much.

belated happy birthday. it is great to be with you this morning. to me has fallen the rather dubious task of attempting to summarize what has been a health care legislation in 10 brief minutes. the house walked through this a couple weeks ago and took three hours, you are going to get the speed read of this. i just want to begin by saying to underscore the point that access is about more than having an insurance card and everything in these bills, in some way, shape or form, is about access, sometimes you hear people say this is an affordability issue, this is the cost issue. you need to think of these things as being very interrelated. it would be great if we could just have the luxury of dealing with one problem at a time but we don't. we know a lot about the strength of the health-care system involving the last 11 years or

so, and we know about the weaknesses and we're going to have to work in a lot of different arenas even on something that sounds as simple as access. that is really what these bills are about. let me quickly moved through my slides here. i am going to talk about the obama administration's reform and some emerging t-bills, now i am down to just nine. here i go. there is not an obama plan, notwithstanding what you read even in the washington post, there was a store that mention the phrase obama plan about ten times, there is not an obama plan, there is an obama framework in which the bill coming for from congress are being organized. you see even in the president's eight principles, he attempts to address all of these issues, reducing the a ministry of costs, reducing the rate of growth of health insurance premiums, aiming for universality of coverage, moving

toward a universal coverage systems so that more people have access, providing portability of coverage, you can have access to health insurance policy in one job and lose it in the next if your employer, your next employer doesn't offer it. affordability of coverage is an issue, providing a choice of health plans is an important feature of access for many individuals, investing in public health measures in order to keep coverage affordable over the long run, we're clearly going to have to have a healthier population. if you have health insurance that is too expensive because most of the population is obese, you're not going to have access to health coverage. underscoreing the point that all these things are interrelated. the primary goals of reform could probably be summarized in these three, ensuring access to good health coverage, we don't want to ensure access to data mediocre health coverage, for as much of the population as

possible. we do want to cover the uninsured but we also very important we want to ban the health-care cost curve because otherwise nobody is going to be able to afford the access even people who are currently in short. just to briefly recap, we know how people basically below the age get health insurance, most get it through the employment base system, some people buy it up from privately in the individual insurance market, some people get it through medicaid, some people are uninsured. how do we broaden coverage in all the bills? we actually are proposing to take all of the existing mechanisms and stretch them so you can think of various safety nets that help coverage. every single one of those would be stretched under the congressional proposal. we would shore up the employment system, we would create a new pathway for other people to get insurance that is not strictly speaking through the employer base system, we would expand the

safety net, particularly medicaid for low income people, and some combination of all of the above is to be proposed in the bill. as i mentioned, the cost piece is extremely important here. this is a chart we ran several years ago in health affairs, making the important point that over time, national health expenditures, the talk bold line, have been growing 2 percentage points faster than capital, real economic growth, real gdp. this has held pretty constant over time. there will be some differences this year because we have an extremely weak economy, but more or less, this formula has held to a surprising degree. why is that problem? in one sense that is great, the economy is booming, this is a piece that might turn off and some of his colleagues did a few years ago. they will update this in our

september issue about bending the cost curve. stay tuned for the new numbers. essentially what these economists did is look at what is happening in health spending, grew 1% faster than real gdp verses 2% faster than gdp. what would happen to the other resources we would generate over this time? there calculations of several years ago showed that if we manage to slam on the brakes and bring health spending down to 1% faster, we would devote 55% of the entire increase in u.s. national income from now for the next 75 years to healthcare. that is if we slam on the brakes which would mean we have 45% leftover for everything else, defense, is education, the national parks, everything else you want to do with your life that is not about health care, 45% of the real growth in the economy will be left over for that.

if we go 2 percentage points faster, 24% of real national increase goes to health care which is a way of saying everything we are now spending on health care goes into real gdp, all of the increase in real national income goes into it and we take away resources we are currently spending on other things. ask yourself how affordable health coverage will be in an economy where nobody's doing anything else but working in a health care system or buying health-care. as herbert stein once said, things that cannot go on forever will stop. we can be pretty confident that this will stop but it won't stop on its own. we need to figure out a way to put on the breaks. how do we deal with all of this? let's take a piece about covering the uninsured. most of the bills foresee a medicaid expansion primarily aimed at picking up those people

who do not now have coverage, who are in fact work, it is the dirty little secret that our program for the poor doesn't cover half of the poor. we are going to stretch that safety net. you see the proposals cluster around the notion of expanding eligibility to 150% of the federal poverty level. new pathways, we have to figure out a way to give more of the population avenues to get health insurance that more closely resemble what people get if they get employment based insurance. if you are in an employment base insurance plan you are in a big pool, your risks are spread across the entire pool so that sick people don't have to pay more than healthy people because all of the risks are spread across a large pool. we need cooling mechanisms to create that same avenue for people who don't have employment based insurance, and this is the secret behind the extern -- insurance exchanges or gateways. i want to hear more about how

mass. the that in place as well. those have different ways of getting to them but they all, in essence, allow the states to have exchanges or gateways or the national government to create a national exchange or gateway. different avenues to create these pools so that people have access. affordability credits would be granted people lower on the income scale to help them afford the coverage and a lot of debate is how far up the income scale you go for that. we have, emerging from the senate finance committee, the notion of supplying tax credits directly to small businesses to help them afford coverage. this is in order to help them sustain another aspect of the bill, which is mandate least on the house side, mandate on employers to provide coverage, stretching that employment base safety net. we have a number of insurance market reforms that have to take

place, otherwise people are going to be screened out of insurance, and the fact that you're buying coverage on the individual market you can be subject to condition restrictions which means if you have diabetes and insurer could happily fill your policy to cover everything but your diabetes. obviously that is a nonstarter. if you're going to try to get everybody insured and in the sense that you will have somebody actively involved in helping to manage their healthcare costs, this is just some more about the insurance market reform. big question is the role of the public plan. the public plan is also seen by those who are in favor of it as another way of insuring access for people. in the house bill, there is a national public plan, the senate health bill talks about community insurance plans, the senate finance committee finally seems to be coalescing around the notion of, ofs. it is being perceived as they're being the need for another avenue, not just access but also

to enact the delivery system reform that will -- we will say more about that in a moment. make sure people offer coverage and take it up. there has been a growing consensus that the whole system is not going to work unless everybody is in the pool. the costs have to be spread across everybody, the young and the elderly, the healthy and sick, etc.. that is how we will keep coverage more affordable overtime for everybody. we have a lot of problems in our u.s. health care delivery system, side by side with many strings. to a large degree health-care reform will be about delivery system reform. and 75% of our spending is tied up with chronic disease reform, a large part of the delivery system reform will be figuring out a way to deliver a chronic disease treatment and care much

more effectively. what do people have in mind for doing that? the house bill broad authority would be handed to the secretary of health and human services to launch a lot of tests, delivery system innovations like accountable care organizations, we will perhaps hear more about that in a few moments, medical homes, value based purchasing, different ways of paying providers, not to just pay on a piecework basis but to pay people to really nudge them towards providing a whole system of care that works to expand people's health. you have heard some discussion on steroids, another aspect of reinforcing new payment delivery systems. i will not spend much time on that because i am out of time and a couple of other key issues, on the work force, we will not have access to care unless there are the right people in the right place at the right time to care for people. a lot of emphasis in the bill on

more training of primary-care doctors, expanding the pipeline of people going into health professions, making better use of team focused care with others delivering primary care, nurses, physicians and so on. finally, the major work in progress remains finding the revenues and savings, putting that package together to pay for this. on the senate finance committee side, this is a work in progress. lots of savings being anticipated coming of medicare/medicaid. with that, we take our hats off to you the baron who said once a prediction is very hard, especially when it mulls the future. i will turn this to my other distinguished panelists to have a better crystal ball than i do about predicting where this will come out. [applause] >> thanks very much.

the robert johnson foundation has excellent web site called appropriately enough healthreform.org mary will find a lot of background material and the kinds -- kaiser family foundation have a side-by-side comparison they of the frequently on the major provisions in the bills as they are merging. recommend that you as well. we are going to turn to dr. nancy dickey, president of the texas a&m health and sciences center, vice chancellor of the texas a&m system, she is a family doctor by background, a former american medical association president, share a lack of the academic health centers association and the part i am most proud of, she is a member of the alliance for health reform board of directors. she is in a unique position to talk about how to meet america's need for primary-care practitioners, and how well the reform initiatives address that because she is doing that every day.

thanks for coming up. >> thank you, i am delighted to be here. as a member of the alliance board let me give you welcome from the board. i have a number of perspectives to look at the issue of primary care including that i established and ran a family medicine training program and was an interim dean in the medical school for a time. perhaps the one conclusion i can draw is this is one of the biggest challenges ahead of us. let's talk specifically about primary-care. currently there is widespread belief and a good bit of data that says we have been a it -- inadequate primary care providers, however it is you want to slice and dice, this is the list of the groups we look at as primary care providers. interestingly enough, you all look too young but if any of you were around for the 90s, we have lots of people who wanted to be primary care, i talked to friends is that i am a primary

care anesthesiologist or primary care dermatologist. perhaps susan will give primerica's and stature and have people fighting to get in instead of scrambling to get out. the generally accepted group is this group in front of me. unfortunately, some of the same things that happened to primary-care physicians, where larger numbers of our graduating medical students have chosen to go into specialty care rather than family medicine, general internal medicine or general pediatrics, has also begun to take a toll on a group we had thought would be if part of the solution. we discovered that they, just like physicians, find themselves drawn to metropolitan areas and specialty practices for many of the same reasons. they're the pay differential, there's often a work distribution differential, how hard they work, how long the hours are, so we will be talking about all of these groups as we talk about how to increase the

numbers of primary care. the other issue i couldn't fail to address with the profound nursing shortage, instead of being able to seen as practitioners as a big piece of the solution, we will find more call on their practitioners to the faculty members, to meet the needs in some specialties. as we look at recruiting into primary care, i would say that there are number of issues i am going to talk to you about and towards the end will talk about what is addressed in the bills that are in front of you. what this says is simply creating more positions, to train more primary care providers, is not the solution. as you can see from looking at this, there are unbilled -- unfilled positions in all of the primary care areas, 10% by family medicine, some of them only 5%, but the reality is there are plenty of positions if more graduates wanted to go into

primary care. the problem is they don't. we will talk about the reasons why. in fact, the story is even perhaps more challenging than what this slide would indicate to you because although there are still 6% of family medicine slots that don't have anybody training in them, there are substantial number of foreign medical graduates, international medical graduates, who come in to fill primary-care slots. so u.s. physicians occupy an even smaller portion than the percentages you see in front of you. so why don't people want to go into primary care? in order to decide what to put in the bill to attract people into primary care, the first issue, as you already heard reference by susan, is money. i grew up in a farm on a small town and those look like decent incomes to me, even the ones on a smaller end of the scale. but you have to keep in mind

that we don't let very many dumb people into medical school, so they say you want me to invest the same amount of time to become a radiologist or family doctor, but over the course of my career there are millions of dollars differential in terms of what i am going to have to retire on, or by retirement homes someplace, 7 com is a part of it. i have a young lady is spent time with me when i missing practice, thinking -- she wanted to be a family doctor and looked at me with great seriousness, if i do that, will i ever be able to buy a house or car? i think so. the difference is if i have a choice between $600,000 a year, and $200,000 a year, for the same amount of education, and actually probably less work hours down here than up here, an awful lot of people wisely say why wouldn't i want to go into

dermatology instead of family medicine? there are other reasons, not just about the money. when we get people into medical school, we often don't mentor them, we don't tell them family medicine or general internal medicine is a good place to go. in fact, many times, we still hear students say there too smart to be just a family physician. i was handing out scholarships the of the day and asking a young lady about who in her family was a physician, she said my dad is, he is just a family physician, i almost took the check back. that is the mentoring we provide. they want to be highly respected, they get that kind of encouragement into specialty care. they watch hospitals spend big dollars to recruit, the neurosurgeon or the interventional radiologist, they go to primary care settings and

find they don't have the investment and infrastructure to allow them to do information technology. it sends a subtle, nonverbal message. medical school recruitment, we have good data that this young men and women from small towns are more likely to go into primary care and more likely to go into rural primary care, and yet the numbers of people going into medical school, being accepted into medical school, continue to increasingly represents metropolitan areas. that is where they get access to education that gives them the high end gpas and so forth a. practice demands, hardware, long hours, additional challenges for rural and inner-city areas that are difficult as well. you wonder how any of us would choose to go into family medicine. there are things we can do. we can enhance medical school recruitment. there is not in any of the bills, we could talk about giving bonuses to schools that either have hire ethnic

variability or bringing students from rural areas and non urban areas. we can do better faculty mentoring though the numbers aren't adequate. there are still lots of good family doctors, general internists, if we could talk them into telling their story more often. the things that are in the bill, we talk more about our loan payback, many times when you are facing the end of this aeons of training, you want to be able to buy a house and pay back your loans as we were talking about earlier. if we give you loans paid back, that $200,000 a year for primary care may look more appealing than if you have to payback $150,000 in loans, by house and the you're going to be making a third of the income as your colleagues happen to be. we are going to talk about opportunities for training and we want to be sure there are opportunities for anybody who wants to train primary-care. as the second slide shows you, there are plenty of vacancies today despite the fact that we

have closed a number of training programs because they couldn't fill their slots with students that wanted to go into primary care. so the bill again creates lots of opportunities for additional training. the other thing of the bill does is talk about the medical home. restarted having conversations about this in the academy of family physicians, academy of pediatrics and general internal medicine. many of us thought that was we had been doing most of our lives, providing coordination of care, trying to help patients decide when they needed a specialist in which specialists they needed but the reality is we moved away from that in a lot of health care today so patients self refers to specialist, they may have half a dozen doctors treating them simultaneously, often with prescriptions that don't always fit well together. what this bill does, what these bills do is recognize the potential need to change the way we deliver primary care and they called it the medical home. patient center medical home

provides comprehensive care for children, youths and adults, that is the definition agreed to buy family medicine, they have been very involved in trying to be sure this definition is represented in the bill language. a couple interesting quote to suggests this isn't a new thought concept, william osler a hundred years ago said you treat the disease, you treat the disease the patient has rather than -- let me read it because i'm doing a bad job. the good physician treats the disease, the great physician treats the patient who has the disease, and primary care often is seen as the group that perhaps embraces that whole thing. giving us financial incentives to create medical homes, coordinate the care and hopefully entice our specialty colleagues to participate in that coordination rather than separate from that could move us in the right direction. we talk about why people go into primary care, there aren't

enough and you will hear from people in massachusetts who discovered that. let's talk about what the bill does in order to address some of these needs. loan repayment, it increases the loans that would be paid back if you go to primary care areas, $50,000 in some cases, that is half what the average medical student comes out with in loans, more than they could currently get. if they go into primary care they can get a lower interest-rate. expanded national health service corps, another way to pay back your medical school loans, there is good data again that if we could entice these young men and women into the health service corps which is primary care, the substantial number of them will stay in primary care even though they were considering going into some specialty arena when they finish their pay back. they decide maybe with their doing is kind of fun.

in several, tied to moving medicaid payments up to what medicare pays. he thinks this is a step up. it addresses medicaid payments, medicare payments, and an update for medical payments updating primary care and the sub specialty groups. it talks about training, the fact that primary-care doctors cannot practice in hospitals yet most graduate medical education most of the time we spend training is in hospitals. maybe we should move the training out so it looks more like the training you are -- more like the practice you will do when you are absolutely out earning a living. the problem is the money to support graduate medical education, specialty training, is tied to hospitals. what this bill does is actually

ties payments to the opportunity for doing ambulatory training. if you see what it is like and you enjoy it you are more likely to continue in that arena but we have to make sure the dollars follow the residents. transition of unfilled primary-care physicians, if there are positions, if you go back to the first slide, ten% or so of some specialty positions that don't fill, this bill would move those positions, funded positions into primary care arenas. as i said to you early on that won't do any good unless you convince more graduates to go into primary care. it is not that there are not enough slots, there aren't enough people willing to go into those slots so we have to address those other issues before transition of unfilled positions do any good. i find interesting, there are some pilot projects for training interdisciplinary. we tend to train in silos, doctors over here, nurses of there, pharmacists back there

someplace, even when we get out and practice, we all have to work as a team and the concept that this team is going to be more efficient than any of us individually is a very interesting concept, but one that we don't have any money to train for day. medical homes, many of the same things i talked about for physicians are included for nurses, dentists and public health. there are special funding pilot programs for accountable care organizations that you're going to hear more about. extension of geographic core for were, they will pay more if you go to a rural area. that is a huge step forward. up until now, most payments were tied to what they perceived to be the cost of living. if you are in a rural area the assumption was a cost less to practice and they paid less to go to a rural area rather and the same or more. despite the fact that those are some of the most challenging work places that exist. i added in comparative effectiveness research because i believe as we do the research about what the best quality of

care for the best dime is, we will discover over and over again that starting at primary care is the best bang for your buck. i can't think of anything that is going to fans primary-care more than us actually investing in what is the most efficient way to deliver care with the smallest number of dollars as opposed to whether we can prove that the new bill is better than a sugar pill rather than the existing bill which is what we do most of our research on today. bibliography, for some of the sources, many of the best sources are in your packet and all of these will be available on the web site. the reality is we need primary care to make this work. we have an awful lot of things that need to be changed in the existing system, not the least of which is the way we pay folks to make fat happen. >> thank you, nancy. [applause] you have heard an overview of the actual situation in general

and the situation with respect to primary-care and its associated issues. we are going to turn now to a case study of how this works out in a specific place, the commonwealth of massachusetts. we have asked our next two speakers to address first private sector approach, and then a public sector approach for dealing with the question of access. that means we are going to hear next from deborah devaux. deborah devaux is executive director of community transformation at blue cross blue shield of massachusetts. one aspect of responsibility is dramatic new initiatives on payment reform that was recently launched by blue cross blue shield. the ceo of that corporation, i was telling deborah devaux before we parted -- started, has

been describing this initiative at meetings of a commission that he served on, that i attended the meetings of, and it is a fascinating experiment. the congressional negotiators struggle with how to reshape health system payment for care in a way that encourages hi quality and cost effectiveness, she and her colleagues in massachusetts are actually starting to do it. try to explain a little about how it came to be and how it is working out. thanks for coming in. >> my role will be to talk about how payment can help support access. i will be eager to hear your questions and how this relates to your work. division in massachusetts is similar to the vision of our country, to create a system that

all have access to, effective, safe and affordable. the challenge for the plan is when physicians in hospitals and patients look at how we pay for services, what they could say is we do not pay for any of those things right now. we are not paying physicians and hospitals differently if it carries a 4 or more effective, we are not recognizing them if they manage to produce more affordable care, and so we, as elf plans, blue cross of massachusetts feels very strongly is that we need to play our role in changing that, and let's start to pay for the things that we all want, safe, effective, affordable care. as you will hear from sharon long in a moment, our state to the first steps to try to provide insurance coverage to all the citizens in our state. we have made some good progress

on that. we immediately, once we may access to coverage available, we immediately bumped into the issue that care was still not affordable, was not the safest care that we think we can provide as a system, was not necessarily the most effective. we have grave concerns about losing the broad coverage if we can't create affordable care. what we have begun to do is to offer an alternative contract to the providers that are in our network in the state of massachusetts, it is not required for participating in blue cross, but what we say is if you are prepared to accept accountability for cost of care, effectiveness, safety of care, you will be recognized with

greater revenue. the basic structure, the relationship, we have created long-term partnerships. in health care, it is five years. one of the barriers in physicians and hospitals being able to restructure the way they do things, knowing what their payment is going to look like, most of the paris make decisions about how they're going to structure payment on not year-to-year basis. what we have done, willing to commit to a 5-year contract, we will guarantee their payment levels over that five years which gives them the opportunity to think more creatively about how they want to recognize the efforts within their system to

change care. the contract does for both outpatient care and in patient care paid differently according to the results of that care rather than just paying for each service provided. this shows you the basic structure. this establishes budget per patient, the providers pay regardless of services we provide. to provide service unless that service creates that. and the providers freed up to offer services that might not be recognized or paid for in a traditional fee for service model. what we feel the global payment does is get the insurer out of

the way. is the admission needed, that is left in the hand of a provider. it is needed and providers can avoid the admission by offering services in a different way, they are recognized for that. the second component of the five year contract is there is a guaranteed inflationary increase each year in the contract. this is where the benefits to those who are purchasing the care, the employers or the individual member is realized because that increase, that year-to-year increase is lower than the increase we are experiencing in the rest of the system. if the rest of the system is producing at 9/11 increase, the increase annually in these contracts, much closer to cpi, closer to the level of increase we are experiencing for other

services in our economy. the final component, which is the component we are most excited about, is recognizing quality. for us, recognizing the better providers is the most important part of a contract, we will show you the performance measures specifically in one minute. but one of the key questions we got from those who lived through the decapitation models of the 90s, haven't we done this before? why is the alternative different? we certainly have an experimented with this previously, with disastrous results for certain physicians

and hospitals. we think there are number of differences that relate to how the budget is constructed and the fact that we are now able to better predict the expected health care costs of members that we were 15 or 20 years ago. however, we do feel that we need to continue to look very carefully at how these budgets are constructed because there are still things to be learned and we obviously are protecting the providers from unexpected insurance risks, so the cost of neonatal care for someone in a car accident, those things that aren't subject to better management, insurance problems, we feel the global payment that can be done in 2009 is a different one and subject to

better predictive science. i am not sure if you can see these well on the screen but reestablished performance measures that are nationally accepted, will recognize measures of care. these are not measures uniquely developed by blue cross, partially because we feel that providers have developed measures that they believe are important and can be measured in a valid way. partially because we want these measures to be able to be adopted by other payers. so we recognize that any other single plan, blue cross of massachusetts covers 35% of the people in our commonwealth, and we know that even if all of our members were in this arrangement, that it is very hard for physician to completely restructure their practice for 35, even 50% of their patients. we want to collaborate with

other plans, whether that is medicaid, medicare, the other commercial insurance plans, to adopt similar measures so that the physicians and hospitals can perform across a common set of measures for all the plans, and we think that is going to be the best way to move the dial, not to have different measures for different plans that caused physicians and hospitals to be trying to move their performance across a broad variety of measures but to limit that pool, so these are measures both for the hospital and outpatient care that fundamentally address the structure, the process and the outcomes of care. the other thing we thought was exciting about these measures was we initially provided the same financial weight in our incentive for all the measures because we felt there wasn't any

science around how to weigh those measures differently. when we took the construct to the providers, the physician said to us, don't you care a lot more about the outcomes then you do about the structure and the process? don't you care a lot more about whether a patient has gotten the hospital required infection that was avoidable for a complication after surgery that was avoidable, or their blood sugars are at the right levels, they you do about some of the clinical process measures? we said sure, but we know they are harder to achieve. the physicians said why don't you triple those. if they are achieved, you get three times more than those measures that structured and processed. that made a lot of sense to us because like many other people who have bought an exercise

bike, that is the structure. i may have used my exercise bike but unless i actually lower my blood pressure and am in better physical health, buying a bike is not enough. that is what the physicians were saying to us. if i put in the rate structure and the right process, if the outcome for the patient isn't achieved, there is a problem. we have to awaited the outcome measures. finally, we have created a scale so that those physicians who achieve the highest rates of performance that are possible we are not setting the highest gains at a level that is not achievable, we are paid significantly more. our belief is that this type of

payment system, the incentives for the delivery to restructure, the only reason for payment reform is to allow providers to restructure care, and we enable the access including primary care to be reimbursed appropriately, recognized appropriately in terms of quality and efficiency and can fundamentally helped solve the problems of access. >> thanks very much. [applause] as i said, we are going to turn to a look at what government in massachusetts and the people who are subjected to it, have done about access questions and we are going to hear from sharon long, a senior fellow at the urban institute health policy center in town,

she is a health economist of national reputation, she directs the urban institute's evaluation of the massachusetts reform initiative as well as the massachusetts household insurance survey for the state government itself. she is doing evaluation work on a number of other state reform efforts so she has a perspective that is uniquely useful to trying to take a look at the reform measures in massachusetts. there is a health affairs article, the gold standard in massachusetts, there is an electronic version available through our web site at healthof shares that updates that paper and i commended to you. tell us a little about what is going on in massachusetts on the public side. >> my job is to give you an update on our real world health

reform example. let me set by acknowledging the founders of this work, blue cross blue shield of massachusetts and the commonwealth fund and robert johnson foundation. i took one of susan's slides. i want to give an update on massachusetts relative to the goals of health reform she mentioned. as you will remember, it was to improve access to care, cover the uninsured, and health care cost curve. when we look at massachusetts, i will go into more detail as i go through the slides, massachusetts has significantly improved access to care. this was before implementing all of the elements of health reform, before the minimum credible coverage standard for implemented and before small-business could buy into the commonwealth choice program. significant gains. in addition, this was before what some were calling round ii

of health reform in massachusetts. the state made the decision to this expansion and coverage and improve access to care first and to turn to health care costs. that is where the state is just beginning to address health care costs. financial progress for the first two goals, just starting on the third. the work i reporting on today is based on a survey in massachusetts, we did a baseline survey in fall 2006, that is our pre reform world and we have done follow-up surveys in fall 2007, and fall 2008 and we're working on funding for fall 2009. we are looking at our insurance coverage and affordability have changed as health reform is implemented in the state. one of the limitations here is we are looking at changes overtime and we capture health reform and other changes over the same time period. in this world we captured the

impact of the recession and rising health-care costs. it is not your measure of the impact of health reform, but what i caution here is those two effect, the recession and rising health-care costs would dampen the effects of health-care reform. we are underestimating what health care would have got of the economy stayed stable and health costs stayed stable. with an overview let me turn to our findings. let's start by looking at the impact of health reform and insurance coverage. this slide shows insurance coverage in fall 2006, which is the yellow, and fall 2007, which is the blue, and fall 2008, which is the purple. the first set is the overall population in the state, the second set is laurin, dolls and affairs that is higher in, adults. we define lower income as adults with income, less than 3% of poverty, the cause of point for eligibility for messages is subsidized insurance program. there were significant increases

in health insurance coverage across the overall population as well as for the lower income and higher income groups. for the overall group, insurance coverage in fall 2008 was 96%, pretty close to a near universal coverage. this compares to 80% in other states in the u.s.. well above what we're seeing in other states. not surprisingly given the scope of changes in massachusetts which were targeted for the low-income population most of the gains in insurance coverage were among low-income adults. you can see a gain from 76% coverage in fall of 2006 to 92% coverage in fall of 2008. substantial gain over three years of health insurance reform. i should note here, i am not showing it in the slide, the increase in coverage, both canes and public coverage and gains and employer sponsored insurance coverage. we don't see crowd out of employer sponsored coverage in massachusetts with the gains in health insurance coverage and it is of to the individual mandate,

increased take up in the coverage in the state. in addition to seeing gains, we also see gains in continuity in coverage. look at this slide which shows people had coverage for the full 12 months, you can see substantial gains there as well. less cycling on and off of insurance coverage which should translate into more continuity of coverage overtime. when we turn to look at access, you can see that the gains in insurance coverage have translated into gains and access and use in the states, the first set of bars looking at having a usual source of care. this is people reporting that they have a provider that they see when they are sick or they need advice about their health. this is the measure of connection to the health care system and continental care overtime. as you see we see an increase in that under health-care reform. the next week to set of bars looking at doctor visits and multiple doctor visits and again, you see a gain in access.

more people are seeing doctors and more people are having multiple doctor visits overtime. to place these in context, 83% of adults in the u.s. have the usual source of care compared to the 92% in massachusetts in terms of doctor visits, 78% of adults in the u.s. have a doctor visit and 85% in massachusetts. we see better access to care in massachusetts and gains in access to care under health reform in the state. a limitation of the survey we have done is we can't identify people who gained insurance coverage because of health reform. all we have our three cross sectional pictures. what we wanted to know was whether the gains in access from insurance coverage or were there gains in access for other people in the state since there were changes in minimum credible standards for insurance coverage. we look at people who have employer sponsored coverage for the full year and looked at those over time. what we see with that population

is gaining access to care for that group as well. it looks like the massachusetts reform effort, both expanded coverage and improve what counts as coverage in the state so there are gains on both fronts. consistent with that we see gains by income level. most of the gains in axes are in the low-income population. that is the population that gained the most in insurance coverage but we also see gains in excess among hiring, dolls. one of the areas where we see the strongest gains is access to preventive care, people less access to get preventive care and credible coverage where preventive care is covered before the deductible applies. the gains and access are more broadbased than those that gained insurance coverage. another way of looking at the care is to look at the need for care. this slide is reporting on people reporting the need for care over the past year for any reason. we look at the need for dr.

care, specialist's care, medical testing and and follow-up care, prescription drugs and dental care. although these look how i, if we look with in a survey has data, they're lower than other states. massachusetts has lower-level. what you see is strong reductions of unmet needs, strong reductions and offsets of that in fall 2008. a bit of a paradox. we saw increases in access to care, more people going to dr. more doctor visits, we see more need for care. people had a harder time of this you look at the sources of unmet needs, follow-up care as people are trying to get