the senate finance@@rrgj nation's safety net hospitals, generally, to care for those who don't have the ability to pay. and as coverage increases, this is a link directory to coverage, paymen for those be reduced and that would be another part

of the savings. the third part, a small piece, is readmissions. we do know that there are instances where there are avoidable hospital readmissions that cost medicare dollars and we are committed to improving upon that. so that's commitment one. interned $155 billion over 10 years. but i really would like to build on what gail did so eloquently this morning talk about another piece, which is outcomes. we have also made a commitment to ourselves and to the community, a pledge to implement a strategy, a campaign that we called hospitals in pursuit of excellence to improve quality and efficiency. soe are really committed to taking known best practices, the science that is out there, and accelerating and spreading those practices so we can eliminate ese major areas. just to start on those, we have identified eight topics for

which we know, again, best practices exist, hospitals are working on and where mick and significant improvement that as the session talks about, impact of medicare beneficiaries in a very positive way. if you think about these areas, surgical, infections and competitions, centerline associated bloodstream infections, too bad bugs, mercer and sita, ventilator associated pneumonia, catheter associated urinary tract infections, adverse events from medication errors and reducing pressure ulcers, or bedsores. these are again issues that we are working on tay, hospitals are making strides in improving. that we can accelerate broadband and deepen these even further and we are committed to working with all our hospitals to share best practic, and to report nationally our improvement. so actual measures on how we are doing in these areas. in addition to those commitments, we have also committed that again, as a group working within the health care

system, there are longer-term initiaves that we need to address. improving care coordination, again, positively impacting citizens in our country in terms of facilitating not just the discharge process but care across the continuum. implement health information technology that we all know well is so important, and so critical in terms of modern anything in the health system, preventing patient falls and improving perinatal care. these are the issues where scientists are still evolving, measures are still developing but we feel a commitment that these will not only improve quality but obviously improve efficiency as well. also as just was talked about, we are strongly encouraged by the need to efficiently design, test, and learn new ways of delivery and payments. we cannot underscore that. and so we strongly support voluntary demonstration projects that are encompassed in today's very is bills, to think about

how we may really test and learn new models. so bundled payments. bundling payments together from different providers into one lump sum payment that could go to a provider core set of providers, and then it was up to them to decide how to deliver the most effective care for a population based on one payment. that is a model that is worth testing. we are not there yet. we need to learn about it, but we strony encourage that. accountable care organizations, which have seen some bills which again is organizations that will be accountable for a set of patients who are geisha or a population that will deliver a range of services to provide the best effective care for them. we need to test how accountable care organizations may work in tomorrow's delivery system. so again, committed both financially, committed in terms of quality and improvement in

efficiency and committed to learning and testing new models of delivery and payment that will further our country. i think the impact cannot be underscod. as we view these impacts, beneficiaries will stand to benefit. improved quality today means fewer infections, means avoiding unnecessary readmissions. we certainly know there are plans readmissions. we know there are readmissions that are not related to the initial reason you may have first gone into the hospital, but he said bobby's a there are other areas we need to work on. impact on health care cannot be underscored that we are talking about making the health care system more effient, the entire health care system, which benefits beneficiaries as well as providers as well as purchasers and payers of health care. and it as susan has said quite well this is about reducing the rate of the cost growth. so this is very critical in terms of where our nation goes in terms of the financial organization of our health care

system, recing the rate. these issues, again, the american hospital association is committed to working on comprehensive meangful reform. we recognize the need for slowg the cost growth and we recognize that it is going to take all of us working together to make that happen and it is a quality and an efficiency issue. thank you. [applause] >> thank you, again to all three of you. we will open up the session as well to questions from the audience. and as we are waiting, let me just ask one quick one because i want to make sure we all are o the same page as we emerge from what we have just heard. in essence, what we heard from you, gene, is not withstanding any discussion about class untrimmed cuss o slashing medicare, what is being talked abouin terms of medicare savings quote unquote out of health care reform bills, something in the neighborhood of

400 billion, $500 billion over a 10ear period. really is kind of chump change, you are saying. you ain't seen nothing yet, given the rate of growth in medicare and what the nation will have to eventually do. and in terms of thinking about winners or losers, you said obviously there will be some losers. but we really have an area of ambiguity around the whole notion of what will happen to beneficiaries out of all of this. you said hospitals are committed to providing better care for beneficiaries at the end of the road that will actually cost less, subjected to fewer infections, falls andospitals, everything else. so theoretically, somethings could actually get better for beneficiaries out of all of this. on the other hand, i have concerns aut how uch doctors are going to be paid, who knows whether beneficiaries are going to have access to doctors, transeventy music. and there also seems to be some discussion so much on this panel but there has been a lot of

discussion about medicare advantage plans in particular. and that people enrolled in those and that they may lose benefits. so is there a clear bottom line from all of this of what the impact will be on beneficiaries out of the medicare changes related to health care reform, or not? gene. >> again, remember we're talking about being a cost growth curve. we're talking about was the rate of increase and the benefits of people are going to get. so next yr people are going to medicare than they had last year and the following year they will have better care than they have next year. so the question is if you however put less money into a system, then you would have a system that is basically open which the amount can be almost unlimited, does that mean that there is an impact? simple accounting says there is less money means that the price of something has to go down, or the quantity of what is provided isoing to go down. i think fortunately, maybe i should say unfortunately there is enough waste in the system

and in that practice there are probably a lot of things that will not impact on people. but if there is a consequent of reform, maybe that is making $300,000 a year doesn't get much of an increase, salary increase in the next few years, or maybe when he or she becomes more efficient in providing me surgeries, we ratchet down the price of knee surgeries at a much asked to rate his income doesn't go up. maybe fewer people do need the surgery and maybe the best and brightest by not going to need surgery, they mighto on to education. and so there will be shifts so you can't guarantee when there is less money in a system that somebody somewhere is not going to benefit concert there will not be less money available in a system that provides more. but as i say, it is a little bit silly in the context of health care reform because we know medicare is unsustainable and all of us on this pan are talking about ways we're trying to get at this, by billing payments, for instance, accountable re organizations

does they will provide a little less gwth in these systems can we do in the most efficient way. so that is the question. there will be somebody who gets less care somewhere and there will be some people in the system, some drug manufacturer, some doctors, some nurses, maybe people who are very worthy who mightet less payments in this system because there would be less money than otherwise. >> darrell? >> we have to spend less. if we don't, we are translating this problem to our children and andchildren. given that we have to spend less, if that's all we do, if we simply put the brakes on, reimbursement, there will be holes that began to appear in the care for beneficiaries. but we are not in the dark here. gail made a very important reference earlier. she talked about -- she mentioned three systems tt are frequently cited because they are low-cost, high quality, high

patiensatisfaction. she mentioned the mayo clinic. and having visited those and talk with their leaders they have very clear ideas about how to bring cost out of the system while preserving quality. the problem is they are in relatively simple environments. poverty rates are low, incomes are high. we need to take what they know and empower more people in america to scale it up and apply it to tougher environments. if we do that, we really can. i mean, bidding the curb ian empty policy phrase and let you talk about what a care delivery system looks like. we actually can see those kinds of systems out there. we now need to translate them to the rest of the country. it will not happen by flipping a switch. is going to take really, gail used the phrase was, supercharge demonstrations involving lots of

willing parties to do this. >> we all have a shared responsibility in bending the cost curve. so that is clear and we have to address it. if it is just payment cuts, then there is a risk. absolutely a risk in service of. shortly hospits will not cover my squally by any sense but there is a risk. it must be met with copies of reform, and the innovations supercharge demonstration projects have to be part of it in terms of the overall picture of reform. so yes, if they are part of it, we can do better in terms of cost and quality. >> let's take some questions now from the audience. do we have one right here? we have one right down here in the front. >> good morning. i am judy paris. i am a clinical social worker and a consultant in longerm care. since this is the medicare section, i had a question. i was part of a negotiated rulemaking committee in the late '90s on provider sponsors

organizations. and a number of the panel members, dr. kirch and others talk about the need of system reform, giving doctors and providers together. and i left that issue long ago. i am just wondering, i think it is still in statute and i am wondering how that would fit into your thoughts, if you know of it, and if there is anybody who haven't tried them in terms of system reform and pulling the comprehensive pieces together. >> we have a toolbox in the united states that is brimming over with a very solid concepts, things like accountable care organizations, provider responder organizations, medical homes is another one we are all hearing a lot about. but my observation is that we are suffering from concepts in search of people to implement them. and right now what i think we need to do is use the considerable power of the federal government in the case of medicaid state governments to

empower the increasing number of people who are willing to implement them. the number of places where they know it's about interdisciplinary team-based care. it's knowing about having every provider, regardless of discipline, practicing at the top of their license as opposed to some optimizing each of the. there are so many people i've encountered around the country who would like to pull the pieces together, use the tools. the tools are there appeared the authority is there. i think we need to use the opportunity of the legislation to really inject it with some energy. >> did you want to add something? let's take another question. we got a couple here and then we'll go over on this side. >> i am from the american college of teratology righ next-door. i've been practicing in the ademic center for the last 25 you're so i'm really glad to hear a little bit about the academics and what is going on with the work force. question, and also just excited to hear about mentioning

quality. and like we have a lotf@@@@@rrh, paper on it. and you have to reinvent yourself with each visit and each new doctor because there isn't the it platform we need. >> let me just jump in your. for people who might think that registries are things you sign up for when you're getting married.

why do you clarif what registries are? >> there are various forms of registries, but often there are ways of garnishing information from populations of patients, perhaps population of patients with the same disease or sing thsame kind of treatment to learn from them, to learn what works and what doesn'tork and what is most cost-effective. >> so it is a way of tracking. what is done to patients, what happens to them over time and then try to figure out how to learn from that to improve care going forward. >> more than tracking. it is the learning, but you need information to learn from. >> gene. >> if i can add maybe just a disheartened know, i worked for four years with the national coittee on vital health statistics which in recent years has devoted a amount of time to trying to implement electronic health records taken with regard to this question, the previous one, it is quite clear that improved information systems themselves do not necessarily been to the cost per. they offered the opportunity for more efficient systems, but in

truth if you have no budget constraint the incentive to take advantage of these information systems is pretty small. in fact, i often appear before doctors and often shocked them by the state about half of all doctors are below median. at which point they said that for a while and think about and finally realize that's going to remain true under any information system. and the only information systems can really have the pressure to do something is when there is a budget constraint. gm did not improve or try to make more efficient many of its cars until its budget constraint forced them to do it. this is tru of every industry, true of every discipline and it is true in the hospital sector. one hospital can make a lot more profits by increasing volumes and we provide all these great information systems, but the hospital that is more concerned about volume increases than it is concerned about quality of care continues to make money and drives the other one out of business. it is going to have an effect. so you have got to somehow or another, you've got to match all

these efforts, electronic health records, provider groups, registries, you have got to have them within some sort of a budget constraint where there are incentives for people to do the more effient higher quality thing at a lower cost. and it may include in the case of radiologists whether there are some alternative providers with a slightly less gail might be able to do the same amount of work for slightly less these. those types of issues -- there has to be an incident to make those types of changes. >> i think we had another question here and then let's go er to the side. >> former dod in congress. there is a question that i would ask you gail as well, but let me make two assumptions. one, that we ought really are trying to build a healthier country. and a second, it is 2019. a question for you all is

comparing the current track run versus some sense of where health care reform may take us, how are we doing in 2191 versus the other on status, quality, affordability, and access? >> in 10 or 15 seconds, if you would. maulik. >> we don't have a choice that we will be betr. we just don't have the choice we have to commit to it and we have to move forward on it. it might not happen in three years. it is going to take some time but it will happe >> darrell? >> i think those things will change at different rates. the one thing that won't change sadly overnight is the problems with health status in the united states. the obesity, diabetes spectrum problem of problems didn't appear overnight and wre not going to reverse them overnight. so i think you're going to have to be patient that while we can redesign systems, reimburse rationally, it is going to be a slow turn for us in improving the overall health of the american people.

>> i don't know the final answer to your question but i would say we are on our current after our book basically, our economy is in the threat of blowing up and health care could end up taking hits that will not be inmated very efficient or very done very well at all. and i think come i don't think it is just a matter of waiting a few years. i think actually in the next few years we will seek enormous pressures on health care, if not to wait for some of these improvements that we want to take place, but to make other changes that are a bit more drastic. and that will mean i think quickly changing the payment system to reward quality, to reward of volume last, to allow for alternative providers, to do all of those things that i think they do enhance our probability, enhance our chances of leading quality increase at the right rate. out the mystic side says we have always grown as an economy and we've always gone as a people because we're always able to stand on the shoulders of the giant who were there before us. as long as we can take past

knowledge and build upon it i am fairly optimistic about the future. >> all right. we had a question over at the rear. >> judy, new york city health and hospital corporation, safety net hospital, largest the book hospital system in the country. no one is more committ to health care reform than the safety net hospital. we served last year for hundred 50000 people with no insurance. by the disproportionate share hospital payments, or dish payments, are about a lot more than just the uninsured here they are also because medicaid under pays. and so in new york, for example, they have been paying about $0.35 on the dollar for outpatient dedicate this at. they are improving that, but they are cutting inpatient so one of the questions i have, and safety net hospitals should not be destabilized. they are needed now more than ever. and so what are my questions to the aha representative here is how will you accommodate that

medicaid underpay when that will continue since the states have such drastic deficit while you are cutting dish payment? thanks. >> dish payments go away. i think that is a prick of these because ectly what you mentioned on the safety net hospital stabilizing still continue to be uninsured and other issues so it does not go aw. it does get reduced as coverage gets increased. so there is a direct linkage, and as coverage is increased for a while but it cannot go awa by any means and we have to seek again to protect safety net hospitals. >> any of e rest of you want to comment on that? okay. let's see, did we have one more question. let'take one back there.

>> again, david. the atlantic monthly published an essay by david this month i don't know if you're familiar with it, drawing a lot of discussion about health care, how american health care killed my father. has any of you, of the panelists read it? he makes two interesting point. one of course is hospital required infections which was the cause of his father's death. if you combine that with medical errors, that is now the third leading cause of death in america queered a really bad job on transparency reporting errors. i would be interested knowing what their position is any other point for gene is the article, the authors cite that the problem is through medicare being asou suggest, the market maker i think is another phrase for your comment, medicare has done a bad job of basically subsidizing to many hospitals keeping the acute care system in place and not evolving the syst as we know to more sort of aging in place, more decentralized care delivery.

>> the first question on hospitals and hospital acquired infections and so on. >> i think in terms of the 10 year anniversary, we clearly have a ways to go, but there has been sigficant substantial progress in the last 10 years. incredible progress by hospitals and every health care provider in terms of patient safety. in terms of the infections, that is why we specifically focused on these issues. we know it doesn't happen overnight but we are committed to making that work. and the only way to make it work is to really promote best practices, learn from each other, and transparency is a part of it. aha has always promoted transparency on meaningful relevant indokrs measures. and more and more organizations and national and state bodies are following that. >> in terms of medicare, i don't think any panel would disagree with the comment you made or reflecting in what was in the article. i should say that a lot of the bad incentives and medicare does reflect a bad incentives that are reflected throughout the insurance system in which we

have a volume. and there was some incident where you and i go to the doctor to that is just a system that is not sustainable. i should say that one of the more interesting aspects of e health reform debate, given that this is an evolving system and given that we never know all the answers, is this an attempt to empower medicare, or hhs or some alternative body, to have much greater power to epaulet suggestions that they make overtime, suggestions they make not only for larger experiments, suggestions they make for perhaps not just lowering our changing the rate of growth in payments but actually ratcheting down payments in certain areas, where technological improvement allows services to be done at a much faster rate. suggestions where they really think we can improve the quality of care. i am not saying those will answer all the questions were certainly that they would end the fact that half of all doctors will provide below

median surgery i don't think that will stop. but we can provide better information systems. we can provide better incentives to actually try to improve upon the record that you signed. >> darrell? >> i have not seen the article but i always become concerned about the focus on medical errors, poor quality in the abstract. i was responsible for hospitals and medica nursing staffs and nobody felt the failure more acutely in the face of medical errors than those professionals. it isn't that we have uncaring people in the system. is the design of the system itself, and it actually goes ck to the reimbursement methodology. if everything is paid in pieces, then each activity becomes a standalone piece and there is a scene between the activity. one consultant doesn't speak to another. the primary care doctor doesn't get thinformation they need.

it is those scenes that have to be close and to close them we have to change the way we pay and we have to change the way we actually designed them and deliver care. >> we are going to bring this tale to a close here shortly. i do want to mention that if there a those who are interested in receiving more information, particularly from gene's perspective, you can e-mail him at srling. take a look at the health care website. as well as the websites of the american hospital association and those are respectably aha.org and a amc.org, for additional information about what we have spoken about this morning. i just want torap a. i don't know if all of you are lucky enough to have your parent still surviving, but let's say for a moment that you are. but they are busy, retired

people. they have a few minutes to listen to you while they dash off to play golf or whatever it is that they do. so you have got about a 30 seconds with image are going to sit down and explain to them. mom and dad, here's what i want you to know about medicare and health care reform. you have 30 seconds each. gene. >> first, i would come into them that my daughter is a pediatrician who works actually at one of these systems and tries to be accountable car comes close which is kaiser in northern california. she gets paid a lot less than a lot of other people in the system. she loves her work. i would say we need to actually fund many more people like her and provide more payments to those people who are providing preventive care, who are focusing on cures rather than just chronic care. and i would say to them that as a current member of the elderly, you're probably not going to be fected very much by this health reform. and that, even the medicare

reforms are going to come along will probably not affect you and your as much as they are your children and grandchildren. so help us think together about how we want the health care system to evolve over time. how we want government over time. what we want to live in the way of health care for the elderly versus the uninsured versus the young. ani think they would very much engaged that conversation. >> darrell, your folks are even busier than gene's. they have 25 seconds to listen to you. [laughter] >> using the two medical school because you believe it was a noble profession. doctors and the nurses and the other professionals are not going to abandon that if they are not going to abandon you but we need to fix this system, or the o granddaughters you love are going to be in real trouble. >> maulik? >> will have a stake in this. it is important to all of us, and to all our kids. and to get there we need to address efficiency and we need to address quality, and it will

take time. it will not b pretty butt will happen in the next decade. >> arai. on that note we are going to take a 15 minute coffee break. let me urge you, please, to come back for our final set of discussions today, which are on very critical end-of-life issues, and why it ght or might not be important to address them in health reform. to a proposal that has surfaced in the house bill, h.r. 3200, to pay practitioners under medicare to conct advanced planning consultations with patients. we have three terrific mandalas to discuss that issue. will also have an extended q&a session at the end of

>> welcome back to our final session of fact versus fiction, making sense of healthcare reform issues. and we have left for our last session today one of the topics that has obviously become very, very emotionally fraught on the town hall and other electoral -- i guess it's not literally electoral but i guess everything in the end is the electoral trail, which is the issue of end of life. for all of us, we know we all have a 100% probability of death.

it's something we prefer not to think about. however, most of us have had to think about it just in the last year alone. personally, i've lost several elderly relatives. i know that we all thinkbout our parents. we think about ourselves. we think about our children. we know we're going to get there sometime and so it's an issue very close at hand. therefore, understandable that it is so fraught with emotion and with often lack of reason. this ptester probably kind of a fake protester holding up a sign at one of the recent foru - it's hard to see. one protester is saying no to healthcare reform. but the other fake protester, i thk, is saying, oh, i'm sorry. we thought reading the bill was your job. and your is spelled u-r. the standpoint being made is it is very difficult to read

through legislative language and understand what is meant by it. and this particular provision in h.r. 3200 section 1233 advanced care planning consultation, obviously, has caused a lot of difficulty for people. it is a very tediously long section, as you see here. and this is just a tiny fraction of it. i didn't load the whole thing up onto slides today; otherwise, it would be a 20-minute presentation in its own right but as you see, it kind of goes on and on and on. and it's understandable that not everybody cod read it or has read it or understands what is. but that's the point of our panel discussion here today. it's to put all of this in context. and particularly, to put it in context of the end-olife issues that we see every day in the u.s. healthcare system and that many of us will experience in our personal lives. as we know on the campaign

trail, this provisi for advanced planning consultations that would be paid for under medicare has caused a lot of difficulty. again, i'm just going to mention one news story which is an abc news piece that kate snowe did on this back a week or so ago and pointed at a healthcare town hall with obama, president obama, hosted by the arp a man said, this is being read -- this being section 1233 is being read as saying every five years you'll be told how you can must die. i don't have to mention all the other people you know who have evoked this language and worse in describing what is in this provision. and because there is so much emotion, we thought it was especially useful to have these is next three parcular individuals speak about this from their perspectives. so i'd like to introduce now,

first of all, christine castle who's an m.d. who's president of the american board of internal medicine with a lot of end of life care experience and knowledge under her belt as you will hear momentarily. she will be followed by dan meier, m.d. who's the head of center of care at the mt. sinai school of medicine, a very noted expert from way, way back. they have written about almost every aspect of end of life care from physician-assied suide to euthanasia to pallatative care and they know there are people doing literature searches on them right now to see what they have put their names on in the past as has been the case with so many people over this period who have written and thought deeply about these issues and are now being accused of holding all kinds of beliefs. you kn, that's not what it is all about. what it is all about is really

trying to put into perspective how o goes through in america the last stages of serious illness and how one does or does not prepare for them. how one's family does or does not prepare for them and what happens to you if you don't prepare for them and you end up perhaps in a situation that you possibly would have wanted to avoid. that's what they're going to talk about, notwithstanding, everything else that they've written or talked about in the past. and then we're also going to have -- and this gentleman holds a very special place in our hearts atealth affairs, jerald winakur from san annio. the reason why he's so dear to the hearts of healthy affairs he was the author of an extremely important narrative matters piece. it's the section of our journal where we ask people to give first-person accounts of

encounters with healthcare and with the healthcare system that have a policy point to them. we call them policy narratives but that's a dull phrase compared to what they are. the really are first-person accounts of the joys, the pain, the suffering, the complexity of being a patient or being somebody wking with a patient in america. and jerry's piece of 2005 on the aging of his father and the dissent into dementia of his father a his own work as a doctor watching his father what do we do with dad is the piece was named is one of the morable pieces we've ever published. so with this -- with these three individuals, spectacularly situated to discuss thesew! issues, let's turn first to the first of them chris cassel. >> thank you, susan, and thank yo -- let me add my thanks to

you and to health affairs for pulling together this important conference and helping to restore, i think, both civility and important substantive content to this important national discussion about healthcare reform. and my -- so my topic is to talk about the data that -- and very quickly i'm going to do this 'cause there's a huge amount of research that is now available to us about what patients want, what families experience as people have advanced in progressive illness. but before i do that, i want to point out that you're going to be hearing not only from me but from two other physicians who actually have the knowledge and skills to care for people with advanced andu complex illness.

that is to say geriatricians and given that all three of us are board certified geriatricians that it's probably about -- you know, a tenth of the nation's supply of geriatricians -- [laughter] >> are here today and so maybe we should actually be goingut and taking care of patients. it would be better. that is an even more of an endangered species than primary caren the united states for all the same reasons. it's very difficult to do. very challenging and undervalued and underrewarded and needs better systems of car. -- care. it's also important to recognize that taking care of patients ho as sus mentioned are goingo die, as all of us are going to die, usually means you don't know which patients are going to die and you take care of people because you want tir care to be personalized to what they want, to what their values are and to improving their quality of life for every day that they have left, every week, every month, however long that might

be. so it's kind of a fiction to think we can set up policies that look just at end of life care as if it's a definable and predictable slice of when a patient gets to that point. and so what we really need is a healthcare system and providers who have the skills to be able to work with patients over the course of that process. so we're talking about patient-centered care here, really. and so we really have a good deal of knowledge about what patients with serious illness want. now, mind you, it is a diverse country and people want different things and one of the most important skills that th providers, particularly, the physicians need is to be able to have those conversations with patients about their values, with their families or without, at their choice or if they are unable to speak for themlves, having known them over the

course of their life so that they can have told you before they became incapacitated what it is that they would want for themselves. so it's -- a lot of is about communication and about relationship-building. but iyou look at surveys like this one, people want pain and symptom control. they want to avoid a painful prolongation of the dying process andctually the vast majority of people will tell you this is what they want. they want a sense of control and dignity. so that word "control" is very important. the control has to be with the patient. they are concerned about burdens on the family, both emotional burdens and financial burdens. and they want help with that. they want help with understanding how to reduce those burdens. and they want to strengthen relationships with loved ones. you know, we often talk about the beginning of life, birth at

a time when there's great meaning to the significance of giving birth to a child and a new life. well, the e of lifes just as profound and potentially just as meaningful. and, unfortunately, in our healthcare system, we haven't given it the kind of prominence and the kind of spiritual and otherwise emotional significance that the patients are telling us they want. and deed there's a lot of data that they're not getting what they want. suffering in united states hospitals has been well documented. and this is in more than one national data set. this is one of the first ones that was also supported by the robert wood johnson foundation that really put this information really in front of the nation's medical community in a very important way. this w a huge study across many different hospitals with people with many different conditions.

50% of whom only lived for six months after they entered into the study. so this is a very sick population as i said earlier th they -- you can't always predict, but it's a way of defining people who have very advanced illness. half of these patients had moderate to severe pain more than half of the time duri their last three days of life. so that is clearly unacceptable. that is not what patients want. 38%, almost 40% of those who died spent more than ten days at the end of life in an intensive care unit unconscious and on a ventilator. again, if you talk to most people, they will tell you that is not what they would have wanted. and while it's not on this slide, the same study pointed out that one-third of the families of these patients lost most or all of their savings in that last)illness. this is not medicare dollars.

this is not health plan dollars. this is their personal family savings. so when you talk to family members -- now, you know, when patients die, of course, we try to ask people as they're going through these illnesses what they want and what the experience is like for them and how can we improve it. but part of what matters in the way we care for patients at the end of life is the memories that are left behind. and the way to find that out is to ask the families. so family members tell us this is what they want. they want their loved one's wies to be honored. they want to be included in the decision process. they want -- and those are the two things, by the way, that the legislation that susan put up there addresses. a way of getting -- the patient to tell the doctor that information. the rest of this is what good pallative care and good hospice

programs can do. personal care needs, practical help, honest information -- i can't tell you how many times i, f this. not enough contact with the physicians. 78% said they did not get enough contact with the doctor. not enough emotional support. not enough information about what to expect in the dying process.

so we think we're uncomfortable -- that patients don'tant to hear this. the patients are telling us and the families are telling us they want their questions answered. and by and large in our medical institutions and our training we don't teach how to convey this kind of infoation in a caring and supportive way. and then not enough help with pain, 20%, 1 out of 5 families said this. and, in fact, while imphasize that this isn't only about money, t is important and actually interesting to look at how the costs break down, the spending of how we spend on end of life care. and so if you look at this pie chart, this is the last two years of life. and mind you what i said before. that this is only in retrospect these people died. these are people with very advanced illness. how did they -- their cost guessguescosts of

care lined up at the end. and i think you'll hear from dr. meier is a very important place. as much as we try to get people at home. people want to be in hospice or at home, it's not always possible. so hospitals have to actually provide a lot of pallative care and they have to be able to shift gearsnd have the skills and the capabilities to do this. you can also see -- well, the other point i want to make about this is that it isn't -- it could be 54.7% is exactly the right amount of money. we don't know how much is the right amount. what we do know for sure is that we're not spending it on the right things. so we have two kinds of issues here is how much money we spend and what is it that we' getting? what kind value for that money? well, one thing we know, though, from many, many studies is that more is not necessarilbetter.

so you can draw some inferences from this. and this is another study showing association between cost and quality of death. so the quality of life for t people who were dying during this final week of their life and graphed along the horizontal axis here per capita cost. how much was spent on them during that final week of life, and you can see that the people who actually had less money spent on them actually had a higher quality of life during that last week. so there's a lot hidden in that data that we need to understand better. and we need to work with. but at least i think it's pretty fair to say that spending more moneys not the same as getting better care or getting bter quality of care. so the last point i want to make is about advanced directives

because that's what was in the legislation and that's what gave rise to this really unfortunate mischaracterization that somebody else is going to make decisions for you. in fact, advanced directives are about exactly the opposite of that. advanced directives are about you making your own decisions and the people who take care of you being able to know about what those are because think about what happens if you're ill at home, the ambulance comes, you may go to a hospital emergency room. your doctor might not be available. you're in a nursing home. you might go to a hospital where the doctor doesn't have privileges there. so there has to be a stable document, a stable way of having this information come across wherever the patient is. so that information can be transmitted. so i went to the definitive medical information source,

wikipedia, for this definition. [laughter] >> actually, you know, as we looked around for definitions, this was the best one that came up so i guess wisdom of crowds really does work sometimes. so i won't read through this entirely but i do want to make a couple of points on it. first of all, that these are decisions that are put in writing for the event that you might be incapacitated so you couldn't speak for yourself. if you have an advanced directive and you're not incapacitated. at any moment you can change your mind and speak for yourself. people will not need the advanced directive if you're mentally conscious and competent. it's for those situations where you're not that the advanced directives are so important. the other thing is that advanced directives can be something like a living will where you say under what circumstances you might want more aggressive or less aggressive life-sustaining treatment.

but it also can be used for what's called a power of attorney or healthcare proxy where you assign decision-making to someone you trust. and often people are more comfortable doing that because it's hard to think about what might lie ahead. and so as you think about advanced directives, it's not that you have to imagine every possible circumstance that might occur. but you can make a decision about who you would like to be making these decisions on your behalf in the event that you're not able to make them for yourself. advanced directives are a way to empower patients, not to turn these decisions over to doctors, to hospitals, to insurance companies, or to the government. now, the last couple of slides here are just to point out is that when people have those discussions with doctors and get their questions answered, that, in fact, they are more likely to

choose less aggressive care. and that's actually bourne out in the work on shared decision-making, not in the pallative-care arena but in the elective care. but in the decision, not always they will choose the less costly and less aggressive and frankly less risky course of action. t everyone and that's why these are individualized decisions. but i think there's pretty good evidence that patients know how to use information and they want more information. so in conclusion, a summary of what at least the tricommittee bill has which is the one that i think has gotten the most attention. it provides medicare coverage for voluntary advanced care planning consultations, at least every five yes. and the every five-year provision is just so that the door can get paid for having this conversation with you, which right now is not the case.

we've heard about this unfortunate fee for service volume-driven healthcare system we have. well, the volume of conversations with the patients does not get theoctor more money. that's the one thing that doesn't. so all this provision does is say that medicare every five years would pay for you tha that conversation with the patient if the patient wants it. it also requires quality measures which are getting more sophisticated all the time to be taken advantage wherever possible an end of life care and particularly advanced care planning. and that some of the medicar pay for reporting plans be linked up with that kind of performance data. now, the other -- the last point i want to make is that there were a number of us who were in conversations with the hill's staff during these -- the drafting of some of this and urging that they include actually what might even be more

important than advanced directive provisions, and that is to say, education, work force issues. we do not have a medical or a nursing work force who is very skilled in this arena. so we really need to find ways to create both training programs and incentives for more young physicians and people that darrell is talking about to go into this work and then, of course, increased emphasis on evaluating different approaches to quality of care and research. thank you very much. [applause] [inaudible conversations] >> thank you, chris.

thank you, susan. thk you, health affairs, for organizing this event. and i'm very appreciative and grateful to be here. and i have the opportunity to put some flesh and bones on pretty much everything you have heard so far today. and i decided to speak to you about two of my patients so this is a tale of two patients. one of whom i think suffered because of the way the current system incentives are set up and the other of whom iope you will agree got what i would consider to be optimal care during her chronic and then ultimately terminal illness. and i hope as i tell you about these patients, you will think about what are the lessons to be drawn from their experiences and how they relate to the discussions about the health reform that's on the table now. so the first patient is mrs. g. who was an 82-year-old nursing home resident with moderate

dementia and recurrent pneumonias. she had what i would consider to be business as usual in the american healthcare system. multiple hospital admissions. she had four hospital admissions to my hospital. hdr nursing home is down the street from mt. sinai and we see muiple revolving-door options from that nursing home. in her case she kept aspirating and kept developing pneumonia. she had dementia for 10 years prr to her hospital stays. whoever her primary care doc if she had one 10 years before never discussed her wishes for care in case of future loss of capacity so there was no healthcare proxy. there was no living will. there was no evidence of any type, verbal or written, of her wishes. on this day i'm going to tell you. she had six weeks of intensive

care unit she had predictable diseases. a tremendous amount of pain associated with devopment of a pressure, severe pressure ulcer during that six-week icu stay. and a devastated adult son who was both very angry about what was happening to his mother and very guilty that he was unable to stop it. or prevent it. and this is not mrs. g. this is another patient who did give me permission to document her care, but this is the situation mrs. g. was in. and she also was restrained. you notice the hand restraints on this patient in the icu and the reason the restraints were here because people were afraid to use too much sedation because of the underlying dementia so rather than sedate her to keep her from pulling out her tubes, they tied her hands. so just imagine what that is like. she as i said had a six-week

stay in the icu. she had a different attending physician every two weeks. we rotate on and off so almost no continuity of care. she left the icu during week 7 of her hospital stay to go to a regular floor. the hospitalist documented in his note that he asked the son if he wanted us to do everything for his mother. and that was the question, do you want us to everything you want for his mother and, of course, the son said, yes, what family would ever answer that question no. so it's the wrong question, obviously. but as a result, this patient continued to receive all aggressive, life-prolonging treatments that we know how to give and that included very difficult twice-daily dressing changes for her ulcers which were very deep down to bone and muscle and painful and her reaction to these dressing changes was to lash out and try to strike away the people who were trying to care of her

because it was very painful and to scream essentially. anthen in between dressing changes she was curled up in a ball facing the wall and did not respond -- seem to recognize or smile when her son visited, which was causing him tremendous distress. after the nurses had had enough of what they described to me over the phone as torturing this patient they called for a pallative medical consultant. day 63. we sat down with the son that afternoo and this was a 90-minute meeting with the son and his two sons. the son was in his 60s and his two sons were in their 30s, so three generations. and we asked the son a different question. we asked him what he was hoping we could accomplish for his mother. d note the tone difference between do you want us to do everything for your mother versus what are you hoping we can accomplish for your mother? and he just erupted with anger and upset.

isn't there something you can do about this pain? you know, every time i come in moaning, she's screaming. she won't let the nurses anywhere near her. she's afraid of anybody who comes near the bed. you might ask why wasn't anybody treating the pain for that. well, there isn't much medical education about this i have to tell you and there's very little work force incentive where people are trained in the management of pain and, in fact, there's a myth out there that you don't give annaljesics to people with pain. that people who have uncontrolled pain are delirious and agitated and that people whose pai who's controlled have a much lower risk of confusion and agitation but a lot of that doctor don't know about that literare 'cause they're not trained in it.

we gave her 5 milligrams under her tongue 30 minutes before the dressing changes and the dressing changes went fine after that and that's all it took twice a day. she was relaxed. she started recognizing her son. she would smile and squeeze his hand when he came in. and four days later went back it to her nursing home this time with hospice at the nursing home to make sure she got good pain management during dressing changes that the nursing staff were grossly understaffed for people this complicated. we're getting support for hospice expertise. she actually lived another four months miraculously probably because her symptoms and her wounds were being properly cared for and because there was more support for this staff. the son actually wrote a letter to our ceo thanking him for the quality of care our hospital provided, you know, go figure. and which he forward to me.

the cost of her kayn that last hospital care was well over $4 million that did not occur what occurred in the final three prior hospitalizations over that year. the suffering really incalcuable. think about the incentives. the incentive of the nursing home is to refer to the hospital taking care of a sick complicated patient nanursing home ty can't afford it. and the staff in the hospitalization it's their incentive because we get paid for every stay, right? the system is perfectly designed to get this result for this patient. patient number two, judy f. 65-year-old with metastatic lung cancer seeking guidance on what to do. she was diagnosed with age 59 with nonsmall cell lung cancer,

no prior history of sming. given a prognosis when she was diagnosed of 6 to 12 months, well, you know, so maybe on average people with this disease live 6 to 12 months. so much for averages. if you followed what people are talking about thate're wasting money at the end of life, this might have been a patient who wouldn't have gotten any treatment 'cause on average she's at the end of life so why are we wasting money on people at the end of life? well, she got appropriate treatment. she lived six years after diagnosis. with care of a superb oncologist at nyu. she sought me out at about 14 months before death becse she was starting to have progression of illness, pain, fatigue, difficulty concentrating, insomnia and it was very clear to her that her oncologist was not capable of discussing what the future was going to hold. he's a great oncologist, really

good at cancer care, not good at these bigger questions of meaning and purpose and what is it going to be like when this treatment no longer works. for about 14 months she received simultaneous care from me in palliative androm her oncologist and lived reasonably high quality of life during that time and it wasn't until the last three weeks of her life that it was clear that the tumor was progressing despite the very sophisticated chemo she was getting and she decided to stop the chemo. she was no longer able to go how the that's when we called hospice. only in the lasthree weeks of her life. she remained at home in the care of her husband and her daughter sarah, and died peacefully at home surrounded by family. so that's judy. at the time of diagnosis. a remarkable human being. i wish i could tell you more about her. psychotherapists. she was in three different

reading groups. she's about the best read person and we talked about books. that's her daughter, sarah. that's her husband, george. this is one of the trips they took to italy while she was undergoing treatment for lung cancer. quality of life was the most important thing to her. and you can see that she achieved it. now, this is a cartoon from the new yorker of a doctor saying to a patient there's no easy way i can tell you this i'm sending you to someone i can. so her oncologist, as i said i have enormous respect for him. he's a great doctor. and he did give her six good, qualityears with what ordinarily would have killed her much earlier. but he is really, a, not trained and, b, not comfortable, and, c, does not have time to have long conversations about what the future holds, what the pros and cons of different treatment options are and how to help judy come up with a plan based on the facts plus her preferences and goals.

now, those of us in palliative thinks this is a really good doctor. why? because he does not ignore the issue. he refers her to someone who can help her with it, me in this case. you know, or another palliative medicine doctor or a geriatrician. and, in fact, what judy got is what i call the conceptual shift in palliative care where patients receive life prolonging treatment and palliative care throughout the course of a serious advanced illness until the life prolonging care is not neficial at which point they are sent to hospice. that's not another reason i have problems throwing this term around, end of life. we didn't know she was at the last end of life. if we had made her to wait to receive palliative care until it was obvious she was at the end of life, her last 14 months would have been a misery.

so this is judy during that three-week period at home where she -- they moved the bed into the alarm because it was the brightest, sunniest room and sarah and george taking care of her at home. so what are the implications from these two stories? first of all, we need to match the care to the patient's needs. we do not know as chris said who is at the end of life until weeks to days of death. we cannot save money by cutting off care for a population of patients identified as at the end of life because we only know that in retrospect. policymakers are saying we're wasting all this money at the end of life, i want to say back to them, well, if you, policymaker, were diagnosed with metastatic small cell cancer, should we label you at the end of life and say, sorry, no chemo for you, buddy. you're at the end of life. we're going to save money for you. of course, you wouldn't want

that. you would want every effort to prolong your life for as long as possible with as good quality life as possible. that is not the solution. needs-based treatment is the lution. advanced care planning for both mrs. g. who didn't have it, 12 years before that hospital stay and for judy who did have it at the beginning of her diagnosis is important at the point of diagnosis. not at the end of life. long before the end of life. non-hospice palliative care is appropriate whenever symptoms, functional impairment and family burden mandate it. regardless of prognosis. and at the same time as all other appropriate life sustaining treatment. hospice only when life-prolonging treatment is no longer effective or the burden outweighs its benefit. and the multiple studies which i will not bore you with is

genuinely patient-centered care and markedly lowered costs and this is the one place that's a win-win-. it's a better for patients and families. it costs less. it's very clear from the data. art buckwald talked about this very humorously as only he could do. this is from his obite. so far things are gng my way. i am known in the hospice as the man who wouldn't die. here's someone who failed to die. he lived over a year. he had to be discharged from hospice. and that's why he says here how long they allow me to stay here is another problem. i don't know where i'd go or if people would want to see me if i weren't in hospice but in case you're wondering i'm having a swell time, the best time of my life. life is pleasant, death is peaceful. it's the transition that's troublesome and helen keller writing in a book called

"optimism," a wonderful essay if you haven't read it. although the world is full of suffering, it is also full of the overcoming of it. and i just want to thank judy and her family for sharing their story and personal photos with me and with all of us today. thank u. [applause] [inaudible conversations] >> i also want to thank susan and health affairs for inviting me here to be a part of this panel. and it's a real honor to be here with dr. cassel and dr. myers. as you've heard. i'm a geriatrician a primary care doctor on the front lines who helps care for the oldest among us. my livelihood derives from a

very flawed but necessary single payer system, medicare. i deal in nuance, not numbers. you heard numbers from policymakers today. in any health reform they may actually occur in our country. i want what's best for my patients. and i'm here to speak on their behalf and my patients and their families that are struggling through difficult times. i'm now in my 34th year of practice. in my doctoring life i've had well over a quarter million face-to-face encounters with patients in the exam rooms, in my office, in emergency rooms, in icu cubicles, hospital bed sides and nursing homes. i spent most of my life ministering to the medical problems of the elderly and counseling them in their families during illness and end-stage disease. many have been my friends now for decades. they trust me and i honor that

trust. i advise, i advocate, i explain, i educate. at the worst of times and when the end is near, i do my best to remain by their sides. three-and-a-half years ago my father died from alzheimer's disease after a long struggle. in the beginning of this ordeal i thought that i of all people knew what to do when a serious illnes befalls a loved e, gains a stranglehold on a family. i was wrong. we muddled through day-to-day as so many families have done and are doing across america. this is my father leonard winikur. he couldn't wait to get back home and marry his sweetheart, my mother fran shi i came along in 1948. in his late '60s my father had a major heart attack. in his 70s, prostate cancer.

one night past his 80th birthday my mother called me in a panic. he's pacing through the house saying he needs air. he's all agitated. i ran over there. he was incongestive heart failure. i called his doctor, one of my younger associates, i'll meet you in the e.r. he said. it's such a reassurance to hear these words from a physician one knows a trusts. this was the beginning of a seven-year siege for my family, the beginning of the end of my father's story. it started in the hospital where i made rounds every day for three decades. no one made any mistakes. my father received excellent medical care, the best available in america today. his heart failure improved. but within two days he became confused and paranoid and delusional. his dementia had been unmasked. the medical condition is called delirium and it is an increasing problem in our frail and aging

population. i stay with my father every night fending off bed rails and i.v. poles, checking every pill he took and every fluid-filled bag plugged into his arm. and when he became too agitated to rest i reassured him with my his shoulder and one night to quell the demons ofs his delirium, i crawled into bed with him and held him as he had done with me a lifetime ago. after four days in the hospital and with the assent of his physician, i took my father home because i knew as a giatrician that if i did not, it would be unlike lip he would ever come home again. to continue this hospital stay in this frightening environment would only a to my father's confusion and agitation. it would require more medications and engender even more potential side effects. a further stay would have just been a way station to placement in a long-term custodial nursing home.

what my father needed, what many of our patients with end-stage illness need was less medical care, not more. they need guidance not cat scans, familiar faces and places, not 24/7 institutional care. they need, familieseed to understand the limitations of modern medicine and with on the spot help, education and regular communication with trusted caregivers, many folks can remain in their homes and be more content there. and so my family took my family home and i promised myself that i would never put my father back in the hospital again. that i would do whatever it took to keep him in his home. and my mother, my brother and i would be there by his side. what did my father want? i had spoken to my parents about advanced directives and about the durable power of attorney of healthcare for years before. as in most american families, these are difficult conversations.

americans do not like to talk about death. 75% of us have not had a conversation with those we love the most about how we would like our deaths to be. what we would want done and what weould not want done. i'm not the first one to make the observation that humans have a powerful desire for immorality. no one wants to admit he or she is going to die one day and perhaps it is this. our fear of death that fuels this debate we are having. years before i had spoken to my parents about these things because as a geriatrician, a primary care doctor, i know how important it is to get people thinking about these issues. it's a process complex and time-consuming. what exactly is cardiopulmonary resuscitation? what does it mean to be fed through a tune? how does one live on a ventilator. if i sign this form, are the decisions irreversible? can i change my mind? in the end my parents had signed

the forms and made me their healthcare proxy. you're the doctor in the family, after all, they said. i took a deep breath and filed the forms away, tried to get that one day i might need them. i wrote about my father's illness in an essay that you've heard about that first appeared in the narrative matter section of health affairs and ended up getting excerpted in the "washington post" outlook session and i awoke in august of 2005 to find 500 emails in my box. thousands more followed. i was not prepared for this. i've spent my life trying to solve my patients' problems, patients like dorothy here and weent through so much together. but i tried to solve these problems one-on-one together with families, the basic principles of medical ethics as my touchstones, autonomy and justice as we teach our doctors in training today.

and what i learned from thousands of people all across the country all are at sea. all too often they had no one to turn to, no voice of reason, no trusted resource. i wrote about my experience caring for my father about my life as a geriatrician, about all the lessons i gleaned heing from so many people in this book which i call a memoir manifesto. and in it i outline the failures of our healthcare system to adequaly address the needs of our aging population and their families. i try to reach out to all the people who are struggling as my family has struggled. imagine you arelone in the house with your debilitated or demented loved one or you had flown in from across the continent and are now at the bedside of your father or mother in a hospital icu wondering what to do next as the respirator hiss and clicks in the corner. you pace the halls of the nursing homes as the aids come to clean your mother's bottom

and opaque fluid is through the plastic tubing which snakes under the sneet and into the stomach of someone you once knew and still love. you feel guilty, and powerless and abandoned and angry and bereft. you have decisions to make and no one to guide you. your father's doctor or some anonymous care jet stream on daily rounds floats in and out of the room very early or very late. you think they are trying to avoid you on purpose your difficult questions and maybe theyre. your own children live far away. your siblings are objects nit or in denial or still angry overhx some long-ago slight, some fallingout which seems silly now. you are afraid that you'll make a mistake, decide the wrong thing, choose the wrong path, honor thy father and mother. your head spins. why can't i feed it through the

tube. if i discontinue this infern respirator i know he will die. the doctor says she must go back into the hospital treat this pneumonia again. how many times can she survive this? is this hurting him? would she want this. if i said enough am i committing a sin, murder? will mom forgive me? my sister. will i ever be able to forgive myself? i considered my responsibility to help patients and families make these difficult decisions and for decades i have done so. i have spent hours and hours with patients and spouses hours more with children and siblings. the conversations are often complex and emotionally wrenching. but as far as medicare is concerned there is no monetary value assigned to the time and efrt it takes to have these difficult conversations, not only in a time of crisis but in any time. there are now proposals as you've heard to compensate a patient's personal physician doing this hard but essential

work, proposals that had been misconstrued and misrepresented. on february 24th, 2006, my family celebrated my parents 60th wedding anniversary, the last one as it turned out. we had managed keep my family at home it took a toll and yet none of us would have done it any other way. the cost, though significant, and this is an important point, were much less as if my father had been placed in custodial care in a dementia unit. and i believe he was happier at home than he would have been anywhere else. still these were difficult times. we had weathered his incontinence, his belligerents and his falls. i always thought he would break a hip and i would have to make the decision to have it fixed or not. i know he could never survive the surgery and rehabilitation.

in my dreams i fantasized about autosized my poor, agitated and confused father when the time came and he was in pain and there was nothing more to be done. but that was the grieving son, the lost boy having those thoughts. the doctor, the professional, knows more. i know that as a doctor, as a geriatrician i could never do this to anyone. i had been steeped in the healing traditions of my profession. i could never by law or sanction or regulation or edict or order cause purposeful harm to anyone in my charge. i know that excellent palliative care is available these days as you have heard. and adherence to m professional code i join the ranks and my colleagues who practice with me in time, those who came before me and those that will follow. soon 20% of america's populace will be over 65. by 2050 there will be 18 million people over 85. one-half of them will likely

have some form of dementia, only 20% will be fully mobile. at the same time that this most vulnerable population is growing, the numbers of physicians and trained nurses caring for the eldly and other professionals is shrinking. the number of primary care doctors being trained is half than a few years ago. our current circumstance a collapse in primary care. only 300 or so geriatricians are trained each year, fewer than those entering retirement. currently the is one geriatrician for every 8,000 people over age 65 in america. why did this happen? how has this happened? doctors didn't create this problem bad public policy created this problem. reverse payment incentives have undermined primary care medicine. have promoted specialization and technology over face-to-face interactions between doctors and patients and families. all insurance systems from

medicare to managed care have undervalued doctors like me for decades now, devalued our time, our cognitive conferencing and consensus-building skills, rewarded us for another thing, another trip to the e.r., another round of antibion theics and another course of therapy. we need to take the time to restore where the primary care doctor-patient relationship has meaning and value again. people's family want and need someone to trust, someone to advocate a for them, who will go to bat for them, who will tell them the truth. who will talk to them in the most difficult times, educate them and offer options. and study after study has shown that the healthcare provided by primary care doctors, restoring them to the center of the paradigm will be less expensive care and more satisfactory care. and it also involves educating the public about the importance of advanced directives. this is a wonderful website put together by the center for

medical humanities and ethics where i teach by bioethists, texaslivingwills.org. we need to educate the public. what procedures under what circumstances are helpful and which are not? what are healthcare proxies? what are their role and what can they do and not do? what is the role of your family, of your doctor? let me make this clear, nothing in anything i have seen is proposing that doctors substitute advanced care planning for medical care. no one is proposing death panels or outside experts decide who lives and decides. i would not be part of a system nor any physician i know. but any system tha refuses to reward the work of healthcare professionals for doing advanced care planning and conferencing with families during difficult times is preordained to be cold and bureaucratic, sterile.

and it will subject our frail elderly and anyone who finds himself at an end stage disease to inpropriate, unnecessarily exnsive and possibly futile care. end of life discussions are complicated. decisions are often arrived at incrementally. family members often at odds over men things must all be on the same page. and an electronic medical record is not much help here. most of the time there is no need to rush the process. it's a lot like health reform ought to be, well thought out and implemented with caution and concern. at the ends of his life, my father no longer knew that i was his son. but after each visit with my father, if he was still awake, i said to him, i love you dad. and it was always a surprise when he answered, i love you, too, because this was something my father could never bring himself to say to me when i was his 12-year-d son or his

50-year-old son. from the depth of his dementia my father gave me a great gift. he would be honored by my presence here today. thank you. [applause] >> well, thank you so much all three of you, for giving us is sense of what it really is all about in the areas you operate in every day. i want to start -- we're going to open this up once again to questions from the audience, but i wanted to ask you -- we've heard now in the weeks since congress adjourned that many lawmakers want to back away from section 1233. that it's basically been thrown overboard as far as some of the members of the senate finance

committee is concerned. it's just too hard to explain. people are too confused. it's just not worth it. how does all of this make you feel given what you've talked about? dr. meier, diane >> i have very mixed feelings about it. i think in the end the national dialog of national healthcare will turn out to be positive just as the terri schiavo debacle turned out to be positive. with the heat and smoke, there was light. people basically said throw them t. throw government ou these decisions belong within families. this is not -- you know, this belongs to us and i am hoping in the end, that will be the same conclusion as the recognition that advanced care planning is about restoring power and controlo the objects of all of th discussion and expense, the patient and the family.

and that we've begun as i and all my colleagues have increasingly been doing talking to the press about what advanced care planning really is. that we've begun tourn the tide on these lies about death panel and all they are is just lies. and we need to keep saying that. i also think that the most salient health reform changes to improve access to primary care geriatricians ke me and jerry to improve access to palliative medicine are things having to do with work force. those are much more important than, you know, a $75 payment for aiscussion about advanced care planning, frkly, which is not going to be sufficient to turn the tide on the physician incentives to keep doing things. all the incentives need to change. this is a strawman for assault but not that critically important in and of itself.

if we could do something about loan forgiveness to get people to go in to geriatric nursing or geriatric medicine or if we could do something to get medicare dollars to support palliative medicine training which fellowships are entirely supported by philanthropy which is a frail read for public policy, i might add, those policy changes which are unlikely to be controversial would have a huge impact to access to quality care. i hope some of those measures and they're in some of the bills that senate finance is considering survive. and if they don't survive this time, we'll keep on working on getting them in next time. >> chris? >> it's a very interesting question, san, and i think m concern is that so much of the heat, not only about the death panel issue but thethers has

not been in any way related to what's in the actual legislation as you know and as we've talked about all morning. so the last thing i would want strategically for the nation is to have -- to hold onto something that gets misinterpreted and gets interpreted and not get to what we've been talking about all morning which is expanded coverage for americans, reduced cost burden for the families and improving quality of care. that's what we really need to accomplish and within that, what we're talking about at the end of this morning about palliative care is part of the picture but it isn't the whole picture. so i would not want to -- i wouldn't want to have that undermine the chances of a reform package getting through. i do think diane's point is very well taken. that there are a lot of things

we need to do in changing the payment incentives. the previous pel talked about bundle payments, medical homes, you could build in expectations about palliative care and about palliative care expertise in every single one of those. that would have much more impact, ovall, than as diane has said paying a primary care physician $75 once every fiv years to have a conversation. i mean, that is not going to transform our care system. >> jerry? >> well, you know, i think a lot of people when they hear about some of the proposed legislation get frightened. first of all, as i said, they're frightened about the subject of death. they don't like to talk about it and they certainly don't want any kind of top-down system imposed on them. so, obviously, you know, as a practicing doctor, i'm in favor of education. you're right.

every five years, you know, in a conference in the exam room is probablyot going to do it. but, you know, you've taken great education campaigns in this country to deal with other health issues. think about smoking. you know, now we're engaged in one with obesity. i mean, this is -- to change attitudes, to get people thinking about these issues and comfortable talking about these issues and i don't really know how to do that but i know there are people who do know how to do that and that's how we really need to be focusing a lot of effort. >> i think you all do a pretty darn good job of it and have done so here this morning. let's open this up to questions and discussion from the audience. once again i'd ask you to identify yourself by name and affiliation. if you would like to address your question to an individual panelists please do that. and while we're waiting f any

more to come forward, if we built this kind of stem, chris, that you just mentioned and that the other panelists also discussed, accountable care organizations where the payment goes to an organization and it's not on a fee for service basis. it's not stimulating this ct scan of that particular intervention that did, in fact, engage people as diane said -- when finally there's a recognition that maybe things are not going according to hope and that the time is near, what would these look like? these are also kind of scary concepts for americans 'cause there's not a lot of entities out there to point and say, see, this is something you might actually like. >> well, there aren't -- there aren't a lot of them but there are some of them. and they are not small. i mean, we've heard this morning about mayo and kaiser permante

and intermountain and aumber of other integrated goups. what could happen with something like an accountable care organization is that you could force the hospitals and all the different physician specialists to come together and say what do we need to take good care of this population of patients and then they would figure out they needed a palliative care expt and they would figure out a way to pay for it. and it wouldn't require any specific sort of overengineering of we're going to pay this much for this and this much for that and these systems would figure. that's what you would see at mayo. most of these physicians are on salary. if they have any incentive, it hs to do with patient satisfaction, which is a pretty good thing, it seems to me to care about.

and then ultimately it does end up costing less and there's very good data about that without anybody having to ration anything or limit any care that actually makes a difference but by really coordinating care and getting rid of the things like that, a frightening story diane told about the first patient where, you know, huge amounts of that expense not only wer unnecessary but were terribly paful for that patient and for that family. >> and, ane, would you agree with a comment darrell made in an earlier panel that there are lots and lots of physicians out there who want to participate in this change? >> absolutely. one thing i didn't mention was a conversation i had with judy's oncologist when he offered her chemotherapy directly into the brain. towards the last four weeks of her life and she called me and

said, m doctor offered me chemotherapy into the brain. what do you think? you know should i say yes to this 'cause -- you know, he'd been hitting them o of the park for the prior six years so we wanted very much to take his recommendations. so i called him. he and i had been in regular contact for about 14 months about judy. and i said, you know, what are you hoping that this treatment might accomplish for her? and there was a pause, and he said i actually don't think it's going to help her. so then there was another pause while i took a deep breath and i said, well, do you think we should be recommending that she do this given it's pretty hig risk because if you put a foreign object in the brain the risk of infection and toxicity is quite high and his response was very instructive. his response was, i don't want judy to think i'm abandoning her. so this wasn't about money. this wasn't about that's what he

get paid for. he did not know any other way to signal his commitment to signaled how much he cared about her. my job with him was to help him show how much he cared about her by going to visit her at home, which is what i did. i said she really wants. he had never made a home visit. he's in his middle 50s. it was increasingly meaningful to him and her and he spoke at her funeral and hopefully it will make it easier for him next time. but he never knew how to have that conversation. he never knew his presence, his commitment to her is what she needed, not another procedure but the motivation was to show but the motivation was to show so doctors do desperately want to do the right thing for their patients. there are no evildoers here. the system is structured to get the results that wsee.

>> jerry, i've seen you nodding. >> i want to pick upn a point. teaching young doctors, medical school residency, teaching them the kinds of behaviors that you mentioned. getting them to understand the importance of doing things to patients that aren't technological but are humanistic is very important and i have to say tt in front very -- in not as many places as it ought to occur is this occurring in america today. i really had the privilege -- it's been privilege -- my wife and i -- my wife is an attorney, and we both volunteer our time to teach a basic ethics module at the university of texas health science center in san antonio both in the first year and the fourth year and, you know, what do we do?

you know, we have conversations like we're having today. we read essays. we read short stories. we read poems. we talkbout these very difficult conversations that we must have with patients and how important it is for us to be attentive to these needs. i mentioned in the beginning of my talk that i deal a lot in nuance. you know, patients very often are afraid to ask these questions of us, how long do i have? what's the therapy going to be like? what can i expect? but if you're taught to read the nuance in your patient in a face-to-face conversation, it can make a tremendous difference. you can really he a breakthrough with someone. this needs to be a standard part of medication. very often, the dollars aren't there for medical schools.

i mean, we don't -- we don't treat patients at the center. we don't get research grants. we read poems with medical students, you know, why should that be paid for in our system? well, let me tell you, i believe that this can make a big difference. it has made a big difference. so aside from educating patients in end-of-life issues and advanced directives we need to educate health professionals in being able to engage their patients during difficult times. >> can i just add to that. think about mrs. g.'s pain, untreated pain. really her doctor did not know how to manage pain. i mean, i hate to break it to you. most of your doctors have never been taught to manage pain. you should be scared. they don't know what they're doing. it wasn't in the curriculum. most medical schools have no mandatory training on this.

they're very good intubating someone and putting them in the icu or, you know, ordering a pet scan. we're really good at that. but the most fundamental human needs have been lost from the curriculum. in most american medical schools. and we have no national control over that curriculum. medical school by medical school determines this. it's a huge problem. and there is no health reform without medical education reform. >> let's take a question here in the ont from gail. >> i agree with the concept that's been raised several times about the need to change the reimbursement system, reward the kind of behavior we'd like to see. i'm very supportive of selective loan forgiveness. i think it could be much more effective in an era when medical schools tuitions are very high and physician income growth has been very low or negative and we

are not giving it enough attention. but aside from changing the monetary incentives, important as that is, i'm going to implore you to use your influence to indicate this is more than just about getting the money redistributed. it is going to be how do we try to make sure we have the full spectrum of people who could be working on these issues, on can we make more and better use of advanced use of nurse practitioners to help us with our shortage of primary care physicians? you talked about training new physicians in these issues, which i applaud. i'm going to plea with you we need to figure o to figure out the physicians that are out there we can't rely only helping to retrain the new ones coming through. i have to say when i have spoken

to physicians that are in residency or while they're still in medical school, i at no, ma'am overwhelmed their training seems much different from the training of other physicians including my husband who was trained in the 1960s. some. but not fundamentally different. so i'm going to urge you because you spend your life on these issues of trying to think about in addition to arguing for more money and for better recognition for primary care and geriatrics and in particular to think about strategies that we can use to reach out to existing physicians. i was going to ask you, diane, when you talked about the lack of knowledge about pain management what i don't know is do you think most physicians know they don't know about pain management? and is that sort of the first thing thate need to do of you don't what you're doing but

actually there are ways to fix that just like you can call on other people to help you and here are -- here are modules you can take in your next cme about pain manementnd other issues? it's just not enough to talk only about more money and not enough to talk aut only reaching out to the medical students. i mean, that's not going to get it done. >> gail, you couldn't be more right. i would point out we do talk loud about the pipeline but every physician is expected to learn new stuff throughout the course of our careers. we all do that and actually now all 24 specialties within the abm s boards require periodic recertification to show that you've been keeping up with your knowledge so we actually have a tool now where we could begin to both offer that kind of education and also measure it and hold physicians accountable

and actually recognize them when they achieve it. so i think your point is very well taken. you should be aware that some good news on the horizon. we've been talking about all the problems out there. is that ten different specialties got together to create a subspecialty certificate. diane was very involved in this in hospice and palliative medicine. there are board certified specialists in this aa and not just in the primary care arena but in several different surgical specialities, in psychiatry and pediatrics as well and the fact there's a recognized way saying this person actually has these skills should allow us going forward to be able -- and maybe even have, you know, educated consumers, especially, family members ask these kinds of questions, you know, do you have apecialist in this area or do you have

expertise in palliative medicine learn that term and ask people about it and that will begin, i think, make a difference, toú >> well, you know, i appreciate another comment, gail, but i have to say this. someone who's worked in a fee for service medical sector for over 30 years who has been basically at the mercy of whatever medicare cms decides every year whaty services are worth, i have to tell you this, when you talk -- let's not talk about more money in the system and i'm not talking about that either. i would like to see some shifts of money in the system. when an ear, nose and throat doctor gets more money for cleaning the wax out of my paent's ear because that's a surgical procedure than i get when a 90-year-old woman comes in and tells me she had a little spell and i have to use my time, my diagnostic skills to try to figure out is this serious?

does she need to go to the hospital and it might take me an hour and somebody cleans wax out of an ear and get more money well, i'd say there's a problem with the system and in my estimation -- and i talked about medicare being a flawed system. it is very flawed but it is fixable. it is fixable. if someone will sit down with doctors who have been doing this for a while andglxsay, you know how would you fix this? ist right that an mri scan is reimbursed at $1200 but you get -- but, doctor, you get $60 when a patient comes in with a little spell? well, i say, yes, we don't need more money in the system but we need to reallocate what's in the system. >> all right. well, as we wind our way to a close, i want to do a slightly different version of what i did with the earlier panel where i asked the earlier panel to speak to their elderly parents. i'm going to turn things around and ask you to speak to your

children or grandchildren. and i know chris in particular has a very smart 13 or so-year-old grandchild. i want to imagine you a couple really sharp 12 and 13 years old who are your grandchildren or your children. i wanted you to tell them what your hopes are for the healthcare reform debate that we are having in this country and in éparticular, with respect t these issues? now, these, of course, are going to be 12 or 13 yrs old. they're not prepared to think about death or dying. but they perhaps are smart enough to know that they too will get there some day or they certainly sense their parents or their grandparents will. so you've got 30 seconds of their attention because they're about to go play on the wii or something else like that. what do you say to them, chris? >> what a great question, susan. well, what i would say to micah is, you're right.

not to talk about death but most importantly -- and this gets to the whole topic of the session today is that my hope for her would be to live in a country where she didn't have to worry about going broke because of healthcare expenses, herself personally. that she could live her life and be confident that there would be some reasonable approach to providing medical care for her parents, for me and for her should she need it. that would be affordable and that she could actuay be reasonably confident that it would be good quality care. and so that -- that would be the main thing. what i would also say, getting to jerry's important point is that i've been trying to entice her into thinking about going into medicine, of course, and what i would say to her is -- and it would be a system that

would provide you a very personally rewarding career as a physician knowing that you could help people in the ways that made sense. >> diane? >> well, i have a 23-year-old and a 20-year-old, and what i would say -- what i do say to them is that i'm working for a time so that when they're my age, there will be no debates about health reform. everybody who is born an american citizen will know that they have access to high quality medical care just as they know they put a letter it will arrive. you know it's not true in many parts of the world. that's the postal system works. i want a healthcare system like the postal system that people can take for granted. it works quite well. it's consistt and standardized across the country. that people will get the care

they can benefit from and the care they need no matter where they are, where they are and no matter what color they are or their income is. that's what i'm working for so that my kids and their kids will inherit that kind of system. >> jerry, the last word to you. >> i have two daughters with -- who we call doctors. one has a degree in british romantic poetry. lau[laughter] >> and the other is about to learn her doctorate in counseling psychology why they did not choose to go into medicine i think -- well, we've touched on some of those issues today. but what i want to tell bet and emily is that your father has writn down, and, you know, where it is, what hwants when it's his time. and i encourage you to -- at

some point in your lives have this conversation among yourwn family and write it down. >> and on that note, we will bring this to a close. i want to once againay that health affairs really is so grateful to the organizations that made this forum possible today. the robert wood johnson foundation, the association of medical colleges, the american board of internal medicine and the american hospital association. we pledged to bring you a serious discussion that was at the level that the topic demands, a serious health reform as we said, demands a serious discussion. i hope in the process we also brought you one that you have found provocative, simulating, informative, and as we heard from the last panel, even emotional. thank you very much for coming today. please take a look at our website, www.healthaffairs.org

for additional information including the policy briefs we published to date and the policy brief we'll be bringing out today. thank you so much. thank you to this really excellent panel and the previous panels. good day. [applause] [inaudible conversations] >> from i'm carmel, indiana, what do you think about healthcare? the healthcare reform? i think we don't have all the facts. i don't think anybody has bothered to lay out everything that's going to happen, what's in tojact. no one has bothered to communicate it to people. they couldn't vote on it before

recess. they need to share the information with us now so that we know. >> whato you think the end result is going to be at the rate they're going? >> i don't know. the bottom le is it doesn't matter who writes the check for healthcare. the whole delivery system needs reform. that's what they need to look at it. not who's paying for it how it's delived and the cost of it. >> is there any politician in washington that you agree with at least some of the time. >> no. >> not really. >> no, not really. >> i'm james hobson i'm from somerville, south carolina. concerning the healthcare debate, my biggest concern when you ask a generic question should everyone have health insurance i truly believe that. but then when i think about the thoughts of government option, my concern is does the government outprice the private insurance and have a monopoly and individually take over the entire process? that scares me. that concerns me. and i don't have a clear answer on that. >> my name is timskinner, i'm a

social studies and i'm a state senator from west central indiana. i think the debate about healthcare is long overdue. the things that are on the table right now, i think lend themselves to a pretty broad discussion of some of the problems that we have in hot pick in the united states. and i'm very confident that the piece of legislation that we end up with isn't going to be anywhere as near as encompassing as all the things we're talking about but that's what the process is all about. we have to have this discussion and, you know, the people i think personally, i think, that are opposed to this probably have good insurance. they're working and they're rtunate enough to be covered. you talk to the 47 million or whatever the number is today, people who are uninsured in this country and they're adamant about having this discussion. we have to have it. our country has to have it. >> has there bee discussion of this in the state sate at all and what was the outcome?

>> well, we st had a national congress and state legislators in pennsylvania and we were going to send a resolution to the administration encouraging them to continue the debate on healthcare and there ended up being a debate at the state again, it fell on party lines, the republicans opposed and democrats thought the discussion ought to happen but fortunately we were able to send our resolution out of the state legislators convention and it's going on to washington and it really -- all it is is just encouraging them to continue the debate. >> my name is carole finnell i'm from indianapolis, indiana, and i think as american citizens everyone is entitled to healthcare, and i'm personally

hoping the public option will be considered strongly. i have two sons who have been unemployed and they don't have y healthcare because they lost their healthcare when they lost their jobs, so not only for my two sons and before anyone who's in a similar situation, i'm hoping that healthcare can be available for them and for everybody. >> i'm kenneth w. scott iii of meredosia illinois, i'm against the government health insurance. i believe there's various different items and things like that -- i don't believe government takeover of the health system is going to be what we're looking for. they've proved so far that they're inefficient in 3=h @&hc% everything they've taken over

and i don't have any faith or trust in the governmt control of a healthcare plan. >> who's your congressman and has he had a town hall in your town yet? >> the congressman is aaron shock he hasot had a town hall in our town. i know he had various functions throughout the district. he's a very good congressman. i believe he is -- without putting words in his mouth, i believe he's against singletp payer!! system. >> and as congress continues its summer recess, we want to hear from you. are you attending a town hall in what do you think about the being debat]t share your experiences and thoughts with us on 9xvuoñvideo. go to c-span.org/citizenvideo. ernt÷ppñ snñ ..

>> okay. we are very pleased that the secretary chose to use this occasion to launch more information about their efforts. it is very clear he is real focused on doing what works.

anxiously moving forward, kids will not be able to benefit from the american dream. we will change this a little bit it is keeping in the session this morning. judy and cindy will share with us what is working around the world and what we know about american education. what else do we need to do to make sure our kids are getting ready for college and couriers with no mediation, a singular focus on making sure kids are getting ready. it is my pleasure to introduce -- i will start with judy so i don't have to interrupt, so i will introduce both at the same time. let me say this, america's choice and act have had a stronger partnership for

year-and-a-half. it has been my pleasure, i smile all the time when i see judy and cindy together because they should have known each other years and years ago. they make a perfect partnership. judy has spent the last 50 years taking a look at education, and every high performing nation in the world at america's choice. we use that information to develop our own strategies to support student growth. in addition to her strong background as ceo of america's choice, a long history of being relentless, she was a fabulous -- in a couple places around th country, she likes to talk often and shows her love at the high school in pasadena that she led which was exactly opposite of a

high-school that she led in new york. again, it was a perfect example of the haves and have nots, this is a lady who is relentlessly focused on making sure our kids get the upstanding information they need. other than that they are not successful. i have had the pleasure of knowing cindy for the last four or five years now. i had the benefit of getting to know actrom the inside point of view. those of you who don't spend enough time online, if you want to expand what you know and be provided with some tools to share with your colleagues, i encourage you to go on the web site and take advantage of these

wonderful reports. act is very happy they have had her for a number of years. we want our people to think you are 22. everything we see in terms of the growth of that organization, their movement not only to say attentive to the kind of assessments we need to have so that our kids are successful in college but turnaround and saying what else as an organization do we need to do. we know what else is included, adding other programs to their tool kit. a few years ago, saying it is important for us to take a closer look at what is happening on the inside of schools, and from that, their quality corps program. i am going to stop here and we are going to be let judy shed the rest of the world with us.

>> thank you, pat. [applause] >> i know you join me in thanking secretary duncan and jim shelton for coming to our symposium which is really designed for you, not the rest of the people who are here, really talk about the subject of innovation and how important it is to our nation that we do things differently for all of our children. it is very coincidental. people asked why did they choose this symposium to make this sort of pushing forward on the concept of innovation. i think that the work we are here to discuss today in terms of what is good for kids with the rigor and readiness initiative, is one of the

examples of the kd of innovation that is going to be necessary to tremendously raise the achievement of our students, i would like to echo past's comment to those of you who are sitting and doing the most important work in our country today, those of you who are in districts as superintendents, chief academic officers, teachers, other people who are absolutely on the ground critical. we couldn't ask you to come to a symposium at a more inconvenient time. so i thank you. we recognize this. i thank you for that. obviously, in part, it depended on the secretary being available and we wanted you to have that opportunity to hear what he had to say firsthand. thk you very much.

it is very clear the secretary spoke about the performance of our kids and i want to say a little bit more about it but before i do, i think all of you know who act is. act is an organization that i have had enormous respect for, having been a high-school principal for many years. the reason i have respect for act is because they actually wanted to measure what kids learn. that is a very big difference in testing in our country. is an enormous pleasure to be in partnership with act. but not a lot of you know anything about america's choice and i want to take just a minute to say something to you about america's choice. the secretary said america's choice was a program, the national center of education, the economy, we are now separate

company, national center is our parent company. our mission has never wavered, and that is to get all students high standards and high achievement, no matter where the kids start. that is an important issue, it is one that we share in common with all of you in this room and we have had the opportunity to work with over 2,000 schools and have been the turnaround partner for a number of states including arkansas, hawaii, massachusetts, mississippi, new mexico, etc.. we work intensively with school districts, schools, states it, and we provide professional development, coaching, technical assistance, capacity building, and provide instructional solutions for students who

struggle to do grade level work. i think that puts in context -- pat talked a little bit about my own background. i had a unique opportunity of being an elementary school teacher and middle school teacher and principal, a high-school teacher and principal, some of the most privileged edution systems in newton, mass. a bronxville, n.y. i had the opportunity, to work on a project in africana and do extensive work in the people's republic of china. but the most important work that i have done was to be a principal at an inner-city high school in los angeles county. in my own life, i came to the conclusion after spending many

years in suburbia, that i needed to understand what it would take to dramatically increase the performance of kids in some of the most difficult situations, so all of you get the picture of schools in los angeles county, it is not without exception, with the gangs and drive-by shootings and other things that go on in the life of a school in that environment. but what that experience did for me is it convinced me that the most talented students in our country are sitting in our cities, the schools in our cities, in our rural areas. they're not just sitting in suburbia. that also convinced me with the right conditions and support with quality teachers and principals and clear high expectations, those kids will

perform as well as any kids in the world. that is what we have to perfect. everyone who works at america's choice is committed to doing whatever it takes to support our most challenging educational situation. and you wouldn't be here for this meeting if you didn't care about the hundreds of thousands of our young people each year toward giving up on formal learning, abandoning school and are actually prepared tdo very little with their lives when they graduate from high school. and trust has recently told us that we are the only industrialized country in which our young people are less likely than their parents to graduate from high school. that is startling to us.

and what we see is the gaps are growing and they are tremendous. so when we talk about the achievement gap in our country, i am not sure we're talking about it in broad enough terms. you have to look at the achievement gap and the differences between students of different ethnic and racial backgrounds within the same district. that has been a primary focus of no child left behind. we also have to look at it in terms of different income levels, we have to look at the achievement gaps between similar schools, similar students, different systems in our country. so if you look at it from the different performance of kids in schools, and you look at it with a different performance, schools

in the same system, the same schools across regions, the other issue we don't ever talk about very much is, as the secretary mentioned today, the achievement gap between the united states and other nations. i think it is very important to look at all four dimensions of this achievement gap. and the initiative sponsoring this symposium by act and america's choice is designed to address all four components of the achievement gap. but the one i am going to focus on is the difference between the united states and other nations. st to get your attention on this topic, the economic conditions of the time. of mckinsey report recently came

out that indicated the persistence of the achievement gap between the united states and other nations imposes on the united states the economic equivalent of a permanent national recession. think about that. as a country, we are in a permanent national recession because our kids are not performing as well as other kids in the world. dave and to the trouble to define economically what that meant and said if the united states had closed the international achievement gap between 1983, and 1998, that i a 15 year period of time, and raised its student performance to the level of such nations as singapore and south korea, the

gdp in 2008 would have been between $1.3 trillion, and $2.3 trillion higher, represenng a 9% to 16% gdp. that is astounding. what is the achievement gap of our kids compared to other nations doing to everyone's quality and way of life? it is astounding. i think in terms of what the secretary said, that it is very clear that we can't continue with the status quo, we have to do things differently, we have to look at different ways of educating our children and meeting tir needs. therefore, the $650 million fund, that every person in this room ought to be applying for, without exception. let's take a quick look at the

data that the president of the united states has looked at and the secretary of education and his staff have been poring over, that caused them so much concern. i think all of you are really familiar with pizza. it is something that, if you are not, it is important that you become familiar with. pizza is the most comprehensive international assessment to date. what is very interesting about pisa as opposed to tims, it looks at 15-year-olds from a real world learning and problem solving point of view.

it takes -- skills and knowledge by themselves will not help our kids in terms of the lives they need to leave to be able to solve the problems that will be presented to them. knowledge by itself is not important unless our kids can use it. this is the underlying assumption of pisa, a recent people focus on pisa in many ways. is also interesting that in terms of the geographic and economic coverage, pisa covers the countries that produce 0.9% of today's economic output. it is an enormous collection of countries that participate. pisa also should be said is across many subjects and is not constrained to multiple choice questions. this information you know clearly about the result of our

kids. you heard the president refers to it, the u.s. ranks 20 fifth out of thirty nations in math, 24 out of 30 nations in science. among 15-year-olds, our kids are on par with the students of portugal and the slavic republic rather than students in countries that are more relevant to the service sector and high-value jobs. we lagged considerably behind the top performing countries and in some cases it is by the equivalent of several years in schooling. in other words, even though our kids have as much schooling as their kids, our kids are several years behind their kids. but what is not well known about this international data, which we don't talk about very much, is the performance of our students compared to the

performance of top students in other nations. because i think we are all, having been a school teacher and principal, very high achieving places, our kids performing very well, we have some of the kids perforthe best in the world. but we are looking at a cold war of our top kids. the united states has the smallest proportion of 15-year-olds performing at the highest level of proficiency in math. korea, switzerland, and the czech republic, top performance at the united states. if that is not enough, the achievement gap between the rich and the 4 students of families is much more pronounced in the

united states than in many other nations. in other words, in other nations, because your family struggled and did not allow lot of money, it is not a key determiner for student achievement in the same way that it is in the united states. poverty in the united states in many cases becomes synonymous with poor student achievement. shame on us as a nation. if you look at this, and i hate to go back in history, it touches on my own generation, think of what the landscape looked like in our country and where we were in the 1960s in terms of the proportion of

individuals who successfully completed high-school, a minimum entrce ticket at that time in the 60s for the knowledge economy. when you look at the united states, you see where we were, number one in the world in the 60s, and you see where we were in the 90s, we were number 13. it is not that so many fewer of our kids are graduating from high school, as the rest of the world caught up with and went beyond where we were. we remain more static and struggle to keep that static when the rest of the world has gone beyond where we were. look how astounding it is. they were 27, they became number-1. they are not only number one in terms of quantitative number of kids, but also in terms of

performance, in terms of the measures that are important. in960, south korea had the economy of afghanistan today. so look at what education, the rise of education and the rise of the economy and the quality of life has done r the people, same thing with finland, finland went from 14 to eighth in quantitative terms but went to number 1 in pisa in terms of student achievement. this is why for us as a nation, doing the same are just a little better than the year before, will not be enough. this is so wide is innovation money is going to be important. we have had a great deal of pride in our nation about the

quality of our higher education system. some of us in k-12, in many ways, take pride, we have a little resentment of the quality of our higher education system. in 1995, when you look at the united states, we had the second-highest number of college graduates in the world. in a ten year period of time, we went to 15. from 1995 to 2005. for those of you who have watched the show on cnn on sunday, you know he talked about it in terms of the rise of the rest. th is the way we have to look at it. we are satisfied with where we were, rather than the pledge to

do a lot better. the next thing is the woman who was -- superintendent that had to deal with me as a high-school principal in california is here. i was not an easy one, she would tell you, to deal with. i always wanted more money. i never had enough resources for my kids. this particular slide sort of puts in international perspective the issue of money. when you look at it, we can't say that money is the determiner for student achievement across the world. this is a controversial slide, i want to put that out to you because oecd has released trouble to make sure they're comparing apples to apples, with

free and reduced lunch, bus service and all those things we do that not every nation does. they really struggled to make this an apples to apples. regardless of what you do, the united states has one of the highest expenditures on education. and you look at who the high performers are, above the yellow line, if you look at it in terms of expenditure, you can see a collection of countries, finland, netherlands, canada, japan, australia, korea, who don't begin to spend what we do, but whose studentchievement is more. there are many political, societal, cultural reasons for this, but it is not acceptable for us to accept it as do for our kids. this next slide is not something

that people look at either in terms of pisa information that i think is very important, and it begins to get at what is important in terms of what is necessary. in oecd they often use the word challenge. we would use the word standards. what are the challenges that are put for kids? we would talk about it oftentimes in terms of standards. this is really looking at the dimension of challenge and support. where our ambitions are low, teachers and schools are poorly supported, nobody would expect much, right? lower left. but by establishing high standards, without backing them up with good support for teachers and students, high standards, doesn't make any difference, they're not going to reach them. it is not enough.

conflicts often develop. that is the lower right. strong support with low standards. what is that going to do? it is going to produce uneven achievement and uneven performance. where we all want to be is high standards with lots of support, right? the upper right hand quadrants. where do you think in terms of oecd looking at all of the country's. where do you think the high achieving country is clustered? a right. right? where do you think the united states fell in this? this teaches us to have high

expectations across the board for our country. it is extremely important. one last piece of information that we need to look at, so that when we look at what is happening around world, many people talk about the 20th-century as being the century of the west, the twenty-first century as being the century of the east. we have to really think hard about that. if you look at china and russia, they collectively have about three million people. if they only educated 10% of their kids, only 10%, to a high level, that would be the same as our population, if we educated everyone to a high level. t's just say we educate only 25%, which is high right now. if we educated 25%, that would give us seventy-five million people. when you look at the global economy, you have a pool of three hundred seventy five

million people. and then you have cost of living, standard of living, if people are really pushing for these global jobs, who is going to get them? if our kids can't be adaptable, flexible, smarter, mord innovave, it is going to have a lot to say about where we are going to be as a nation. i use this as a backdrop to talks next about what, in visiting all of these countries over the past 17 years, that i had an opportunity to visit, 23 of them actually, in europe, australia, new zealand and asia, some of them might have been anywhere from four to eight times, i look at some people have been with me on some of these trips. and what we try to do and

understand is very important. what does it take to produce successful schools and high achievement on a large scale? how have other countries than it? is there something we can learn from how they have done it? i enter this conversation with you today saying that our kids are as capable as any kids in the world, and don't ever think any different. that is no excuse for us. what are the highest performing countries? what are the common characteristics? i have to say to you at the outset that what we didn't do is take the design of the government as a criteria or as a characteristic. many of the highest performing countries have a federal or national system. we do not. there are othe, australia,

canada, they don't have the same national or federal system. let me say a word about each one of these. one is high expectation for all students, i am looking at the time because our time is so off. the best performance is very high in the high achieving countries and there is very little difference between the best performance and the worst performance. the worst performers in those countries are, in fact, performing very well against international standards. what you see is, in one way or another, the mission in those countries is to ensure the t 10 of the students compare favorably with the top 10% of any students in the world. remember what i said about our top performers. they actually benchmark the top

performers to the top performance of all kids in the world. what is so interesting is there is not a big gap between the top performers and the bottom performers. and hence, what those countries have done is they have addressed all four components in the achievement gap. what we see in this country, if you look at talk with kids and of their curriculum, look at their standards, what we see is what is expected of the average student in american schools is far below what is offered and expected the average student in the highest achieving countries. by closing the achievement gap in our country, won't do it. if we don't make the top

performance much higher. in order for us to be competitive, we have to ratchet up the whole system while at the same time closing the achievement gap. i don't think there's any better definition of what the purpose of an innovative fund should be. the second thing has to do with a coherent line in the structural system. the term lined instructional system is used a lot today, it is a favorite word of people today but it is not used in the same way in our country as it is used when you look across the world. across the world, and aligned instructional system is driven by an examination system that is a result of tools and is linked

curriculum -- for to the train wreck and course syllabi with instructional materials focus on preparing students for the exams. teacher training focuses on comparing features to teach the curriculum, and it is all aligned in this high quality examination system that is designed for all students, not just for some. it is fought in those countries that teaching to a good test is thought to be good. like many teachers in our own country think teaching to the ap is a good thing, most of the people in our country today don't think teaching to their state test is such a good thing even though they have to do it. in each of the high achieving countries, it has a more less fixed curriculum for the first nine or ten years of schooling.

everyone takes the same courses in the same sequence with very future leases along the way. there aren't the red birds and green birds in reading, there are not the high math and lomax by the second grade, all kids are expected to achieve at the same level and the supports are there for that to happen. what is important when you look at that is it means that kids can move from school to school or town to town and teachers don't know what to expectf kids. i want to say one more word about the core curriculum students take in high-performance countries. the reader of the course is well defined. it is not each teacher making up his or her own rigor. course design state the form of supply which descriyllabi whichs

of the course, what projects kids need to be engaged in, indicate what kind of quizes and exams along the way will be given. even goes as far as the kid knowing what their final grade is going to be based on. isn't that interesting that kids know? i don't want you to confuse this with what many districts are doing -- i apologize, i just want to put it out. differentiated instruction is the key in a high achieving countries which is not something that most allow. the system of this sort, the suite of available courses is not accidental, this course or this course, it is the result of

a a carefully designed student corps program, not just the design of the subject but the design of the program. i will touch upon another - i have never seen, in these high performing countries, test prep going on. i have never seen it. i see a lot in the asian countries about cram schools and preparing for exams to university, but that is outside the school day. that does not dictate what the curriculum is. that is what is described as a line -- aligned in structural system. sorry.

sorry. the third area i want to focus on is the safety net system or a system of safety nets. in those countries as you imagine it is not acceptable for any kid to fail. in a standard driven system, the standards remain constant and the time is variable. we pretend today that we put in place a standards driven system but when you look the rest of the world, we have not. time is constant in our system, the standard of achievement is the variable. think about it. four years of high school, whether you achieve what they need in order to be successful or not, also in those countries a safety net system does not refer only to what is done in school, it is what needs to happen to ensure the success of each kid. we have a difficult problem with thir, child poverty in the united states, the highest, the

18 most developed countries, with almost one out of every four kids living in some degree of poverty. no wonder finland or denmark beat the pants off of us because they have less than 5% of our kids living in the kind of poverty that many of our kids are today. what is interesting is in those countries, it is that 5% to get the most services, assigned to them the most highly qualified teachers, receive extra support not from aids but from the most highly qualified teachers, and are provided with extra years of schooling. they bring the source because it goes back to the moral

imperative, that every kid is worthwhile, not just the ones that are achieving. schools at the bottom 5% in our country, predominately do well. they serve high poverty enrollment. they generally have the least qualified teachers, they generally have the worst physical conditions, they generally have the least resources spent on them. so when i went from scarsdale and bronxville jenna lee spent $20,000 for kids, and went into the syst where we responding $3,500 per kid at the time, you tell me money doesn't matter? the kids who needed the least getting the most, firsthand experience. but poverty can't be an excuse

for low achievement. we have to change policy but it cannot be an excuse for low achievement and everyone in this room has poverty schools in their district where some kids are excelling in extraordinary ways and we have to capture that. we know we have to intervene on the part of kids. we know we have to provide intervention and acceleration programs. the role of the safety net system in the high achieving countries cannot be overemphasized as critical to the success of the students. high standards, demanding curriculum, appropriate performance track, they are all important. but they are not sufficient. safety net is a key determiner in making sure the mission of the top 10% and the lower 10% are very close.

i got to hurry. the next one is a belief that performance really matters. we saw in both asia and much of northern europe that what is done in schools is done to support high student achievement. i have to tell you that when i first saw this, it caused me to do a lot of reflection, because it was clear that as a high-school principal, i'm that too many things to interfere, to become a distraction. in high achieving countries you don't walk into schools with announcements blaring. you don't see interruptions during instruction to deliver lunches, you don't see class periods canceled for pat riley's and interiorscholastic sports. the schools know their purpose, that is to educate all kids to a high standard. in most countries, is believed that education is a civil rights and is treated like that.

the fifth area, focus relentlessly on results. it was first in asia, all the schools were immersed in student performance data. the analysis of that data, people use program is. they stopped doing things that were not working, we add on instead of taking away. this was a big revelation to me. when you diagnose a problem, you need to treat it, you need to not use old medicine but new medicine. the old medicine isn't treating it. you have to plan carefully for it. the sixth area is in professional development and you see a real link in those countries between policy and

practice. the policies we know by themselves do not create good practice but they create the conditions for teachers to be able to receive the training that they need in order to do the right thing for kids. the main link between policy and practice in those countries is between teacher training, the way teachers are trained, and the ongoing professional development that you receive through out their education career. for example, in finland, lifelong learning is built into the fabric of the education system. it is expected that teachers participate constantly in carefully designed professional development programs. it is not an ad on, not something you try to fit in, but it is a design of the system. the other thing that i noticed is they encourage teachers to explore on their own time, they

would never take a math teacher who wants to take a cooking course and give them sour credit for it. it is a very different system. i don't need this. the seventh area is high quality teachers, the secretary has spoken about this. we have been hit on the head about it. when i asked the minister of education in finland what she attributed the enormous success of finland on the international comparison, she said three words to me. what were those words? three words. and i thought our meeting was going to be over. teachers, teachers, teachers. she had no other explanation. to give, as to why finland had risen to be the top performers. singapore topped the list,

participating in pisa. finland tops it in pisa. it cannot be by accident that the policy of the government of singapore is to recruit teachers from the top third of the ranks of high-school graduates going to college. finland does the same. in finland, the university's accept only 10% of the applicants into the school of education that they receive. they only accept &. there are cultural reasons for this that we caniscuss. right now, as opposed to singapore and finland, what we do is we recruit our teachers from the bottom third rather than the top third of high-school graduates. ed trust indicated that 88% of the teachers in highest poverty schools across the nation are in the bottom floor tile on basic

skills tests for teachers. 88%. surprisingly, 11% are in the bottom who are teaching in middle-class schools. how can we expect our kids to meet the demands for the twenty-first century, to achieve the kind of results we are looking for? if our teachers aren't able to teach what our kids need to know. this is a critical policy issue. we are in a state of emergency over it and it is not something that any one person can solve. the last issue of want to mentiothis to incentives. we have done very little about students in our country, this gets back to the notion of an aligned instructional system. virtual in none of t highest achieving countries has anything like the american high-school diploma. believe me, as a high-school

principal, i am not advocating that we do away with that right of passage, but maybe we can learn a little something from what they do. many of the countries that are high achieving issue a piece of paper that shows how students have done on their exit exams. many of the pieces of paper just like this list the course and exams. these pieces of paper are typically called qualification, no diploma issue, their qualifications because they show how well qualified a student is to go to college or enter a defined program of technical training for a career. kids keep that peace of paper with them all their lives. you going to those countries, you can ask to see their exit exam paper, they will pull it out of their wallet, generally. because one cannot go on to

further education or get a decent job without a qualification, and because the kind of further education or job that one follows for depends significantly on how well one does on these exams. there is a strong incentive for young people to take tough courses and to do well. in those countries, high school completion rate is high and the dropout rate is low. in our country, what incentive is there for students who are not seeking admission to a very competitive college or university to work hard in school? i come from a state where our students can go to community college without a high-school diploma. how seriously are you going to get kids to work hard in high-school when there are no

consequences for not doing what they he to do? follow these are the common characteristics of the highest performing countries, none of us can be naive to believe we can pick up any of them and transport them to this country. each country sits in its own societal, cultural and political context. but what we have to do is be able to learn from others, and have to adapt what we think would be good for our kids. these eight characteristics serve as a foundation of thinking for our rigor and readiness. as daunting as it might be to think about why -- whether we can actually address the entire range of the achievement gap, i actually think there is good reason right now to be very optimistic. we as a country have proven that we can do anything we put our

mind to. think about it. remember, it was the united states who pioneered universal free public education through grammar school in the nineteenth century, creating a vast, literate work force for the conditions of the time. it was the united states that led the way in high school for all. so i think we can be the innovators, the first time in my life, we are going to be given the resources to prove what can happen for our kids, and i have an enormous optimism that we can all do the right thing, and have our children and grandchildren live the kind of life that we want for all children. thank you. [applause]

>> good morning, everybody. i am pleased this morning to be able to share with you the research journey we have taken at act -- a.c.t. in the last 20 years, looking at college readiness, looking at the relationship between college readiness and college success, and taking -- sharing some of the insights we have gained from that research and why it has led us to the rigor and readiness initiative that we will be talking about for the next day and a half. let me explain that the data that i will be sharing with you this morning is coming from a.c.t.'s career readiness system, that is a system of assessments that begins in eighth grade, continues to tenth grade and certainly through the twelfth grade. we also are able, through longitudinal data set, follow these individuals on into and through post secondary

education. we are fortunate that much of what we will be talking about today really includes a longitudinal cohort of students from theime they begin in our assessment system in eighth grade call the way through college completion and graduation. with that in mind, i would like to start with the 2009 high-school graduating class. these are the results of this class that we released yesterday. numbers about 1.5 million kids who graduated this year from high-schools all across the country. what we found was this -- only 7 in 10 of the 1.5 million kids took a core curriculum in high school. let me say it at different way. there are still three out of ten kids in our country who are not

even taking the right numbers of courses in high school to prepare themselves for college and career. second of all, of the 1.5 million student only 23% of them met or exceeded our college readiness benchmarks, which signify that they are ready to go to college and take credit bearing entry-level courses in english, math, social studies and science. 23% of 1.5 million high-school graduates, which by the way, represents about 45% of our high-school seniors in the country. 23%. what we have done, when we say college and career readiness, let me quickly define how we look at that. we put college and career readiness at the level of

knowledge and skills kids need to know to go into credit bearing entry-level college courses without the need for remediation. in that regard we look at such courses as standard english composition, college algebra, the typical social studies courses such as economics, psychology, that students take in college and college biology, these are usually the most popular, most frequently taken college and resources. 1/4 of our graduates are ready to go into credit bearing college and recourse is in all four areas. another sobering statistic, of those kids in the 2009 graduating class he did take a core curriculum that is four years of english, math, social studies and science, only 28% were ready to go to college and take college and regretted bearing courses in all four

areas without remediation. these statistics, not unlike last year's, the year before, cause of to want to and have to delve deeper into get a better understanding of what is it that we can do in k-12 to better prepare our students to the college and career ready when they leave high school so no matter whether they going to work force training programs for post secondary education, they need a foundational skills to nefit from those additional courses in and training that they will receive. by the way, when we say college and career ready, we mean college and career ready. three years ago we did research and looked at whether the level of knowledge and skills that kids need to going to secondary institutions were, in fact, the same, higher or lower thanhat they needed to go into work force training programs. guess what we found? the level of skills kids need to

go to post secondary education is comparable to the level of foundation skills they need to go into work force training programs. let me be very clear, we talk about work-force training programs that are focused on jobs, that afford a livable wage that can support a family of four that offered career advancement and expected to grow in the future. the jobs that are projected, the majority of jobs in this country. the level of knowledge and skills those kids need to have -- going into post secondary education, the four instution without going into remedial courses. we're talking about a common goal for all kids, not just the ones that were once presumed to be college going, but all kids

after high-school. look a little bit deeper into the relationship between college readiness which ultimately is the proof in the putting. do they end up getting into the secondary education programs, staying in post graduate in, do they go to work force training programs and do they succeed and complete those work force training programs. let's look at corps first, the impact of core on the preparation of our nation's you youth. a want to reaffirm what we found in the class of 2009, we had 28% of the students who were ready to go to college without needing remediation, who had taken a core curriculum. by the way, ready and all four areas, had taken a core

curriculum, 20% were ready in any subject matter area. one fifth, noteady to go into any credit bearing course at any of the four areas, and the rest were ready in one, or three areas. the core being delivered in the nation's high-school, simply not enough. to guarantee that our kids will be prepared and ready to go into post secondary education and work force training programs. these results are very similar to the recent results where we see one third of the twelfth graders the low basic in math, 1/4 below basic in reading. there is a promisebelow basic i4 below basic in reading. there is a promise we are not fulfilling. let