enhance that. but the workforce is a critical piece of this puzzle, and it's something that can't be solved overnight, can't snap a finger and suddenly make sure that there are thousands more primary care docs. but that work has been underway since the passage of the recovery act, which again, passed early in 2009. so there was a significant investment in the recovery act in the workforce. and in particularly in the primary workforce. it's not just for doctors, nurses, nurse practitioners, mental health technicians, the whole host of providers who are essential to deliver primary and preventive care. also a recognition that we don't have nearly enough minority primary care providers, and minority providers altogether. we don't have enough medical

providers who have cultural competency. so that in and of itself can be a barrier to medical care. you may have a dock, but without language skills or cultural competency you may not have any connection with a community that needs to be serve. so again, part of that investment pipeline is set aside for enhanced recruitment. minority doctors, culturally competent providers, and that is being built out along the way. so that has already started. in the recovery act, also an enormous investment that than our 2010, 2011 budgets build upon which is an expansion of the footprint of community health centers. community health centers have been enormously successful in delivering lower cost, high

quality, very i would say community sensitive care, well beyond often health services, but a range of services from counseling in many cases, job fair opportunity, english as a second language, a host of services that really has made the community health centers in many neighborhoods are real community center, a real place that care is delivered. and i think if you think about the footprint that is needed for primary care delivery where you will have a medical home, in many cases community health centers have been extraordinarily successful. over the course of the investments made in two budget years and the recovery act, the footprint of the committee health centers will be doubled in this country, serving an additional 20 million americans. and i think that's very good

news, as an infrastructure that, not only delivers important primary and preventive care, but actually also is now working carefully with hospitals in communities across the country. so they're doing sort of a triage for hospitals, rather than having folks come through the door of emergency room, very often patients are we referred or initially referred directly to the neighborhood health center. but a lot of the kind of accountable kill organization is beginning to develop between community health centers and their neighboring hospital. i was in boston and there's a center around a couple of the busiest hospitals that's going on. cincinnati and a place in denver, there are models that are really very exciting, but the combination of high quality preventative and wellness care, combined with hospitals in doing their work in these a cute cares

is much more appropriate use of both of the facility. and i would suggest it allows a providers to do the work in a much more appropriate fashion. we've also made, in addition to the workforce training initiatives that are coming directly through the national service corps is being doubled. so people who actually agree to serve in underserved areas as an exchange for having their loans paid off is going to be come again, maximized. and that includes doctors, dentists and advanced nurse practitioners, again helping to build that pipeline. but also making sure that we can attract providers to areas where they are underserved. the reimbursement system clearly has penalized primary care

providers over the last several decades. and prior to the passage of the affordable act, those formulas began to be changed. we made the first of in the readjustment of the medicare formula last year with the payment being available this year where the recalculation began about what were the assets that calculate it of medicare reimbursement rate, to make sure that we were compensating the kind of care delivery that's so important primary care. so office visits, say, a consultation with patient's again to get more equal, what rate with some of the higher technical issues provided by specialty care. and that's going to continue. this is a multiyear, multi-step focus. but i would suggest that, among other things, the appointment of

the nominations, i should say, of doctor don burwood as the new leader for the center for medicare and medicaid services is another step in that direction, not only is doctor burwood known for his really landmark work on quality and cost initiatives, but he's a pediatrician. and he knows well the importance in this very exciting era of making sure that the workforce of primary care providers is enhanced and enforce. and i'm thrilled that he will be leading this effort and be one of the essential authors of what needs to be the new framework for reimbursement. and we have an enormous opportunity clearly within the programs that we run, medicare

and medicaid, to actually have this shift occurred. i don't think there's any question, if you look at how, in the long run, we are going to, in america, both have higher quality health results and a lower cost, it doesn't take a rocket scientist to know that we have to begin to intervene at a much earlier stage and in a much appropriate fashion. about 75 cents now there be health dollar is on treatment and care of chronic diseases. about 8 cents of every health dollar is on prevention and wellness. one would suggest that if we can actually attack some of the underlying causes of chronic diseases, get at them at a much earlier stage and have healthier 50-year-olds, that will have a very different, not only costs formula in america, but better health outcomes. i like to remind people that, in spite of the fact that we spend almost twice as much as any

developed country, we live sicker and die younger than most of our competitors around the globe. and that's not a very good formula for, not only a healthy nation, but it's not a very good formula, frankly, for national prosperity. we really, to me, it's a national security issue that we really have to look at, how we actually have a healthier country. so the initiatives in the affordable care act focus on prevention and wellness. i think finally we have an opportunity and a platform to really get serious about them. and it's everything from rewarding providers are keeping their patients healthy in the first place, to looking at strategies and models that we know work. we know that there are very promising indicators that the medical home model works, and

works very well. but again, it takes a team of providers, often not necessarily has to be a physician intervention at all time, but the coordinating care strategy involving the medical teams with nurses, with home health workers, with a variety of caregivers to do everything from preventive care and follow-up care can be extraordinarily successful. but built around a primary care provider. and were just recently added medicare to this system of medical homes that have been in place now with private insurers. in parts of the northeast and the colorado area, we want to make sure that medicare also is able to participate in those efforts. the affordable care act, as susan said, i allows us to move forward on a accountable care organizations.

you know, again a collaborative strategies and using bundled payment techniques that again i think can be extraordinarily helpful, but making sure that along the way, if there is some success, if there is some cost savings both in medical homes and accountable care, that providers to share in those cost savings. that is one of the incentives that has been enormously effective, and actually is an impetus to help drive more appropriate care use so that people spend less time in the hospital, don't return to the hospital as quickly, but there is a care strategy around earlier intervention, but follow-up treatment that really is effective. i know the huge investment that was made in the recovery act, which i think well, again, help enhance the primary care system is the investment in health information technology.

i would suggest that all too frequently primary care providers are somewhat handicapped in a system without an electronic medical record, where there is an inability to actually be able to coordinate the care from a primary docs point of view, where the cardiologist has one set of records and hospital may have another set of records that discussion and deliberation and appropriate treatment is sometimes very difficult. what i hear from providers across the country who have made the shift to the electronic record system is that, first, they would never practice medicine any other way. they would never go back to an old system. in fact, they can't imagine how to use to practice without it, but also the ease with which a patient's record can be accessed

and viewed simultaneously, that appropriate treatment decisions can be made. and again, i think a primary care doctor can often stay in place as that all the important link with steps along the way, which is virtually impossible with a paper system. in addition to just shifting to electronic records, the goal really isn't just to change everything that's on paper and just dump it into a computer and walk away. a really to help drive meaningful use at every point along the way, so that the investments are being made and hospital systems and provider offices are really also to capture the protocol of meaningful use. and again, i think it will enhance the role often of the primary care provider in the stream of medical care.

americans access to care is often difficult, and, you know, when you think about where we are now in losses other systems, it is really ironic that our health care system is so far behind. think about the difference of 10 or 15 years ago in a way that you needed to go access getting cash. you had to wait until the bank opened, you had to have a checking account, you know, show up, make a withdrawal, show an id, whatever else. the difference now to go to an atm machine really, not only anywhere in the country but anywhere in the world, put in a four digit pin and assuming you have some resources to any behind that four digit pin, money will actually come out,

you know, seven days a week, multiple languages, any country. most industries have used enhanced systems to expedite the way they do business. but we have not employed all sorts of technological advances in the delivery of medical care, and ironically, we are beginning to we experimented with some systems that are in place in developing countries, but not in america. for instance, in a number of pretty primitive areas, cell phone technology is being used to keep private women up-to-date on medical appointments, because even in pretty developed nations, there are cell phones owned by most of the population. we don't yet use that in actually -- the program is being

lost right now, text for baby which is beginning to experiment with just that strategy in some underserved neighborhoods to try to get a cell phone to a newly pregnant woman to try and use a very simple text messages back and forth to remind people about everything from appointments to vitamins the steps along the way, to try and enhance the kind of e-mail services that are available -- prenatal services that are unable. said a patient services so people can schedule their doctors appointments online, could ask questions back and forth of medical providers, could be in touch with providers without having to take time off work, to schedule an appointment, wait in the waiting room, go into the office, spend your 10 minutes and then have to go home. again, the systems that are

beginning to be in place with everything from many clinics to telehealth are beginning to establish a footprint. and i would say it's potential revolution. i was in the cincinnati children's hospital a couple of weeks ago, in the outpatient clinic with a mom and her daughter who has some pretty serious health challenges and has had that since birth. and the mother was describing the change just in the last two years where she can actually go and access provider information and a dialogue with a series of questions. they do a lot of home testing. she can send the results in. within 30 minutes she can get an answer back about whether or not they actually need the provider visit or whether not, you know, it's a change in medication or whether not it's just take a deep breath, this will pass. and she said you can't only imagine the peace of mind is to my husband and me, but also just

the extraordinary amount of time it saves for both the providers and for the parents and patients. and i think that technology is on the horizon, enormous investments have been made. and i think the recovery act investment gives the real tipping point. we are confident that as more hospital groups and provider offices take advantage of this, then the market will take over, but what got to get to the point where the majority of providers actually are using electronic systems, are ordering electronic prescriptions, are following patient care with coordinated care. and again, i think it really enhances the opportunity for primary care docs. so i don't think there's any question that underway is what has been talked about for decades as a system that needed

to be fixed and put back in place. workforce investments are underway and will continue to be made. and it's everything from encouraging more medical students to choose primary care fields, but also the more appropriate payments when they graduate from medical schools so they are not sitting with a pile of debt, comparing notes with a classmate or colleague who is looking at making three or four times the amount that they may make over a lifetime, and has the same amount of debt to pay off. that's not a very good incentive for people to look at, at primary care. i think that the focus on the sorts of efforts that we need to make fo for prevention and wells have never been in place in the way that they are right now. the affordable care act actually a lemonades the co-pays for

preventive care, for screening, encouraging everybody am medicare patients to private pay patients to actually, not only established a medical home, but follow the protocol producing the financial barriers for that to the efforts underway for childhood obesity and the prevention and wellness grants which we now distribute across the country for both obesity related efforts and smoking cessation efforts, again, can not only i think change, begin to change the health profile of americans, which is very good news, but again put in place and highlight the importance of prevention and wellness efforts. if we are able to, once again, decrease the smoking patterns in this country and decrease the proximity, the secondhand smoke

and really make a serious effort to go after what is and obesity challenge were two of three american adults, and one of three of our children are overweight or obese right now, and the underlying health impact of those conditions are extraordinary. they are extraordinarily expensive, but they are also extraordinarily costly in terms of comorbidities and in terms of lifespan that so having that effort and initiative underway, which again, what a primary care doc at the center of a coordinated health care strategy, investment and electronic records, not only to have the ability to coordinate care throughout a system, but have a true medical home model, a true accountable care organization, but then employ the underlying technology to really allow providers to once again be providers. i can't tell you how many docs

i've talked to who tell me, first of all, they haven't hired a new person in their office to deliver medical care in years. that anybody new hire in the office is to fill out forms and paperwork. you know, the front office, billing office, has grown exponentially, but often the provider side is more difficult and limited. and there are lots of strategies in this new legislation, minimizing overhead, the administration simplification that will help drive for insurance companies so we get to a much more simple billing form, a one-stop shopping for provider forms and for billing operations. and then implementing that through an electronic system can dramatically shift the time elements back to delivering medical care and away from being a clerk, which too many

providers do spend way too much time doing. and i think are eager to have the opportunity to return. and then the future of with every american having a payment system and an affordable care strategy that will come again, allow people and encourage people, and i would suggest access provided at a much more appropriate time, not only not to endorse an emergency room, but actually seek out health and wellness care, intervene at an earlier stage, will be able to build and centers around care teams in communities to outreach to the most vulnerable and most difficult population. and also i think to some exciting experiments with strategies that teach us how better to manage chronic diseases and multiple conditions in a much more effective fashion

than what's going on right now. so the combination would suggest is an opportunity to, not only clearly remain medical care, but use the tools of this in norma's public payment system to help transform the delivery system. and a lot of that will aim at the primary care providers. so it's a very exciting time. i think it's a very appropriate topic to focus on. and there's no question that the legislation that has been put in place and the framework that has been put in place since january of 2009 will he does usher in a new era in medical care, but certainly for primary care providers. and i just look forward to, as we get to the thousands of the secretary shall not not not

provisions, working with all of you to make sure that the strategies are implemented effectively but working communities and learn what are the best practices, what are the features that we need to frame moving forward and encourage and incentivize providers and systems, health care systems to deliver the best possible care to the american patients. thank you very much. [applause] >> thank you so much, secretary sebelius, for laying out that tremendous foundation. we know you have to get back to those shells. soe will move on to our first panel this morning, which is intended to provide an overview of the primary care crisis and

the prospects for reinvention. met ask our panel is on his first panel to come up and take a seat here at the dais. we're going to hear some framing remarks first from larry casalino, and i'm going to introduce him briefly as with all these participants. larry is the division of outcomes and effectiveness research and the livingston farrand professor of public health in the department of public health at weill cornell medical college that he came to cornell after nine years at the university of chicago where he was a tenured associate professor. previously he worked for 20 years as a family physician in private practice in california. is also worked extensively with the federal trade commission and physician groups and hospitals on antitrust issues. related to the clinical integration of physicians and of a physician hospital organization. we're delighted, will thereafter

that from kavitta patel is a board certified in internal medicine physician working to shape the future of our health care system and who recently stepped down as the director of policy for the obama white house office of public engagement and intergovernmental affairs. before that she served as a deputy staff director for the senate health education labor committee of his leadership of the late senator kennedy. before her time in washington she was a clinical instructor at the university of california, los angeles, and an associate scientist at the rand corporation focusing on research and health care quality. will thereafter that from joel howell who is the victor bond professor at the university she was also professor of department internal medicine at the medical school, also in history at the college of literature science and arts and health services management of policy division of the school of public health that he is currently director of the program of society of medicine and associate chair of the

department of history, and he's going to be providing an overview of the history of primary care. we will then hear from robert phillips was a family physician and director of the robert graham center of policy studies in family medicine and primary care. grandson as many of you know budget as a division of the american academy of family physicians. it is down by small research team focused on providing evidence to help foreign policy noting that doctor phillips also prices in a community based residency program in fairfax, virginia, and has faculty appointment at georgetown, george washington university in virginia commonwealth university. and then finally as i mentioned order will hear from george thibault, who became the seventh president of the macy foundation and january of 2008. immediately before that he was vice president of clinical affairs of partners health care system in boston. and rector of the academy at harvard medical school.

for nearly four decades, he played leadership roles in many aspects of undergraduate and graduate education at harvard. he also serves on the presidents white house house fellow commissioner joseph advisory group for the department of veterans affairs. let me turn things over now to framing comments from larry. >> well, i'm going to just try to frame one specific issue but i think it's an issue that if it's not addressed i would venture to say that all the things that the secretary just spoke about will fail. so i may be wrong about that, but i think that this is an issue that needs more attention than it has been given. and that is the fundamental transformation of the way decisions, primary care physicians especially spend their time. so right now we reward bad physician and we exploit could

physicians. and i don't think exploit is too strong a word. if you look at a barons article in the new jingle new england journal of medicine that you see e-mail and other non-visit base care that the physician and that practice provide, it's just stunning. these are good physicians and those things that they do for patient are very, very high value. there are many physicians in the country, primary care and specialists, who don't do those things very much but they see a very high volume of patients every day. i can say for my own experience in practice, they may see 40 patients in the day, they go home at 6:00 and to make a fair amount of money. what i'm going to be good physicians seem more like 20 patients a day and they go home at 9:00 or 10:00 at night. they're providing high quality care. but they are not rewarded. so d