to a model that according to the pew research right now news on the internet is not economically sustainable by itself. >> host: mr. calabrese. >> guest: so i agree with the former fcc chairman in general. i think there's clearly a convergence, an ongoing convergence toward the internet particularly as people get, you know, superfast fiber to the homes. what's important about broadcasting, i think, really ultimately is the content including local content and not so much the transmission mechanism. people increasingly want tv programming on their time and not, you know, at some single time. >> host: and we're going to have to leave it there. sorry, we are out of time. michael calabrese, david donovan, both on the commerce spectrum advisory committee for the commerce department. thank you for being on "the communicators." c-span.org/communicators is our

web site. you can find this book shelf or this quilt of spectrum if you'd like to look at that for yourself. you can find it hyperlinked at that site. thanks for being with us. , >> as the primary season continues, we'll bring you another debate featuring republican candidates vying for the open seat. >> and now a conference on primary health care. you'll hear from two panels of industry professionals on how primary care is affected by the new health care law. this event is hosted by the policy journal health affairs. from the national press club, it's about two and a half hours. there are

>> we will now move into our discussion about teams, and you've been hearing a lot about this concept earlier in the call for the educational system to begin to train people as team players on down. and we're going to hear first from lew sandy who's the senior vice president of clinical advancement at unitedhealth group. and unitedhealth, again, foundation having been an important funder for this issue. lew at unitedhealth leads efforts to promote efficient and effective health care to provide tools and information to doctors and patients to promote health and to foster the growth of evidence-based medicine. he was previously executive vice president and chief medical officer of unitedhealth care, and before that an executive vice president of the robert wood johnson foundation. he's an internist and a senior fellow at the department of health policy and management at the university of minnesota

school of public health. we'll hear then from eric holmboe who's vice president at the american board of internal medicine also having been a supporter of this issue. eric leads the section on clinical performance services and oversees the board's research on evaluating the ongoing education of physicians in internal medicine and subspecialtieses. before he joined abim, he was an associate professor of medicine at yale and also served as directer of the robert wood johnson clinical scholars program. then we'll hear from joanne pohl who's a professor at the michigan school of nursing and has held faculty positions in nurse practitioner and doctoral programs at michigan. she's also directed the adult nurse program and served as an associate dean for community partnerships. recently, she served as the president of the national organization of nurse

practitioner faculties. she also maintains a primary care practice in one of the michigan school of nursing's nurse-managed health centers. we'll hear from jim cawley who's a professor and a vice chair of the department of prevention and community health in the school of public health and health services at the george washington university and at is directer of the joint physician master public health program and a professor of health care sciences in this the school of medicine. he's a certified physician assistant and has been for 36 years and practices a primary care pa at the johns hopkins hospital as well as having had faculty appointments at johns hopkins, stony brook and yale medical school. and then finally we'll hear from marie smith who's head of the pharmacy practice and clinical professor of e-health at the connecticut school of pharmacy. her teaching and scholarly activities include working with

policymakers to address public policy issues concerning e-health as well as enhancing medication safety and improving patient adherence. she was formerly vice president for e-strategy and integration at the north america commercial operations. so let's turn things over to lew sandy to get us off started on the discussion of teams. lew? >> well, thank you, susan. good morning, everyone. i appreciate the opportunity to participate in this symposium, and on behalf of unitedhealth foundation which is an independent foundation supported by contributions from unitedhealth group, we're really pleased to have been able to provide support to this issue and to this symposium which we really think is incredibly important and incredibly timely in this post-reform era. in thinking about how to frame up my comments for the purposes

of our discussion around teams, rather than talking kind of from a policy perspective, i guess i thought it would be better to share a kind of experience cial view of teams. this is kind of like the narrative matters equivalent of this similar podium for health affairs because i've practiced primary care internal medicine for over 20 years in a variety of settings and a variety of different team structures. and i thought i'd just kind of tell you about that as a kind of set up and share some perspectives based on that experience. i want to go all the way back. i was in an integrated premedical medical program at the university of michigan, and my first experience really with clinical medicine, i didn't come from a family of doctors. i had a course called the impact of illness on families, and as part of that i actually had to go and follow a family around and understand how they interacted with the health care

system. this is before i knew anything about anatomy or physiology or anything like that. so i went up to a small town in the upper peninsula of michigan called crystal falls, michigan, that was a tiny little place. and the entire medical community was constituted by a family physician, a surgeon, a nurse practice decisioner and a pa. and what i found was a sort of early imprinting in my experience was that this was the medical care team, they had to practice as a team because there was no alternative. that was it. you had to -- they took calls once every fourth night, etc. , and worked in a very interactive way, so that was kind of a very early imprinting of the idea of team from my perspective. i did my internship and residency in boston, and i went there because it was a very strong clinical program in internal medicine. what i didn't really realize until i was there was that it

really had a very strong focus on nursing, the idea of a primary nurse. this is work that joyce clifford really pioneered, and they also had a kind of medical home for in-patient care which is fairly common these days. and, you know, the nurses came on rounds, nurses interacted, nurses provided continuity. so i kind of learned early and in the middle of my medical training kind of how nurses worked to provide comprehensive care in a very different way, not a physician-centric way the way many traditional medical programs are taught. after i did my fellowship, i went to join the harvard community health plan, and at that time the entire care model for primary care was built around teams, around nurse practitioner, pa teams, and i think very exciting, and i think

our panelists will talk about some of the alcohollalties and some of -- commonalities and some of the differences between nurse practitioners and p.a.s in the a primary care setting. then i made a career shift and joined the robert wood johnson foundation for 12 and a half years or so. many of you are familiar with rwj's investments in the work force not only in primary care, but in nursing generally. when i was there, we were heavily involved in chronic care particularly the ed wagner chronic care model which, as you know, many of you may know, essentially emphasizes planned, proactive care for people with chronic illness based on a team approach. so, again, very good. we supported r&d demonstrations of that model. so in addition to further investments in nursing and in things like group visits, other approaches to a team, the beginning of thinking about how the relationship between

practice redesign and teams. in 2003 i switched over and moved to unitedhealth group, a diversified health and well being company, and this predates my time there, but united health care had been an innovator in the role of care coordation and treatment decision support really using -- and this came up as a question in the last panel -- the use of telephonic-based nurses to deal with the fragmented care and unorganized care that is really very common and is the modal practice of care in medicine. not everybody, unfortunately, gets their care in places like kaiser group health. so this was a way to actually help facilitate and build a different kind of a team, an extended team that goes beyond the walls of the practice to organize and promote primary care services. fast forward to 2007, 2008. you heard previously about the

patient-centered medical home. my apologies for the typo, the aacp is the aap in this slide, but i suggested the pediatricians maybe they could rename their organization, the american academy of comprehensiveness pediatrics or something, or just fix the slide, either one. but my apologies there. the joint principles of the patient-centered medical home, and i think one of the things i was so gratified by in that experience is not only that initiative, but the collaboration between the primary care societies and us in the design and development of the primary care models that we talk -- that you heard about previously. that was a different kind of a team, a kind of team of organizations working together to advance these models. and really my kudos to the primary care societies. i really want to make a shout out here to paul grundy and his leadership of the patient-centered primary care collaborative. that really had a huge impact in helping advance this as well.

then finally, this year coming to the present, just a few weeks ago wesoo launched along in collaboration with the ymva, walgreens and the cdc the diabetes and control alliance. a really quite innovative model of not only diabetes prevention, but a diabetes care management program in collaboration with walgreens, and another example is the use of pharmacists, and we will hear on the panel about that as well where community-based pharmacists can play a critical role in care management, we believe. and this is kind of a new iteration of actually quite an old idea, the idea of community-oriented primary care. so that's been my lived experience, and i guess i -- it seems to me when you think about teams, the question is, you know, do we absolutely fundamentally need primary care?

the answer is yes and you're here, obviously, manifesting that. does it have to be delivered in teams? really the answer is, yes, if you really want to achieve the goals that we seek of improving quality, having effective access and bending the cost curve. it really has to be delivered in teams. there's more than one configuration of teams, however, and that's what this panel will start elaborating on and responding to your questions. i think in conclusion it seems to me this idea of team, this idea of primary care, it really -- we have a diverse set of models, and we have an opportunity in the post-reform era to really accelerate this process of social change that paul grundy said, and we have to. it kind of remind me of winston churchill who said you can always trust the americans, in the end they will do the right thing after they've eliminated all the other possibilities. that's where we are, i think, in primary care, and again, thank

you. i want to thank health affairs, and i want to thank the authors for their contributions to this volume, and i'll look forward to the panel and the discussion. thank you. [applause] >> also want to thank health affairs, and i also want to thank my research colleague who's actually the anthropologist who led this study who's here in the audience today with us. some of the key assumptions that we've been making, i think, that we agree to be true is that, you know, health care is delivered by teams. however, they're rarely formally recognized or supported, especially in the inventory setting. my own lived experience is that there's been a team there, but it's not been explicit in the way we actually necessarily work together all the time. we also know and believe that

teamwork quality is also linked to the quality of care, patient safety and provider experience. so with that context, we thought we would do do some field work mostly to inform our own work at the board from an assessment perspective as how do we begin to develop approaches that can help physicians recognize the importance of these teamwork skills so that they can actually use that information to improve care? and so a couple of the questions we had going into this research were how do health care teams actually work in context? and i think you've heard from lew and alluded to the fact you see one primary care practice, you've probably seen one primary care practice. our own experience in another study that's in this issue is that if you look at general medicine practice, they're highly heterogeneous, and how might our concepts approach current practices, what can we learn as we think about evolving moving forward? we performed a research study

where we put people into three different offices for about a week where we both observed and interviewed people as they were going through their care processes, talked with staff in the clinics as well as the physicians. and you can see here that we picked three practices, one was a solo physician, one was a multi-m.d. practice, and then we actually had a practice that had qualified as a level iii medical home. and what did we find? well, in the reality when we looked at these three practices, again, it's just a small sample, there really was little interprofessional teamwork. physicians tend to be isolated from staff, but also from each other. we kind of labeled this as the frantic bubble, and if you think pack to larry's comments earlier about cram anything 25 patients a day, that kind of, i'm sure, resonates with the general interns. if that's what you're doing, it really is the frantic bubble.

and we also found that what these internists have is the schedule, there's actually something on paper and the plan for the day, but that's not the actual schedule they experienced, right? so it was kind of this interesting experience the physicians were living, but somewhat siloed from the other staff in the office. the staff do collaborate. in fact, they're very creative on being able to fix and be adapt bl, so we called them the flexible team, but most of the work during the day was not interacting with the physicians in any kind of explicit way. solve problems, solve gaps, but there wasn't any kind of planned activity during the day. some of them certainly had staff meetings, but what happened was this frantic bubble for the decision, and the staff adapted to try to keep things and keep the trains moving, so to speak. for the patients we found many of them up found disoriented, and it was not uncommon for the patient to ask the researcher what do i do next? [laughter] okay?

where do i go? so what we found was that there often wasn't a whole lot of shared communications here in decision making. so i think that this is really kind of the current state, i'm sure, for many of our practices and it certainly was for me in primary care, and this is obviously what we're trying to change. i just want to highlight this slide is just, again, a kind of mental model. one thing we haven't talked much about is the important of competence by all the people within the team. you can't just put a bunch of homer simpsons into the practice -- as much as i love homer -- and expect it to work. i'm sure you'll hear from the people that now follow me that people do need to work up their level of confidence. i was very pleased to see at the medical center where i was division chief of general medicine, we implemented the wagner model 11 years ago, and i learned i wasn't taking full advantage of my other staff

including my 22-year-old corpsman who could do a before job on -- better job on foot screenings. most of my diabetics got the most important coaching not from me, but from my nurse. we had to learn to work with each other in new, interactive ways. and we took care of diabetics as larry pointed out, i could pick make the -- make the case that i could only take care of 8-10 patients a day. i could do that certainly in that payment system of the military. that, obviously, is much harder for private practitioners, but those were hard lessons to learn. i had to basically give up some of my current ideas. and competence matters with regard to skills and diagnosis. paul wrote an article about one of his staff who had a workup for noncardiac chest pain over $100,000, a competent physician would have helped.

right? taking a good history, making the proper diagnosis about $125,000 earlier. so i think this is a theme that's come up a lot today. this is another way of looking at it. this is by francisco virella who said the blind spot of contemporary science is experience. what he meant was if you only lead from what you know in your past, it's really hard to envision a different future, and i think part of what we're talking about here today is giving up some of our past models and assumptions to create these new care models, and that's going to be the hard part. in addition to all the important stuff larry talked about, also an attitudinal shift. i certainly had to implement that 11 years ago, i had to change my attitude about how i was going to do my work. so i'll just leave you with this cartoon, sometimes i think the collaborative process would work better without you. [laughter] i'll actually turn it over to the people who made my clinic work in the military.

thank you. [applause] >> first of all, i just want to thank susan dentzer for her leadership in this conference today in health affairs. i absolutely didn't think i would see this in my lifetime, so i'm very pleased to be here, and i also want to thank the macy foundation and george's leadership because the paper in health affairs that i and my co-authors wrote is a commentary, and it's a shortened version of the much longer paper that will be out in the macy piece in just a few weeks. i actually planned to use this health affairs edition with my students in the classroom as i've looked through it as well as the macy manual when it comes out. primary care is a foundation of our evolving health care system. you know what? i can't even see that. [laughter] okay.

interesting. yipg i was that -- i didn't think i was that short. primary care is the foundation of our evolving health care system in this country. i also didn't think i'd be able to say that in my lifetime. if access to primary care for all is a goal while containing cost and focusing on quality outcomes, then nurse practitioners will be crucial to achieving these aims. let's face it, in our current system there just aren't enough primary care providers to go around and to meet the need. and with an additional estimated 30 million people having access and needing access to care based on the patient protection and affordable care act, we will need additional providers more than ever. physicians are not choosing primary care for complex reasons. we've heard about those this morning, and there are more papers in the health affairs edition on that. on the other hand, a strong majority of nurse practitioners

enter their nurse practitioner programs because they want primary care. they enter them specifically to provide primary care to the nation just as i did more than 30 years ago. in our paper unleashing full potential to deliver primary care and lead teams, we argue that two areas in particular must be addressed before nurse practitioners will be able to fully contribute to primary care delivery nationwide. first, there must be changes in the state by state scope of practice laws and regulation of nurse practitioners. this is because the diversity of laws and regulation of nurse practitioners, the scope -- this is because the diversity of regulations on scope of practice and prescribing authority has been a major barrier to fully utilizing nurse practitioners and providing increased access to quality, cost-effective

primary care. many of these regulations are outdated and not paced on any -- based on any evidence that care is better or safer for our nation. second, there must be substantive change in health profession education that will foster true collaboration, not like your slide there. true collaboration and teamwork among physicians, nurse practitioners and other health disciplines in general so as to capture the full benefit of diverse we competencies inherenn a true team. the nurse practitioner role is rell relatively new having started about 45 years ago at another time when there was a physician shortage, especially around pediatric primary care. currently, there are more than 150,000 nurse practitioners nationally. 66% of those are practicing in primary care, a very different picture from physicians. and 20% are practicing in rural areas.

interesting primary care continues to grow so that yearly there are now about 7,000 new graduates who are prepared for primary care roles, and that number is increasing yearly. there's a substantial body of literature over the past four decades that consistently supports quality, safety, cost efficiencies and very high patient satisfaction with nurse practitioner care. nurse practitioners achieve outcomes that are equivalent to or sometimes superior to outcomes of other professionals and match and exceed national benchmarks especially around chronic disease. nurse practitioners are poised and ready to fully participate in the solution of the current shortage in the national need. however, the hodgepodge of state regulations presents enormous barriers to full utilization of nurse practitioners and access to care.

removing such barriers to practice makes sense, and it will allow nps to practice to to fullest extent of their preparation and to practice under their own license, not under another profession's license as is currently the case in many states. it is critical to point out that removing the barriers does not result in exceeding nurse practitioner academic preparation in any way. it simply allows nps to practice to their fullest preparation. there are barriers to reimbursement for nps as well with some insurers refusing to reimburse nurse practitioner care, others requiring utterly unnecessary physician supervision that, again, is not based on any evidence that patient care is better or safer with this supervision. and in reality, it's virtually impossible to sustain such supervision in actual practice. this unnecessarily supervised

care based on outdated regulations is also more costly. we believe that nurse practitioners must play an enhanced role in primary care as members and, indeed, leaders of interdisciplinary teams dedicating to coordinating and providing patient-centered care. nps have made significant strides in only 45 years towards self-regulation that now includes standardizing educational competencies, accreditation and certification. standardizing licensure regulations across states is just reasonable. there's no evidence that restrictive regulations protect the consumer. there's more than enough work for all of us to do. we can do that working together in teams and sharing responsibility for our patients' health. this is not about competition. one profession versus another. it's about leveraging our resources and our skills to

produce a more effective system that produces better health and better care at lower cost. although our recommendation to remove practice barriers is necessary, it will not be sufficient if our aim is to enhance primary care work force. key to our discussion in our paper and especially our discussions at the macy meeting -- and i do want to stress this -- is an emphasis for the need on interprofessional education. increased access to safe and quality care will become available to more people if medicine, nursing and all other primary care disciplines are able quickly to pioneer more substantial interdisciplinary educational experiences so that this team that we envision becomes the expected norm. the ability for all health disciplines to practice to their fullest preparation and in full

collaboration must be the optimum goal for patients and for providers. the truth be told, quality primary care is really by its nature very collaborative. no one individual or discipline can do it alone anymore. we recommend substantive change in the way health care professionals in all primary care disciplines are trained, regulated and held accountable for the care each delivers. most importantly, we recommend that primary care providers be required to develop skills that support effective collaboration with each other, with patients, families and communities. if we accomplish these goals, we can dramatically improve access to primary care, create health care systems with lower overall health care costs and improved health outcomes. thank you very much. police departments. [applause]

>> i, too, would like to extend my thanks to susan dentzer and health affairs for the opportunity to be here this morning. p.a.s are part of the health care team and were created as part of the health care team, and it's my task this morning to tell you a little bit about portfolio a.s. first of all, acknowledging my co-authors, rod hooker and bill lineweber, from the american academy of physician assistants who shared data with us. to tell you about a unique attribute of p.a.s. but before i do that, i wanted to add a bit of historical addendum to dr. howell's presentation. he mentioned the fact that with the demise of the american gp there was the rise of family medicine and several other approaches that were designed to augment the delivery of primary care.

.. team, but also to describe to you what some people refer to as the capability of p.a.'s to move among specialties. we call this clinical probability.

and some refer to p.a.'s as work force stem cells and they can go in different directions. and the policy implication here may be very important. and i'll mention the fact that -- i'll describe what i think the policy implication of that may be. unlike the profession when it began the p.a. profession like the medical profession is now predominantly women. 65% of all of us. and young women make up the primary recruits to the profession. we're still a young profession at age 42. and most of us who have been trained as p.a.'s remain in active clinical practice. but we've been affected by specialization. and as was described with regard to the medical profession, this wave of specialization and subspecialization has not only affected physicians but it's made a significant impact on the

utilization of p.a.'s. more and more of my colleagues are working in subspecialties and specialty practices. and the reason for this, i believe, is similar to that that was stated with regard to physicians. the level of debt of p.a. students is substantial. and physician assistant students get the same messages as medical students with regard to specialty and subspecialty practice. subspecialist physicians have more wherewithal to hire assistants and pay them higher salaries. our students want to relieve their debt more quickly so that the same forces that affect medical student and early physicians in their career in terms of specialty choices affects physician assistants. about 65% of all physician assistants are working in specialties and subspecialties and beer down to about a third in primary care.

but i do have a solution. and hopefully i can convince you that this may be possible. this is an incredibly complex slide and i don't -- i don't want to intimidate you or i don't want to cause you pain in trying to read it. but the point is that physician assistants, unlike our physician colleagues and unlike actually our colleagues in the nurse practitioner profession have believe capability over the course of their careers to change specialties. and the data that we have in our article is the first attempt to really document the movement of physician assistants between and among the various medical specialties. this is a unique capability. and if you -- if you look just at the second to the top bar, you'll see the percentage of physician assistants in family medicine. i believe it's 53%. and 53% of these cohorts of

p.a.'s initially chose family medicine and have remained in family medicine. but the subsequent bars going across horizontallyhow the percentages of physician assistants who went from family medicine into other specialties. and you'll also, if you look, you'll see that there are percentages of physician assistants who started out in, for example, emergency medicine who later on in the course of their career moved in to family medicine. or other types of family or general internal medicine or primary care specialty. so the notion here is that physician assistants have the capability to go from primary care into specialties. that's amply demonstrated but we have the capability to go from specialty practice into primary care. and as you can see there's a fair retention, a fair retention

of p.a.'s who remain in family practice or general internal medicine. the policy implication here is that p.a.'s can be a solution to primary care problems. and -- the shortage of primary care providers. if policymakers provide incentives for physician assistants to go into primary care or to re-enter primary care, we can provide some strength to the primary care work force in the short term. as we all know, the pipeline for physicians and physician training is lengthy. we can train physician assistants in two years. the model is one where it is of general medical training. and one that is closely linked to the physician. and this is key to this clinical flexibility attribute. so my hope is that you not only have kind of a little more appreciation for physician assistants contribution in the medical work force but

policymakers will also consider the notion of providing incentives for not only physicians and more physicians to enter primary care practices and choose primary care residencies but to include p.a.'s in the picture not new ones coming out but those who may be in specialty practice who may want to come back and become primary care providers. thank you. [applause] >> good afternoon. i think i'm the second vertically challenge that we have today. first i want to say thank you to the health affairs and the co-authors on our paper whom many of you know well. david bates, tom boden that you have worked in the past. let's see. we'll get starred. -- started.

why pharmacists belong in the medical home. however coming from yukon, we do take teamwork pretty seriously up north. and so i like to think of it for conversation purposes medication management is a team sport. so that's kind of the analogy i'll use. and i thought the first thing -- you know, i was hoping another speaker would beat me to it but we haven't had the say of the patient. i'll tell you a little bit about a case study. this is a 90-year-old white male who has a cardiac disease, has had bypass surgery, takes extremely chronic meds today. is very inherent. has a primary care doc who's great. has five partialists i guess if we look at paul grundy's words. goes to a pharmacist-led anticoagulation clinic which is novel in practice. has multiple prescribers, very motivated in self-management. i think there was a question

earlier about that patient's self-management. has an extremely good support system when you think about it. has a spouse who's really -- she would say he's -- she would say that she's the adherence coach in the family model. and has three daughters who are care coordinators and navigators. and this patient actually has great access and tremendous coverage. so those of you who know me in the audience know i don't practice clinically and you're going gosh, who is this person? well, this is my dad. this guy doesn't get away too much when it comes to medication management. and the other side of this story that i know as a person who's one of his care coordinators and navigators who happens to know a pharmacist is that he's had multiple preventible misadventures is the way to put it. or errors with care transitions, around care transitions, changes in primary care physicians,

specialist care that really when you look at it from a systems view, truly have to do with poor care coordination. not maybe intentional but systemic. and has really resulted with a higher cost burden than needed. so with that kind of personal story, i would like to move on to then -- in the primary care let's look at medication use and safety issues and kind of what is the burning platform? so if we look at prescribing approximately 71% of physician office visits record at least one or more prescription meds with 15% of having 4 or more. that's per episode, per visit. when we look at medication discrepancies, we see that almost in one study a quarter of the prescription meds and about three-quarters of otcs or herbal alternative-type medications

compared to actual use at home weren't actually recorded in the electronic health records. so you heard a little bit about my intro about ehealth that's my passion and playground now. and even that is still evolving. it's not a perfect system. around adverse drug events we know that roughly 175,000 visits per year to emergency rooms in this country have to do with adverse drug events. and about a third of the adverse events leading to a hospital admission in this country can be contributed to medication. and then as my dad's scenario showed, care transitions formation management use and safety are another critical time when somebody needs to be looking more closely at what's happening with medication use. and you can see there are 50% of patients had unexplained discrepancies. that's home to discharge.

and then even more importantly now from reimbursement purposes, i think, we need to look at what happens after discharge. and where's the coordination of medication use there? as it relates to 30-day readmits or those sorts of issues which is important for reimbursement. so i like to think of medication management as being too critical and too important to leave to any one person or any one profession. and that primary care really offers opportunities for us to interdisciplinary collaboration, coordination and teamwork as we've heard with all the other speakers. so if we take a look what is the medication use cycle -- so take this out of the realm of the turf issues between health care professionals and let's look at the stream or the continuum of medication management across the patient care experience, we have very disparate, fragmented medication info around prescribing, patient use at home, the real story, i think.

and then medication outcomes and i'll click through those to show you what those are. you as a patient or your loved ones have disparate sources of medication that do not intergrate today at all. not at all. where will the integration come from? i think that ehealth does have promise for that. it's evolving. but patient health care records and health information exchanges that we're seeing not only evolve but will flourish hopefully with health care reform dollars become that shared platform where we can have a centralized, secure, private medication history that can be accessed by any licensed health care professional and by patients. i just put this up as training and background. i know we talked about, you know, what are the training needs? and even clinicians that i interact with regularly don't know all the background and training that a pharmacist has.

so i put this up here on the right-hand side the expertise areas. i like to call it my list of pharmaco-everything, i guess. those are the expert areas pharmacists can bring to the medication use and safety discussions in primary care working with a collaborative team. these core services are really -- and this is in the paper. there are really four main core services. this is one of the great reviewers asked if this was a vision. and i thought that was interesting. i chuckled and said, well, i guess it is if you've never seen it or experienced it as a patient, it's a vision. [laughter] >> but i actually -- 30-some years ago did this. so it's been going on. it's just maybe it hasn't been where you have been in your patient care. so i just mention that as background. but medications management is language that's certainly been embedded in a number of recent legislation -- even in medicare part d legislation.

and the -- it starts with a comprehensive review of the patient's current prescribed and self-care medications for actual usage and adherence patterns. the med list include only prescription meds that are prescribed by that prescriber, one doc or one aprn. very incomplete. what's missing? otcs, herbals, physician samples, meds, complex dose schedules, meds from other physicians, specialists, partialists. discontinued meds and adherence trends. for pharmacists we couldn't get started if we didn't have all that information. even with ehr, electronic health records, eprescribing, most med lists still today in the systems that are out there today are vastly inaccurate or incomplete.

and it diminishes the promises, i think, of what can come from ehealth for medication safety and health. we'll go through a systemic assessment of each medication for appropriateness, effective assess and adherence. it's so critical and you can look at more of that. there's really -- i guess the bottom line is this. there's no sense, commonsense in a pragmatic way of trying to spend a lot of effort on the part of any of us to get a patient to be adherent if efficacy, safety -- i'm sorry. i'm always the kid who colored outside the lines when i was growing up. what it says there -- i think we're on different powerpoint versions here. in our work in connect as well replicated in other places of academics who are looking at medication use and safety -- 70 to 80% of the med-related problems in primary care come from appropriateness in, efficacy and safety.

there's the behavior issues and the patient issues that relate to adherence as well. but it's not the biggest one. so we talk about in the paper a little bit about considerations. which patients i've gotten the push-back. well, marie, that's a great model. every patient doesn't need that level of care. and i absolutely agree. you need to be selective. so here's some ideas that are explained in the paper about patient selection. the biggest thing, i think, is the thinking outside of the box is location. because every person has a pharmacy they go to. however, they don't see the things we're talking about happening at those pharmacies, at least not yet. although i don't know if troy is still in the room. maybe he's got some other things. he's got going in that realm. but primary care offices are not the only place to do this. it can happen in clinics. it can happen in work sites, home visits, senior citizens, community pharmacies, telehealth. the next thing people have a

hard time sometimes getting around well, i have to hire one full time and i can't afford to. i heard a lot of physicians tell me that. wow, you don't really need to. there's an employee model which is the one we all think of as the lens we've always thought about. but there's an embedded model which is a partnership that's going on for 50-plus years i'm certain between academic health centers and pharmacy schools and medical schools and residency programs and family medicine and that sort of thing. there are referral regional models where pharmacists serve the geographic region which i like to think of as the north carolina medicaid model is a good example of that, i believe. and then a contracted model, which is one we just recently in the last year and a half brought into the state of connecticut with some of the work we're doing on our cms transformation -- medicaid transformation grant, which is a network of credentialed pharmacists that are really mobile and can move around. and then the last point is there's sustainable payment sources. and it could be, you know, global payment. it could be fee for service.

there are cpt codes that have been in use for two years and they're vastly -- i'm getting cut off. so lastly i'd close by saying we take teamwork very seriously. i mentioned in connecticut. and even my 3 and 4-year-old nephews and nieces know it takes world leaders and talent. they know it's gino and chris who are the team coaches. they can list the entire list of the basketball teams. so i like to spend time with 3 and 4 years old because it opens up my eyes on really what they're seeing. and the success drivers are clear roles, clarity of roles. everyone on the team knows their roles. trust. that's a big one in my book. and experience. working together. so if you've got those success drivers, good leadership and world class talent on your team, you should be a pretty successful group of

practitioners if we use that analogy. so i would challenge you to ask next time you go to your doctor or your primary care visit, ask who the pharmacist is on your medical home team. thanks. [applause] >> well, thanks so much to all of you. i want to apologize. we did not realize that today the national press club would be conducting its human refrigeration experiment. [laughter] >> on all of you. it's really cold here. we've asked them to turn down the temperature. if you suffer from hypothermia, we'll get you medical attention. so what do we hear about teams? well, we heard from lou the teams pretty much the way the world has worked in health care to some degree or other. certainly in his experience that has been the case. hearkening back to his first days up in michigan with that team.

we heard from eric that teaming often -- when physicians are involved seemed to be made up entirely of quarterbacks. not many people to pass to or at least not recognition among the physicians that there are people to pass to. we heard that teams very frequently backbench the people who would be most interested and most capable of providing primary care, whether they be nurse practitioners. whether they be physician assistants. whether they be pharmacists. and we heard of some additional features that are going on that perhaps are exacerbating that trend, not the least of them of payment incentives that are leading physician assistants that are gravitating from primary care. we heard from the absence of teams there's not sufficient coordination. of patient care and particularly care for complex patients. and particularly care for patients who need some additional assistants with things like medication adherence

and so forth as has been said. and we heard about the things that are necessary to change all of this. we heard from joanne about the need to come back and revisit the state licensure issues, which keep so many nurse practitioners in particular from practicing at the top of their licenses as we say. we heard about the need for education and training to be revamped, again, to focus on true teamwork. and not structuring situations again where everybody is raised to be a quarterback. but where there essentially are -- that the team coordination model is built in from the earliest days that people begin to figure out how they're going to practice health care and medicine. and we also heard again coming back to the question of incentives. that incentives matter shockingly enough. and if incentives were introduced that would lure more p.a.'s back into primary care these work force stem cells as jamie says would gravitate back

into the primary care part of the body. so with that, let me start by asking eric -- i want to come back to your ethnographic research there. when you reflected this back to the teams that they really were not team-like and were actually quite dysfunctional, what do they say? [laughter] >> to be honest i'm not sure we spent a lot of time reflecting it back to them. [laughter] >> i think, you know, ben did go out and meet with the team just to kind of share the findings with them so that it wouldn't be a shock, you know, when they saw it. and they think although there were some interesting reflections on several of them about how they conceptualize what a team looked like, for example, you know, one of the -- we have a staff meeting, you know, i think that was part of it. and the others were like yeah, that's pretty much my day.

i'm a general internist. it's a frantic bubble. and i really am on the hamster wheel. what was interesting even though they could find someone uncomfortable i think for a number of folks with ben and he certainly here can share more -- they said, yeah, that kind of rings some truth. when they reflected back on it. >> ben? i don't know where you are. do you want to add anything? [inaudible] >> we did discuss with folks during the research and shared drafts of the paper. and there were some dialog, yeah, about possibly different perceptions of what we've seen but the basic acceptance that we seem to be observing people pretty much accepted and took for granted. >> joanne, this must sound somewhat familiar as i'm sure it

does to jim. what is your sense of how nurse practitioners have generally perceived their role on teams? >> there's a wonderful qualitative study that we report in on our paper in which it was looked at -- the collaborative relationship between physicians and nurse practitioners. generally, i think if any of you in practice would say out in the real workplace, the collaboration is working quite well actually. quite respectfully in many ways. but what came out of this study was very interesting. in that was general collaboration was seen as one way. which isn't the true definition of collaboration. and that what the nurse practitioner said was that they were -- it was viewed as one way. they weren't respected in this relationship or didn't feel respected. and the physician comment was the nurse practitioners didn't heed their advice. [laughter]

>> and this is another qualitative study. so personally in what we hear from our colleagues -- much of my practice has been in nurse managed centers where we are the team and such but what we hear from colleagues is similar stories that this collaboration or team relationship tends to be one way, not two-way or three-way in terms of all the partners. >> jim, is that reflected in the p.a. to physician relationship? >> we've always been comfortable working with physicians. it sort of comes with the territory of being a physician assistant that we work in collaboration. and this has been our history since the very beginning. and we're quite comfortable being on the team and oriented to the team and working with physicians. >> and so now with 65%, i think, you said of those currently who

are physician assistants or females or coming into the physician assistant practice, is that changing at all? is there a gender dynamic underpinning some of this? >> if you look historically it's a dramatic gender shift in the '60s and '70s, p.a.'s were mostly ex-military corpsman and the profession was 95% male. and like many of the other health professions, that has changed dramatically over the 40 years. >> so i guess you see me struggling to ask the question, is the -- is the disconnect of a certain mars/venus stuff that joanne is talking about. is that the differencing a nurse practitioner or a physician assistant? how can we unpack all of this? >> that's a good question. you know, i know for women physician assistants, they're quite comfortable with the role. i'm sure there's some gender things going on.

but i think -- i don't observe a lot of difficulty with the role, resentment towards physicians amongst our ranks. >> so let's go from mars/venus and go to mars/venus/pluto and talk about the pharmacy end of this. how do pharmacist feel about it. >> at least you didn't call me goofy. i was thinking about that. pharmacists have been sort of an invisible ingredient in the whole mix, i guess, really, when i think about it. it doesn't matter. i'm not talking about just community practice. it could be in the hospital. when you're a hospital patient, you know the physician assistant who's putting your meds and reviewing your chart. there's an invisible ingredient. what we've tried to do in maybe the educational switch we had about at the point years ago of really stopping anticipate pharmacy education to focus on solely just the product

dispensing but to start integrating information around patient disease states and behavior change for adherence and those sorts of things, therapeutics, and training models, you know, have changed a great deal. in pharmacy. so i think we now are thinking of, you know -- it's not just all about dispensing. it's really looking at how can we be that indispensable person on the health care team? >> i would just ask one of my mainly a-ha moments when we introduced the chronic disease model was bringing a pharmacist into the clinic and actually the pharmacist was the last person they saw before meeting with the physician because that really helped with the coordination. all these diabetics were on multiple medications or some combination. >> lou, i want to turn to you quickly. you talked about the diabetes

prevention and control alliance with walgreens and united and so on. essentially do you see that extending to other diseases? you obviously don't just want to silo diabetes into itself. how is united thinking about rolling this out broadly throughout health care? >> yeah, i think what it is a manifestation of is the opportunity that marie talked about how do you ensure people get what it is they really need to get. and in this case it's -- instead of activities that takes advantage of the community network of pharmacists and to really address the issues that they raised medication adherence, questions about the medication -- it's really a kind of version of collaborative care management that takes advantage of exactly the competencies that the pharmacists have. and the optimal care of diabetes is so heavily dependent on

medication adherence and compliance. and in other -- i would envision i would answer your question other disease states and chronic conditions in particular that fit that profile, one would like to extending that model. actually troy made some similar comments as he's thinking about what he's doing at cvs caremark as well. i think the broader picture is to think in particular, it seems to me, about what is really needed to optimize the care of the patient? it's kind of a form follow function thing. then basically say, okay, given that, what are the capabilities that we have on hand within the extended care team to deliver that result? >> and underpinning all of this i hear -- it's not just the notion of the team. it's the team taking more of a population focus as well. correct? joanne, you're nodding? >> yes, i would agree absolutely

that this team isn't just addressing one patient or even a group of diagnostic patients but much more the community in which they're serving. >> we also want to open this up now to questions from the audience. so let's start back here and again we have roving mics and please identify yourself by name and affiliation. >> thank you. i'm janice miller. i'm a nurse practitioner at thomas jefferson university in philadelphia in internal medicine practice. and given that the amount of data that dr. pohl presented today on the quality of nurse practitioners as well as the cost efficiency, i'd like to ask dr. pohl and dr. sandy what further incentives are payers looking for to recognize nurse practitioners as distinct entities. do you think it has to be something like legislation that happened in massachusetts or will the payers take the lead on this as we've heard this morning? thank you. >> lew, do you want to begin on that? >> yeah, i'll start. i think there's a couple of things.

i think one is -- first, just in terms of how united health care our commercial health benefit company work with nurse practitioners. they are part of our network just like physicians as well. so at least from our perspective, we recognize the value and seek to contract with nurse practitioners. i think the biggest challenge are twofold. one is the scope of practice laws and the variation around that. and i would underscore and i would agree with the comments that those in an evidence-based rigorous way, given what we need to do in this country, it's a worthwhile effort to take a look at those and modernize those based on evidence. so -- >> which there is none? >> well, that's -- that's maybe the next special edition of health affairs. i think it really relates to the broader issue not specific to any one discipline. which is to reward performance.

and it's not just to and essentially to realign financial incentives rather than rewarding volume and intensity of service. to reward better outcomes, better evidence-based process. and was mentioned in our previous panel our pilots in the medical home and other reimbursement reforms. and many of the papers in the special edition also address that. the more that's done, i think that creates the substrate for saying, well, then how do we deliver that value if we want to capture and realize that financial recognition, let's think about the best way to do it? i think it creates new opportunities for all the health professions and p.'s and p.a.'s as well. >> there's a number of models that are essentially nursing-led patient centered medical homes; correct, joanne, among others? >> there are nurse managed centers.

in philadelphia there was a study in pennsylvania done and the nurse managed centers met all of the criteria except they were not physician-led. and could not get national approval simply because of that matter. >> as medical homes? >> correct. >> so we have these scope of practice laws that are set state-by-state. there is some potential that in the pilot projects that the secretary will be able to carry out that there may be some ability to have safe harbors from state regulations. we don't know that for a fact. but short of that essentially we'd have to go around the country getting all of these laws and regulations revoked in 50 states, lew. that's a difficult prospect. short of that, what's the alternative?

>> actually if you think about -- and this gets to essentially the access expansions in the health reform legislation. as you know about half of the 32 million will be covered under the new health reform legislation. about half of them come directly from the medicaid -- through medicaid expansions. and that's just an onslaught of new enrollees into strapped state medicaid programs. so i think it's incumbent on states if they're thinking about what they need to do, it really is critical while wrote up in these next few years to really take a look at that simply to manage the access medicaid programs that they have accountability for as well as with the federal government actually. our united health center of health reform modernization just issued a white paper a few weeks ago on the issues related to medicaid and explicitly addressed and recommended that

these issues related to scope of practice laws be addressed. >> do we have another question over here, please? >> yeah. i was wondering in building the team and pulling all these pieces together, how important -- if it's important at all is the electronic health record as an engine to both build and solidify the team in a patient-centered home arrangement? >> and would you just mention who you are. >> ron carlson for the institute of community health. >> so how essential is the electronic health record? eric? >> i would harken back to, you know, the work of like eugene nelson of microsystems, idealized systems and wagners. it's going to be critical. you have to be able to manage information effectively and efficiently. and the more we can do it electronically particularly increasing to the point of care

the better off you will be. having -- even though, you know, it's probably a precursor to today's records having electronic records say it was absolutely essential to our disease management program, i could at least at that time create a quasi registry. i knew exactly who was being cared for by what doctor or nurse practitioner or p.a. in my clinic. i knew what my performance rates were for the entire population in my clinic because our job was to manage complexity. i would have been dead without it. so it's one of those essential but kind of insufficient -- we got to have it. and then you got to have competent people, you know, within the teams and know how to use that information be able to get at it, you know, efficiency. and then, you know, constantly look at it to make improvements. so i think it's essential. so it's one of those essential but insufficient aspects from my perspective. >> and i believe the ability to have data and analytical tools was featured in patel's patient

in the patient centered medical home. >> absolutely. >> okay. was there another question over here? yes. >> thank you. my name is tom. i love -- excuse me, i'm freezing. [laughter] >> join the big club. >> i love in eastern north carolina. i'm a professor of pediatrics in eastern carolina and do a great work of community work in support of small rural practices scattered across particularly northeastern north carolina. and i also spend three session as week inside the phrenic bubble and it is phrenic. i'm speaking again to the issues of our very close and dear partners, our nurse practitioners and p.a.'s without whom i could not survive whether i'm in the local community health center that we built, the bernstein center in greenville or out in the practices out in the region. i've got two nurse practitioners

one out in a county that about an hour and a half from greenville. it has no doctor, no dentist. another in a county that's about two hours from greenville. no doctor. no dentist. they are the sole sources of care for large populations for primarily obviously rural people with a very high burden of chronic disease. i supervise their care because i have to. because that's what the state requires. they don't have to pay for it. because i think it's ridiculous that they should have to pay for it since they really don't need me at all. my primary role is to help them navigate. and by the way they could be p.a.'s. they could be -- we don't discriminate. but my primary role is to help them navigate their way through other parts of the system because other parts of the system are not prepared to relate to them directly. now now here's my question, when we try to break in somebody new in one of those places, it's a nightmare.

because whether they are prepared -- these two women are spectacular. they know exactly what to do. they never require my assistance in clinical matters or virtually never. it's a good thing since i happen to be a pediatrician. [laughter] >> but when we try to bring in a new person out of either background, only about 10 or 15% of them are prepared for that level of independence. and the intensity of supervision that is required is very taxing both on me and on these extremely busy women who are out there doing the work. do we not need to think about a transition, some form of transition from completing the educational process to practice -- is the primary -- the primary care folks are the ones who really are not ready. you can move in -- if you're going to go in and work with a

specialist you're going to help a specialist. the p.a. in the specialty role learns pretty quickly learns how to do physicians for the physician. but these independent people need opportunity to train in the community and team environment, i think. have you thought about that? >> well, let's ask the experts here. joanne? >> as somebody who's been in and teaching nurse practitioner roles and a nurse practitioner herself, i would say when i started out 30 years ago, i too needed a more nurturing environment in my first couple of years and i would say today's graduates probably need that. i'm not sure -- that graduates of, you know, residency programs don't need a similar sort of nurturing environment initially. i'm not sure it's unique to nurse practitioners and p.a.'s and i'll let you speak to p.a.'s and we might all need to look at

how that looks, you know, for the new graduate, whatever we want to call these people. because when you're out in the rural areas, isolated or some of our graduates actually go off into international work, that's incredible. the responsibilities that you have to manage. and so i would -- i would say it's not unique to our training programs. i think our folks come out very well prepared but i'm not sure they're prepared totally to be isolated initially. that's a great question, i think, for all of us. jim? >> that's a good question. and it may very well be that for the type of practice you're describing that there may be an indication for some further training. you know, i think of the way family physicians describe, you know, dealing with undifferentiating patients and what a challenge that is. and i do know among physician assistants, the mean age of our students seems to be going down a little bit.

and the component of having a primary health care experience is not quite as robust as it once was. the other comment i'll make is that there are now upwards of 50 so-called p.a. post-graduate residency programs. unfortunately, the vast majority of them are in specialties, you know, critical care and cardiothoracic surgery and so forth. i think your question makes a great case if there is going to be some additional post-graduate training, that p.a.'s or perhaps m.p.'s would take the primary care might be a good one to work on. >> let's take a question here. [inaudible] >> let's get the mic to you. >> the good news is in the health care reform bill and to dr. iron, someone from my home

state of north carolina, there is a pilot for nurse practitioner residencies in community health centers. so that's the good news. i hope that it's -- it's a friend of ours. marie, it's margaret flinter and it's an amazing project she's taken on and actually got into the health care reform bill. i think that could be something to look to as a model and see the outcomes of that. >> thank you. we're going to break now so all of you have an opportunity to go get a boxed lunch and we'll reconvene here in a few minutes for really, i think, a very exciting set of presentations, really where the rubber hits the road. these are practices that have undertaken many of the innovations that we've talked about. i'm sorry we don't have hot chocolate or scnapps to warm you up. take a break and we'll come back here to complete the program. [inaudible conversations]

>> welcome back. i hope you had a chance to warm up and get some food. we asked a number of different models or we asked people representing a number of different models to speak about how they were going about some of the activities we've been talking about all day. care coordination, use of electronic health records,

team-based approaches, et cetera. medical home formally and indirectly achieving the same kinds of outcomes intended through a medical home. and we asked them specifically to discuss a number of challenges they faced, whether it was payment, whether it was work force-related issues, et cetera. and so you'll be hearing some of those themes enunciated as they discuss their experience of running these various different models. we're going to start with some framing remarks from susan who as i mentioned earlier was one of our theme issues advisors as well as with larry on this issue. susan is the executive director of the john stuckle center for primary care innovation at massachusetts general hospital. and will be joining us shortly here on the podium. she was the founding president of the picker institute. and is a lecturer in the

department of medicine at massachusetts general hospital. and also an associate in health policy at harvard medical school. she's a physician assistant. she serves on a number of boards, the national advisory committees including the foundation for informed medical decision-making, the national patient safety foundation and the harvard institute for nursing leadership. them we'll hear from richard baron who as i also mentioned earlier was our advisor on this earlier who worked with us on the practices we featured in the issue and i hope you'll take a gander at those because more are an issue than is represented here today. richard is going to be here speaking on behalf of what his practice has been able to do at greenhouse internists. and also was mentioned earlier some of you may have read the new england journal of medicine of his and his colleagues with other issues they faced. we asked him to focus in

particular their efforts to create the patient centered medical home within their practice. so he'll be speaking about that. richard is a immediate past chair of the american board of medical board of directors and the trustee of the abm foundation and as i mentioned the foundation was a supporter of this issue. richard has also been a member of the national committee for quality assurance standards committee since 2005 and is also on the board of national quality forum. we will then hear from eric larson who's executive director and senior investigator of rupe health institute, which is an institute within group health, a health care system based in seattle, washington. he's a general internist. a leader in geriatrics research. and is working hard to keep the institute on the cutting incidental of health research. he served as the principal investigator of an nih project to expand the capacity of the hmo research network. and he's launched research

programs at the institute on health and obesity and evaluating the medical home model at group health. his article -- he and colleagues have read an article on the latest results from the group health medical home model and also featured in our issue is a report from the field where we asked a journalist harris meyer, to go out and talk to some of the physicians in group health. and address specifically the cultural issues involved in transitioning to the medical home model. and it's a very interesting read. and i do urge you to read that as well if you have a chance to do that. we'll then hear from alice chen who's the manager of the adult medical center and director of emedical referral services and codirector for the center of specialty access and quality at san francisco general hospital. she's also an assistant professor of medicine at ucsf and her work is focused on creating policies and programs

to improve care for underserved communities. and she's been instrumental in the local implementation and the national dissemination of the ereferral model that she will be speaking about to improve access to and quality of specialty care. this project and another project featured in our issue are particularly important in making the point that primary care obviously doesn't operate in its own universe. it obviously has to have a set of interrelationships with specialty care. and the ereferral project has developed a unique way of doing that and we'll look forward to her presentation. we'll also hear from karen nelson, who's been the ceo and medical director of the united health center. where she previously was vice chair of medicine and consultant to the executive office at the medical center in brooklyn and helped expand its ambulatory network and established a community-based training program

for residents internal medicine. we'll be hearing from her about how the unite health center approached some of its activities around improving coordination of care, et cetera. karen's primary research interests are in developing customized screening protocols for new immigrants in particular and providing academic opportunities for career community health center physicians. she's also on the board of directors and serves as chair of the governance committee of the primary care development corporation. and is on the board of housing works, which is an advocacy organization committed to ending the twin crises of aids and homelessness. and then finally we'll hear from raymond who's president of both quad med and quad med corporate health services which is an entity that markets quad med's brand of health care to other companies. as the president of quad med he oversees a health system with a medical staff of over 200 employees, serving more than 26,000 people at eight clinics.

he was a physician for 25 years before he joined quad med as the associate medical director in 2006 and previously was the vice president of medical affairs for st. michael hospital and medical doctor of infomantic but first some opening comments from susan. >> thank you, susan. the first thing i just want to say is that i really want to thank susan dentzer and all the other staff at health affairs that put together what i think is a terrific compendium of articles and information that hopefully will be very valuable to the whole health care universe.

in terms of the framing remarks i want to make, one of the first things i want to comment on, we've heard a lot already this morning about the importance of forming the payment system and creating incentives that will allow our primary care practitioners to deliver care the way that they and our patients want it. i think that equally important to the payment reform is practice redesign. i don't think there's any amount of money you can pay a primary care physician, p.a. or nurse practitioner that's going to make the bumping down the stairs phenomenon that larry referred to enjoyable. and i think that if we don't have practices that really allow our clinicians to go home and sleep at night and feel good about what they do, no matter how much we pay them, they're still not going to be interested in working in primary care. so i think that the examples

you're going to hear about on this panel are incredibly important as potential blueprints for how we move forward. now, having said that, i thought that in reading the articles and just based on my own work at the stoecle center at mass general there are certainly things that keep me wake at night that we really need to address. i think we touched upon some of them. you've heard a little bit of them this morning. but i wanted to call attention to them because in some respects, i think they're the elephant in the room that could really have an impact on how successful we are. one of the first ones is i think this whole issue of teamwork. i spend a lot of my time also working on patient safety issues where i see lots of teamwork training models that are designed to improve teamwork in high risk areas in the health care system. in my experience, most of those models aren't well designed for a primary care setting and i

think we have a lot of research and a lot more work to do to help us figure out how we design effective teamwork training and models to support our primary care practices. another issue that i worry a lot about is we are undergoing at least from my perspective, the biggest transformation in my entire career as a p.a. and in health care. and we are expecting practices to do that. that are the busiest, the most underfunded of all of the practices in our health care system. and i don't think we're acknowledging the lack of training that our physicians and all of the other staff in these practices have that will enable them to do this successfully. i see a tremendous amount of grief and real grieving about the changes that people are expected to bring about in their own practices. i think most of us who are trained as a health care

professional are really only comfortable doing what we're trained to do. and we don't really train people in the health professions to be innovators, process improvement experts, culture change experiments. -- experts and these are all things that i think are causing a extreme amount of distress in our practices, more so with our older physicians and nurse practitioners and p.a.'s. but i see it happening across-the-board. and i think that we need to be thinking about how we are as kind and compassionate to all of the clinical leaders and administrative leaders that are going to be responsible for these transformations as we expect them to be with their patients. another area that i worry about a lot and there are a couple of examples in the articles and in some of the stories i think you'll hear about on this panel -- but we haven't really done a good job of engaging patients in the redesign work. people ask me all the time, where's the patient in the patient-centered medical home?

other than being the patient that we do things to? and i think it is critical that we engage patients both in the redesign in practices of how we deliver carry. there's wonderful designs and the pediatric practice. i also think the article about the chronic care program in durham, north carolina, where they actually went into the homes of patients to look to see what kind of support and medical devices and whatever do they need services they need by really paying attention to the needs of the patient directly rather than what we assume they need. those are very, very important models that we need to pay attention to. it's critical because now that health reform is underway, i'm kind of stealing myself for the firestorm of publicity around rationing and all of the other things that we know are going to

be terrifying to our patients if they don't understand what this new model of care is going to do to help them get the care they need. and no more. i also was very heartened by the article that you're going to hear about today. the use of the technology platforms to improve the way that we're managing referrals. and we're managing the interactions between our specialist colleagues and primary care clinicians, which i also think is a huge piece of this work that we have to pay more careful attention to. and one of the reasons that caught my attention i'm very committed in how we involve patients decision-making about their care. and one of the challenges we face is that it's very, very difficult to introduce those kinds of conversations into the current way that we deliver care. if you think about somebody who's going in for a cardiac procedure, the minute you show up in the emergency room with any kind of chest pain, nobody

is going to slow down would you like to look at this program about whether you really need this stent or not? that's not going to happen. we find it challenging to introduce shared decision-making into primary care settings. and i think that some of these examples give us some ideas about how we can begin to do that as part of these very sophisticated and i think thoughtful referral processes. so those are some of the main things that i wanted to share with you in the framing comments and because we've got a big panel and it's late in the day, i'd just like to leave you with two of my favorite quotations. the first one is from one of my favorite science fiction authors, william gibson. who came up with the term "cyberspace." and the quote is, the future is here. it's just unevenly distributed. and so i think you're going to hear about some of the places where it is now. and my other one is a chinese

proverb that was shared with me by my close friend jennifer daly in boston. and the quote is those who say it cannot be done should stop interrupting the people doing it. so with that, i will let you hear from our wonderful speakers. [applause] >> thanks. as our first after-lunch speaker not named susan, i want to say how grateful i am to be here. it really is a great privilege. and what are the chances that a small primary care practice in philadelphia would last week have a piece in the new england journal of medicine and be in the premier health policy journal. i feel indeed blessed this week. the new england journal piece describes a period in our practice before we had any additional resources associated with participating in a patient centered medical home. and is meant to be a kind of

honest look at what's going on in primary care practices around the country. the piece i'm going to talk about now and the piece that's in health affairs is really a description of some of the creativity that troy described when cash lubricates the creative process on the barrel head with respect to funded initiative in pennsylvania involving multiple payers. so i'm going to describe our setting. i'm going to describe a little bit about that initiative because i think there's an important less scombron there. -- lesson there and talk about the problem confronted and how we tried to deal with it. so our setting, we're a market risk practice i use those terms. i don't call it a private practice. 'cause i want to emphasize the people whom we serve and the economic conditions under which we served them community-based market i risk. -- market risk. we're in philadelphia it's an economically diverse population

reflecting the community we're fortunate to live in. 4 out of 5 doctors live within the office. i want to describe how this patient medical center medical home pilot in pennsylvania came to be because though the talk is not entirely about payment, none of this would have happened if we didn't have the infrastructure to support this. and the -- there was a joint interest on the part of commercial payers and the medical society acpa, troy at the time was chief medical center at aetna and he said i go to a lot of meetings where there are more people at those meetings than a patient centered medical homes and maybe we should build one. and they came up with a way for six insurers to talk to each other. and this is already a big problem because it's sort of a per se antitrust problem for insurers to sit down and talk

about how they want to pay the payers. ed rendell's interest in trying to improve chronic disease in proximately create a space where they can have this conversation and the product have that -- there are 32 practices participating in our practice it means about a 15% overall increase on gross revenue received by the practice. it is not a pay for performance program. one could ask the question, what were we paying before we were paying for performance? it is not a pmpm case management fee. it's meant to be a revenue stream to support a new business that the primary care practices were going into with a predictable cost and an expectation and a need for revenue stream to make that happen. so that's been really very helpful for us. so the problem that i'm going to describe are addressing of our 8500 patients or so about 6700 of them have either hypertension, diabetes or high cholesterol. as all of you know, these are

diseases where lifestyle changes are as or perhaps more important than pharmacotherapy. merck doesn't make money when you start exercising but that probably has more benefit for you. you don't see it on tv. you don't see it in the drugstore. but that's really a good direction to go in. and clearly for these illnesses, the return on investment for that is huge. and the risk margin is substantial lower. so the idea was trying to get patients to set their own goals preferable to telling them what to do. ...

>> well, we have to develop and expand our non-amt staff. in a community based market risk practice that's called overhead. we recognize and other forms of health care system, it's understood somebody has to support the operating room in which you work. it's understood somebody has to support the cost of that instrument and the table on which the patient is lying. in primary care we have a very well specified what that infrastructure is. technology and teams i think are a big piece of it and we need support to make that happen.

so we hired a health educator. i just got her job as 50% wholesale and 50% retail. the real deal part is the mother to you, sitting down one on one on lifestyle change. the wholesale part was a leadership role among other things in this project. the project was, what if we could train medical assistance and goal setting techniques, medical assistance are often people from a welfare to work program with perhaps one or two years of post-high school education. some of them have been with us longer. by training them and goal setting techniques, if you're going to have them take on this responsibility in addition to weighing patients and measuring patients and asking why are you here today, they need more time in rooms and spend more time in rooms we need more of them. and so we need more of them to actually do things. and then because they're not that will clinically trained, we

want to customize our electronic health record to support them so that a patient with diabetes would have one set of lifestyle changes relevant to diabetes. salt restriction might not be as big a deal with the patient with diabetes as a patient with high blood pressure. we stressed them on perform of example health choices for the patient. and the medical assistant engaged in a conversation with the patient, are you interested any of these things, would you like to focus on taking your medications, which like to focus on education, whatever, it can to set a specific goal. document that, produce a document that can be handed to the patient so the patient is told at the end of the visit these are the things i committed to. and that becomes a permanent part of the record. two weeks later the medical assistants are calling those patient and saying, are you ask a managing to walk three times a week as you said you would, so they follow up. so what does that take?

i don't know how to customize my electronic record. it's an incredible program like is that i had to go find some good film and pay close to 10 grand to get them to execute the thing i just described. and where they said they would do in three months to really finish in terms of where we could use it in terms like last week. that's a big problem. but it really has been helpful in terms of allowing the doctors, patients and medical assistance to be able to have conversations focus on individual goals. and so my message here is that here's the thing that everybody knows we need to do better with patients, we tried to do with a website. we tried to do with custom forms. the patients had other things to do than go to the website and engaged in questions about giving us david on their lifestyle changes. and trying to integrate it as part of it as it was at least one model for that. but none of this happens without

a change in the payment system. i would agree with what lots of people have said today. that's not going to change everything. we need to change our models, but if we don't have the resources to lubricate that creativity, we can deliver what is the american public is looking for. thanks for your time. [applause] >> well, good afternoon. it's a great pleasure to be here. this is kind of a dream come true for me. i've been interested in these topics for many years, but i'm going to play that my perspective may be a little bit different from what you've heard from other people. i live in group health, and we have been committed to primary care for all 63 of our years. and yet i'm going to tell you a story about how we needed to be transformed in the medical home was a way in which we transform

ourselves. the principles of primary care are not new. you have heard about them, but we had to, and we're in the middle of, a cultural transformation that i think will link back to larry casalino's remarks that start offered a we talk about what we really need to redesign and change work and change your perspective. in our case that redesign involved harnessing new technologies, and again the theme of this meeting, making more efficient use of our teams, people, and rethinking what medical care was all about. a little bit of background. group health is been around for 63 years. we are consumer governed, called the clock. we are based in seattle. we have 620,000 members. we are growing. we have 26 primary care centers, sixpence the units and one tiny hospital. 960 physicians, and we contract with a large network of over 9000 physicians and 39

hospitals. i am director of the research institute which is an house, but public oriented, not for profit, public sector research group. and it was the place with a chronic care model developed. and you would think that group health would have no problem with primary care, i'd in fact we have our own strides. one of those of today's meeting should be it's going to be work to transform primary care. and it will probably be work for our offspring and their off spring, because it is not easy to deliver good primary care. but we had something in 2000 to which we called the access initiative, and i would guess that most of the things we did were published in health affairs. many of them were things that work, we want to redesign primary care to best practices. and what we did is we develop

same-day appointments. weevelop direct access to specialists. we develop productivity incentives for physicians so they would see more patients, and leaner, not richer, but leaner primary care teams. we thought we could do this because we had a great electronic medical record, and somehow that would solve everything for us. in fact, it gets all something. patient access improved. people love the ability to see their doctors or commute it with their doctors right away. but quality and continuity of care did not improve. and if you look at this chart that's on the screen here, you will see that there was actually an increase in emergency room visits and increase in hospital admissions. and what happened really was we put our doctors into a squirrel cage treadmill like mentality. they saw a lot of people but they did not transform the way they practiced medicine. and also, a side effect was the doctors and members of the team

were burned out. people were saying we can do this, this isn't working for us. and so what we clearly said was, we try to reinvent primary care and didn't do what we wanted to do. and that was the basis for the work we have done in which i will describe today on the patient centered medical home. and i will say that we base this on the literature of a as well as our own work, plus we did have workgroups which included patients which included the doctors and other members of the team that worked in the private clinic, which is factorial. so the basic design is shown in this language. the idea is we start from the homes being the place where primary care is. the whole system is designed around primary care. you heard about denmark. people came from denmark to look at group health, and went almost to go back to denmark to rediscover that the home has to be primary care. patient-centered is really the

promise i'll primary care. and we realized that we can't just improve access to deliver good primary care in today's world. it has to be comprehensive, coordinated, continuous and patient-centered. and continuous heating patient-doctor relationship is the corporate people. we also look at ordination and collaboration and activated patient as we figure out a way to design this. and we look for the notion that i think larry was alluding to, and which which describes in his paper, which is a lot of the care is done outside the home, outside the physical space of the clinic. so patient friendly access is critical. we also have the luxury of a 24 hour consulting nurse line. and all this is connected to an electronic medical record. we also have a ray of tools, and here we are fortunate because we keep building these for decades

that allow us to have plain language, patient education materials, reminders and summaries have been sort of good for longtime. all of this is metric. we metric it as best we can without being too burdensome on ourselves. so what i'm going to describe now is what we actually did, and this is, what's in the article in today's health affairs. i'd like to give credit to my co-authors and participants. there listed, but rob reid, cady coleman, eric johnson, paul, mike, and michael erickson. and what we did was we really changed the way we use our workforce. we reduced the panel size of 2300 to 1800 patients per physician fte. visits were actually increased from 20 to 30 minutes. the teams were led by a

physician, but the value of the team members was judged to be in a way that had equity, that every member of the team had an almost equal stature, with you a nurse, a pharmacist, a nurse practitioner, ipa, a medical assisting, all contributed as part of their task. we made a major change in how physicians were paid and had their days scheduled and that they were paid to do what we called desktop work. so e-mails, phone calls, coordination of care, how does, those were scheduled into the day just as you would schedule the time for a patient one on one visit. and the expectation was that rather than catch up at the end of the day with all those phone calls, you're often caught up at the beginning of the day or during the day to do phone calls and e-mails. and we expected that more care would occur out of the office than in the office, and we would do that predominately through the use of the technology.

as part of our project, we said we're not sure this is going to work or were not sure how well this going to works we did it before and after evaluation, informal research which is what in the article will be looked at baseline surveys which were done by our survey department of patience and the members of the team. we at predefined measures and outcomes, and we did a two group designs sometimes using the entire group called control, sometimes using a smaller sample of clinics. some of these changes were really big changes for physicians, and you will see this and an article in health affairs. and it was really a matter of what does it take to get people to think in a new way after having been successful at adapting to the old way for so many decades in many cases that these are 30 and 35 year old practitioners. and i think the way this worked was people used very -- a lot of

back and forth in her change along the way. and if i had to say what is the biggest barrier for physicians anyway, it's the management measurement burden that we put on our providers. and i think there's a lesson there. i'm not sure exactly what it is, but i think we do burden people with administration measurement, and that can be troublesome. so what did we find? well, what we found was pretty traumatic improvement. and we were at bit surprised because and our first paper we didn't expect to see any changes right away, so when we saw them in the paper at the one you result we thought this could be a half or effect, maybe it's going to go away and now what you see is i think a more enduring effect. and, in fact, by and large the experiment was really quite a success. the care was better.

the patient experience was better based on the surveys that we did. and the most striking finding was the absence or near disappearance of physician and provider burnout. and we had people who literally changed their retirement plans as a result of how well the clinic worked. and in terms of the content of care, we had fewer primary care visits so we changed the principal income from being a face-to-face visit to essentially a dramatic increase in the use of secure messaging and phone encounters. and overall, there was a far greater level of communication between providers and patients. we saw 26% fewer er visits in the patients in the pilot clinics versus the controlled one, and 6% fewer hospitalizations. and almost all the hospitalizations reduction wasn't ambulatory care,

sensitive admissions. and this is, of course, the bottom line for us, it was financially successful. our cost went down on $10 on average and that was driven by the reduction and er visits. so our roi was 1 dollar invested yielded $1.50. and if you will, gain for the system. because of this group health is now taking the medical home to all of its 26 clinics, and we will have that challenge of doing it in a large group what was done in a small group. we're also trying to work with our contractor providers to transport the medic. so what are my recommendations? at the end of the day here. what i would want to lead you with the is that the strategy to get, to put more resources into

primary care is a strategy which will lower costs. it will improve the quality of care, and it will increase the patient satisfaction. i think there's unquestionable truth to that conclusion. more specifically, you do have to invest in primary care, hiring enough clinicians of all sorts so they can serve their patients will. and have to involve teams and patients when you redesign primary care. you can't redesign it with some sort of top down or formulate way because you see one primary care practice can you have seen one in primary care practice. you have to engage in effective leadership that really believe in what they are supporting, especially because it involves dealing with what patients want. and you have to have managers who are willing to accept change in small steps. this is not something that you could do overnight. for policymakers, i think the key is going to be, that's been

said over and over again, we need to reimburse people for more than just the traditional visit and to figure out a way to do that. and we clearly need more doctors, physicians assistants, nurses, nurse practitioners and pharmacists. not just the numbers but with the competencies towards working in teams, and i think we need to work with our federal partners to make sure that meaningful use of electronic medical record isn't just about storage, but it's about what patients want and what patients can get from their electronic medical records. the reason i said early on i was delighted to be here, partially it's delighted seeing these kinds of results in seeing these kinds of interest. because i do think that if there is hope on the horizon for primary care and for our country's health care, it's probably nation centered medical home. thank you. [applause]

>> i want to start by thanking health affairs for including your throat and its practice profiles and acknowledge my co-authors who are margot, how and kevin were also in san francisco general hospital. i also want to thank you guys are sticking it out, braving the cold on a full stomach to listen to his. so you might wonder why are we talking about partialists at an event that is really focus on comprehensive this. you have to find a better way of an easy way of saying that. and it really gets back to an article that elliott fisher published about 18 months ago in the new england journal of medicine. building a medical david for the medical home. and if you haven't read i would encourage you to do so because it lays out a very compelling case for why we can't, despite the fact that the tension on the patients in a medical home is long overdue. if we only focus on a medical home without paying attention to the special is, hospitals, pharmaceutical benefits

,-comcome help him come all those other colleagues that take up 17% of our nation's gdp. were probably destined to fail. so we have to look beyond the patient center. did i just turn it off? so unless you are fortunate enough to get your care in a very integrated health care delivery system like kaiser, the va group health, this like probably describes your expense we are trying to access to specialty care. in the past majority of practices, the full process is still paper, telephone and facts days which leads to clinical rather than clinical process. were the first person referred is a purse under -- first person schedule. including referring to the wrong clinic, so as a primary care provider i'm ashley for someone to a diabetes click when they should be going to an endocrine

clinic or vice versa. unnecessary referrals meaning there's a patient with hypothyroid condition. it doesn't need to go see a specialist. premature referrals what if i had done a more throat work up the first visit with the specials wouldn't have been spent going out loud forms and x-ray forms. and then obviously things like inability to do for referral questions. at san francisco general hospital we are the sole public hospital in the city, so we take it of the vast majority of uninsured patients and a large portion of medicaid patients. and this slight example place what our system was five years ago. in addition because there are a lot of mismatches between a man and supply. our wait time was anywhere between four and 11 months for routine visits for certain specialty clinics. this was actually the result of

our system, and this is a successful result. where someone filled out a form, faxed it overcome it cannot receive. the facts machine was working. someone got it, the patient showed up, they faxed it back. i don't need to cover up information because you can read most of it. [laughter] >> this was the best case scenario in our system, and the question really was can we do better. and our response was to develop your referral, which is a web-based typical referral and consultation service that importantly it's not just i.t. i.t. is an enabler. what it is is it is staffed by specials reveres so every single referral has a live person, and live specials on the other end, either in m.d. or an mp. so this is how it works. i'm not usually this technologically challenged. [laughter]

>> there are only three buttons here. [laughter] >> i'm not sure. now can i get to go back up? thank you. so this is the workflow. i just realized there is a clearly defined era that i should be pressing here. [laughter] >> a row. [inaudible] [laughter] >> the pcp an issue to the referral, and it goes into a queue. and overnight it gets linked to our electronic health record so pulled all the relevant clinical data and it tended to the actual free text field that we don't have a lot of out of rhythms are guidelines that really is, you know, the pcp putting in what the reason for referral is. and then it gets reviewed by the specialist and if it's appropriate and the workup is complete and it is not urgent,

it is scheduled routinely. if it is urgent it is overbooked. if the pcp can manage it with guidance and the medical home context, or if they prereferral workup is complete or if the special isn't quite clear about what the reason for referral is conspicuous back to the pcp. and the use your referral system. everything is embedded in the program to communicate back and forth back and forth until they decide together whether a patient needs and appointment or not. so some of these opponents eventually get scheduled or referral to. and some are never scheduled. and so the impact has been a decrease in times and all of the medical times a special clinics, we had a dramatic increase in specialty clinics. it went from 11 months to four months, and that's because there were some referrals that were redirected. for example, liver biopsy could go to the service instead coming to labor clinic. there were cases that could be managed by the primary care

provider, by the specials. in the beginning our specialist champion actually was a pending, until we were saying just make it short and pithy, some writer you can to the abstract. but it's an educational tool as well. then lastly, those premature visits get weeded out. we been able to triage urgent cases for some of the clicks with longer wait times, for several, rheumatology in the beginning, after 36% of the referrals were overbooked. where as before you have to call and take and make your case to get your patient seen earlier the next available. . . examined and

that actually happened in our old system. some of this improved efficiency is due to ledgibility. and then we have a newfound ability to attract demand and wait times. so just to conclude, some of the challenges to spread in thinking about some of the other systems. we've actually worked with l.a. county and orange county who have developed other systems. we're work with l.a. care which is the largest managed care program to do a pilot with them. a group from the u.k. actually came and was really interested in adapting this to their chosen book model which would be very exciting but really some of the things that made it successful

in our system which is not widely available access to a common ehr and academic environment is actually, i think, something that's important because all of our specialists are very used to education. it's not just, you know, turning the patients out but educating residents follows their primary care colleagues and then lastly and this ties back what you heard all day today. when we surveyed our primary care clinicians they reported e-referral resulted in better care but it was more work. because before if you think about it, the analogy is a tennis court and we're lobbying off reners some of are getting over the neither and some are returned and some in fact grass and suddenly it's a racket ball court and most of the time is in the primary ball court and i'm trying to field all these things and making sure preevaluations are completed. so again it goes back to can we do payment reform? can we do visit redesign to support this kind of model?

thank you. [applause] >> i am i.t. challenged so let me see if i can do this, okay. so i'm speaking -- i'm a medical center and ceo of the unite health center which is also the unite health center and it was founded by the ilg in 1916. so it's a little bit of a unique setting. it really dovetails well with richard's discussion about medical assistance and that's what i want to focus most of my talk with. i work with medical assistance but i think all of it speaks to how much those of us working on the ground need to figure out who should do what in all of what's going in primary care. and i love your opening remarks about what practices should be. and my a-ha moment in new york city came with the subway strike. all of our members and patients live in the outer boroughs. we're in manhattan. we have 250 to 300ing in a day.

-- 300 a day and nobody came in in those three days and all of us were stunned by that and thought a lot what we're doing we could really transform. it's a multiservice center. we're primary care specialty. we have -- most of them are union members or families, retirees from the workers united unite here. 32 unions. they're low wage, mostly immigrant. most earn, you know, less than 150% of the federal poverty level, intermittently employed. so it's fqhs but it's contracted by these unions. we have 30 specialists from surrounding hospitals. radiology, mamomography, ultrasound, pharmacy and we serve about 10,000 patients a year. we had an emr since 1999 and part of the reason we really been able to do most of our work because we are funded by

capitation by the unions. we have some contracts that are fee for service plus capitation and we have for service for retirees but all our innovation came from that deficit funding and we would never have been able to do most of what we've been doing since about 1999 but for that payment structure. and the other thing that's nice about the health center is that because we work with unions we can noodle with the benefit design of the members' plans. so we encourage patients with chronic disease to come to us by adjusting their co-pay formation physical they use us and don't wander. so we really sort of have gotten to work in the universe that i think is unusual. it's a union health center. the members feel like they own it and it give us a different feeling than other places. we were defined in multiple redesign access and then got very involved in diabetes work. and we decided to pilot a program to figure out how the

medical assistance could work more effectively on our teams. so i think my contribution here is to go in some detail what that was and we've been doing it for a long time and we've had some outcomes from those projects. our medical assistance in most states are higher. they have with 1,000 hours of didacic services so we are an internship site for them and we recruit from that intern pool. and we then developed our own curriculum and takes place over 9 to 12 months with the medical assistants. about three hours a week and we do didactic teaches on all the chronic diseases with them. we do role-playing and we have interactive systems and teach management skills to patients and then help them listen how to facilitate behavior changes with patients and then we've also spent a lot of time coaching them and teaching them how to be a successful team member.

not only do they get training to be team members but spend a fair amount of time with our providers and our clerical staff on teaching how people can work effectively as a team. so all of our medical assistants undergo that training program. and only those who graduate, all the modules go on to become health coaches. and they're actually promoted to be a health coach. there we go. so one of the things that's very important for this, of course, is that we have an emr and so embedded in the emr ways for the medical assistants to work individually with patients by phone and at the health center. they lead most of our groups and what they can do is communicate back to the primary care providers what they can do as a patients from these people plats that we developed in our eml they do have the blood sugar checks and goal setting.

we talked them to do the food exam for diabetics. the provider care provider sees that but there are clinical pieces that we laid sort of handed over to our medical assistants. and then the medical assistants, of course, review a lot what they've done either before the day in our huddles or at the end of the day in these flags in meeting with the primary care providers. so that initial work with our medical assistants we then roll out to the whole health center and we are now a level 3 accredited primary -- patient-centered medical home. and we have outcomes for some of the diabetics since we started this program. we're usually following about 1,000 -- 1,000 diabetics but there are 500 in a group that we follow between 2005 and 2009 where we have parameters every year that they were there. and there were statistically significant improvements in all those clinical parameters in the diabetic patients that were followed and it was paralleled

in the thousands by the 5 hit-and-run group were the ones that we followed closely. and then the other statistic here is just that those who are poorly controlled which is the hem globin greater than 9 you can see health center wide in that time period we have a conflict of interest number who are not well controlled and we continue to recruit patients who have not been well controlled but those whom we do see over time have had significant improvement in that parameter. one of the things we also were able to do was we analyzed the health and welfare fund data for one local where there were 3,000 members who we'd been following. and those who were followed at the health center had a 17% decline in their pmpm costs compared to those who weren't. and we also looked -- you know, we could dig into those numbers and you can see even the e.r. pmpm cost declined it was 50% less.

we believed that the fact that the medical assistants share a lot of the background with the patients and they can really develop this sort of trust and comfort between the patients and themselves and it's really allowed us to make such substantial gains for these patients who have chronic disease. it comes at a much lower cost than using some of the providers that are traditionally used for health education. it's also created an interesting career pathway for our medical assistants. they get promoted to be health code. some get promoted to be floor coordinators who help run the flow of the clinic. with the hospitals closing there's a lot of interest in having medical assistants actually participating in more in primary care environments. and the other is that -- you know, i've really been interested in physician retention in primary care and community health centers and a lot of the talks today are talking about how to push as far as we can the responsibilities that different people hold. and the providers, the intention here was not to take work away from the primary care providers and then add more visits.

so we've really been able to loosen up some of their time again because we're not paid primarily on a fee for service basis. so the environment that they're practicing in has been much more rewarding. and, you know, i think it's just something we should consider as we -- as we look at redesigning primary care practices. thank you. [applause] >> well, good afternoon. >> good afternoon. >> i had to bookend what susan did earlier. i'm sorry. the last speaker of the afternoon. being a z, i'm very accustomed to going last. so it's only promotes. -- appropriate. i want to thank susan with health affairs to hear what i have to say on behalf of quad med and quad graphics. let's see. hopefully i'm not buttonly challenged here.

okay. i've got it worked out. so i wanted to focus my discussion -- we're obviously in the section on the practice profiles and the title of ours is an employer-directed health plan that seeks to reenergize primary care and i'll emphasize that reenergizing piece. but what i've put up for you here today is kind of the direction that we're headed with this health care microsystem called quad med. population health delivered from an onsight primary care platform. and i'd be remiss if i didn't thank my co-authors. dr. lynn is actually my immediate predecessor as the president of quad graphics. you might note some sound there it's quadmed it's a family owned company. quad graphics -- well, we'll get into that. it's the third largest printer in america on becoming second largest by the second largest printer and that begs the whole

question what the heck is a printer doing in health care? well, i'm here to tell you that as my boss the second generation has said, who would have thought that health care would become a competitive advantage for a printer, okay? so this is a little bit about us. it's an entrepreneurial venture given the entrepreneurial of quad graphics ventures off into health care as well. it's not actually out of character for our now deceased founder harry quadracci and if he didn't see anything that he liked or buy a value out in a market he would in-source stuff so quad graphics has it's own ink company and this is our mission statement. we provide innovative high value

health care solutions to companies, improving the overall health and productivity of their people. mostly we focus on quad graphics as our main sponsor but through friends and family we evolved into a bit of a boutique operation where we have a few other companies. but when asked what is kind of the gist of our success and how we do it. i'd like to tell folks that a small investment in primary care leads to a significant payoff with a decrease in the overall spent and that's the theme we evolved over 20 years at quadmed and quad/graphics. harry now deceased founded it in 1991 and this is his words at the i nothing else of the clinic. -- inauguration, we'll keep you well and if you get sick, we'll take care of. bless you. 20 years ago harry was looking for something different. he did not -- you know, he was tired of business as usual and

paying out large sums. health care with double digits. so not knowing exactly what he was getting with that large check that was being written, you know, year-over-year for health care, he said i can't do it any worse myself so he hired a doctor and nurse and started on this path. and it's grown to be fairly -- fairly substantial. i like to refer to the model for quadmed as something as a three-legged stool. the three legs as you see them here. it's theoncept of wellness at work. it's the clinics that exist at the work site. these are primary care collins. in their heart of hearts. yes, we do take care of workman's comp but it's all, you know, driven by this empowered model or re-energized model of primary care. and even though we've had this 20-year track record and it's only been recently that the verbiage around patient-centered medical home has become -- has really entered into the consciousness, we look at the

definitions around patient-centered medical home and say, well, gosh that's what we've been doing for 20 years. it's very easy for us to embrace that conceptually. the second leg of the three-legged stool would be innovative information management. and that's really kind of a across-the-board. it's certainly in flames. and not only are we self-funded but we're self-administered. so we are in essence our own health care insurance company as well. we've insourced the tpa, the third-party administration function. and that's really a helpful source of data for what we do. we run an analytics data warehouse. against our claims and farmer benefits information. and we were one of the bipeers in southeastern wisconsin with electronic medical records. we're in our second generation of emr. it was more painful from converting to one emr to a second emr than from emr to

paper. and we do have some internet portal type stuff still a little bit inmature but what's interesting the most popular aspect of that is the patient's request for refills. it's part of the dialog that's going on through the portal. and then finally the third leg is benefit design. and this could be an hour-long lecture unto itself and i promise not to do that to you at the end of the day here. we're all about value-based insurance design. and that is -- again, kind of one of those buzzword type things but i want to tell you a little bit later in my remarks, i think, about our premium structure. and how we work what's called our lean you and our well you programs. but we're balancing patient choice against steerage. and one of the ways we do which ties nicely that you've heard earlier about minute clinics, if somebody is ill after hours and they're not going to be accessing our on-site clinics

for whatever during the typical hours, they have a 50% out-of-pocket up to a limit of $4 handicap -- $400 venue of the clinic or the emergency room. pick wisely so there's a little bit of consumism and steerage there. lifestyle choices it's going to cost you more if you're a smoker for health care. strategically what does it mean to us? well, we provide onsight primary care in just a handful of cases where we now have this kind of confluence of forces in milwaukee where we have several primary care clips we have selected specialty care on cite. a full day of a cardiologist and a orthopedics.

the main thing is prevention and wellness and what was mentioned earlier on this panel is restructuring on the delivery of primary care at group health. we do something very similar. we salary our providers and we take them off that hamster treadmill of toxic piecework, methodology but don't get me started. that's so prevalent in the fee for service realm, okay? so we've slowed down the pace of care with these salaried providers. we give them plenty of face time. the minimum time is 30 minutes for a visit. and you say well, gosh, that's luxurious amount of time. why do you waste so much time? you could be seeing 30 patients a day? well, no we want our providers to really see 12 or 14 patients a day. and have those be high quality touches because it's that interpersonal relationship. it's that face time, you know, with your pcp. whether that's a midlevel or a physician provider. that's at the heart of the

teachable moment for prevention and wellness activities. and then -- of course, we can't do it all onsite. so then we craft a narrow or high performance network of specialists and providers around these primary care clinics that we have onsite. and many folks have talked about process improvement activities but we've really tried to study from the manufacturing side having a parent that has grown up on the toyota production systems, of course, nowadays that's kind of pejorative. maybe we should be talking about the honda production systems instead of toyota. but anyway we're very accustomed to talking in lean terms and then we've kind of translated that into direct patient care as well. and, of course, we do workers' comp. now, anybody here know the word discom boblation? is that a milwaukee word?

when you come through the tsa and you're putting your shoes back on and finding your wallet and your cell phone, big sign that says recombobulation area. [laughter] >> in the lower left you see it's kind of the way today. good men and women working hard but not necessarily always coordinated with the hand-offs and everything. and we strive to be a little bit more combobulated in that. surrounded by primary but primary care itself is surrounded by a whole host of things that it may not ordinarily get in the community. the direct contracting so the ease of referrals. that's been streamlined. the focus on preventive care and wellness at every visit. support services, a ton of support services. we've insourced pharmacy, dental, vision, fitness,

dietion, and our certified diabetic educators. those are off the top of my head. occupational medicine. again, integrated into the care experience. i will tell you that most of our employees who come through -- it doesn't matter if they hurt their back in the garden or on the shop floor, they just know they have a sore back and they come into the clinic. in those rare cases where there might be an issue about secondary gain or causality or something, our primary care providers do have a nice outlet where they can recuse themselves with occupational medicine. again, the robust informations systems that lead us to measurable outcomes of service. this is just our clinic footprint. so about half of our businesses for the parent quad/graphics and a little bit of a handful for the others. there's just one plan, okay? but it has three tiers and it's tiered in such a way that again you have choices.

but, you know, we're trying to steer towards the most cost-effective. and that would be the preferred tier where we have these quadmed clinics onsite, on the campuses of our printing plants. there you only have a $7 co-pay for a visit or if you go to a specialist that's referred by a provider it's a $30 co-pay and everything is really covered at 100% beyond that. the middle tier again this is a pure point of service system, middle tier is just a ppo, a network that we lease there. it's more like a 75/20 plan with some deductibles that kick in. and then completely out of network it drops to about a 65% benefit. but people do have the opportunity to go anywhere they want to. and there is some coverage available. the premiums are relatively low. but the interesting thing that we do is we stratify the premiums against participation with our incentivize program

which we call a lean you, it's a terrible pun lean on the lean manufacturing stuff but people are, you know, conversant kind of verbiage so that's where we've gone. so somebody who opps -- about 75% of our population does. they opp into the program they can take off $11 off their already low weekly premiums. two bucks for just signing up. $9 for testing they are tobacco free. again it's about 75% of our population. the other thing i will just say briefly, too, on value-based insurance design. we have one fairly mature around diabetes and we call that well you for diabetes. and the way that works -- all of our diabetics who opt into that program and sadly only half of them do and i think there may be -- it was brought up earlier today, probably some significant comorbidities with depression.

why wouldn't any diabetic want to take part of a program where there's a high degree of service from a diabetic carter to help them maintain medication adherence and keep up with all the myriad things that you need to do to be a healthy diabetic these days from eye exams to foot exams, et cetera. so when they do that and stay fully adherent to the assistance of our certified educator they get a zero dollar co-pay for their meds and test strips which on average last year was $540 per diabetic. so, you know, again what -- we're trying to get at here is the primacy of primary care. by doing this in over 20 years this has been our track record financially, the bottom of the two lines here in dark blue is the quad/graphics line and we've

enjoyed significant success when compared to our bench line which is midwest manufacturers. and you'll note that the last four or five years the trend has bent a little bit more. and that's, i think, possibly due to some of our wellness programming but also it's gotten more expensive out in the community as well. so in summary, i think for one thing, it's just delightful to be able to say in conclusion and know you're the last speaker of the day. [laughter] >> a lot of talk about patient centered medical home which we very much embrace. a little bit about accountable care organizations. that's verbiage we also embrace. i would maintain for you that if you take -- if paul is still here, paul grundy mentioned when he visited wisconsin last month that pcmh are opposite sides of the same coin and i hawked onto that. you take the pcmh and the accountable care organizations, wrap them with a high

performance network as much as we have and you've gotten accountable care enterprise and it's way more efficient than what we've been doing for the last several decades. so with that, i'm done. thank you. [applause] >> great. well, susan started us off with that great quote. those who say it cannot be done should stop interrupting those who are doing it. and what we heard today those who are doing it. and i was flashing on all of the conversations we've sat through in the post-health care reform era where people have asserted we will never bend the cost curve and the accountable cost curve will never bend the cost curve, most of these folks bent the cost curve. so they -- we should stop interrupting them and just let them get back to work. before they go, however, just to summarize in every one of these presentations you heard the same thing. team orientation.

a slowing down of the pace. longer visits. more done via phone and email and through ehr and patient portals where possible so that longer visits can be had with the patients who really needed it. different payment structures. smarter referrals, et cetera. all of it put into a big package and resulting in savings. bend the curve across-the-board. so it's a pretty obvious set of conclusions that we can take away from all of this. and i guess the only question is, what is it going to take to replicate more of this nationally. in the interest of time let's go right to some final questions before we let everybody get back to work. over here, yes. >> craig, medpac, i was interested if you have any residents running through your -- your group health?

>> yes. we do have residents in the pilot clinic and the resident clinic itself is running through a group health. and i will also add that the word is out. and if you want to recruit residents for your practice, have a patient centered medical home. we had our most successful recruiting years ever since having the medical home. >> and i think i recall reading in your piece as well as in the report from the field piece we did, eric, you not only have had as you alluded a surge in enrollment, you have an enormous amount of interest now in newly graduated medical students wanting to come to work for the system. you just said was the case with the residents. >> yes. >> the market is going your way. was there another question? okay. if not, let me -- oh, yes, there is. over here.

>> in several of the cases you've managed to lengthen the patient visit and see fewer patients. so what happens to patient demand? do you have to train them to start using email where they otherwise would have visited and do they have longer waiting times or do some of them give up? how does that transition work? >> you want to take that on? eric? >> i'll start. i think the patient demand is a bit of a misnomer. patients want care. they don't demand it face-to-face. and if they can get care in a much more convenient way and have their demand satisfied, everybody is happy. i practice and i used email and the phone. and basically i think basic demand actually goes down when it's satisfied in a convenient way. and in a timely way. so patient demand is not a problem. the real problem, you know, that

people don't think about is how you reorganize a panel. because if you're thinking about going from a stable panel of 2300 to 1800, some patients are going to have to be moved. and that's a very interesting challenge at the medical home faces which i don't think a lot of people have had to deal until they actually made thatlition >> how did you deal with that briefly? >> well, we let the doctors decide. and any patient who wanted to stay with a panel was allowed to stay with a panel. and we thought the doctors would, you know -- there's some patients who are more difficult than others. so you think they would want to make their life easier. in fact, just the opposite occurred. the people that they had the fewest visits with, the lowest level of relatedness to were the ones that were most likely to be repaneled. >> okay. and just in terms of the training patients, i recall an anecdote in the report from the

field piece that we read, there was one patient who was getting email messages from his provider but wasn't opening them. group health dropped into the mail a postcard saying please open up and read your emails and now the patient knows how to keep in touch with group health which is via email. question here. >> mark from connecticut. i wonder if you can speculate how that panel management access issue plays out in a much broader population being covered? so rather than just your 1800 when we bring in 32 million more people, how does that play? >> well, you know, that's a very good question. you know, we're talking here about the spread of access to decent primary care. and i think that's what this meeting is all about. i would hope that we go from this meeting energized to, you

know, develop a population of providers who are skilled at doing this. because right now it's not really conceivable that you could turn a screw and suddenly you have patient centered medical homes for all americans. but it's within sight if we set our minds to it, i believe. >> richard, do you want to add to that? >> sure. i think that it's the profound question 68% of all encounters are happening in groups of four or less in the united states today. so there's really two pieces of it. physicians need to think about reorganizing their practices to meet that onslaught which is is of a critical issue in its teams, its technology they have to do that but when you go and talk to physicians and say could you reorganize your practice, they say, not in the current environment i can't. so unlocking that goredian knot is going to be key. and i think the major thing i would say is that when policy people and payers approach physicians in this situation to

discuss these pilots, they should understand that it's a mutually beneficial negotiation. it's not a charity project. it's not oh, let's do something friendly for them. nor is it a sharp edge negotiation because what you want to do is buy primary care cheaply, you don't have to change anything. i think understanding that there's a kind of social problem out there to solve a limited number group of people who can solve it and try to engage them in addressing that problem by making it possible for them to redesign their practices and have a viable business model under which they could do that, that's where we're going to have to go. >> all right. well, if there's no further questions, i want to say again hearkening back to something susan said, which is that we don't really have a whole way of instructing people in the primary care sector in invocation per se. -- innovation, per se.

and we heard some examples of that being discussed just now. i want to thank this final panel for a terrific set of presentations and once again say thank you to all the authors who contributed to this issue of health affairs, all of the funders who help make it possible and all of you our readers and subscribers and others who keep us going and ready and revved up to care the message of reforms in health care. i thank all of you for being here today. [applause] [inaudible conversations] >> elena kagan, the president announced his pick this morning at the white house at 50 years old, she would be the youngest

justice on the court. she would be the first justice without judicial experience in almost 40 years. the last two were william rehnquist and lewis powell, both of whom joined the court in 1972. ms. kagan was the first female dean of harvard law school and then the first woman to serve as the top supreme court laureate for any administration she was born in new york city and holds a bachelor's degree from princeton, a master's degree from oxford and a law degree from harvard.

>> and now on the symposium relating the internet. the next panel examination the practices companies are using. this hour and 15 minute discussion was held at the ronald reagan building here in washington. [inaudible conversations] >> welcome back to our symposium, ladies and gentlemen. as you all can tell, these things run their ordinary course and we're chock-full in the morning and we have some laggers after lunch. if you look at the agenda, you'll see that the afternoon promises to be just as substantive, just as engaging. and to kick that off, we have

some opening remarks from our general counsel. just a couple of thoughts before cam comes up here. as i mentioned, at commerce we've kicked off an internet policy task force that danny and i colead. the executive sponsorship for that really comes from cam and from my boss, travis sullivan, the director of strategy and policy in the secretary's office. it's been a pleasure to get to know cam. to put it in context, i think you saw this morning the type of leadership that we have both within the commerce department on this issue with michelle o'neal guiding one panel. and larry strickland guiding another and the support we have from the rest of the administration. one of my pleasures at being at the commerce department and looking at the tech policy landscape is i get to see other aspects of it as well. most people don't know it, but

the commerce department is very sprawling in its composition and in its mandate. to the south we have the patent and trademark office and we've got an incredible leader down there. we have our headquarters across the street. and then up in the north in gaithersburg we have nist which is led by another extraordinary executive pat gallagher. as somebody who's at a senior staff level, it's really a pleasure of mine to be able to work with a very, very strong suite of executives going from the pto through commerce department headquarters and out to nist. and one of those strong executives is cam, our general counsel. cam has spent years in private practice. many years as a senior partner at the law firm of minst levin which has a strong communications and e-commerce practice.

cam was until he became general counsel the lead of that group up in the boston office. not surprisingly. but he's transported himself down here to work for the administration. and again he provides great leadership, great wisdom on e-commerce issues for us. and he's just an overall great guy to work with. thanks. [applause] >> thank you. and good afternoon. i think that this is built in the program as afternoon remarks, i thought we might sell more seats and bring in some of those lunch time laggards as we bill it as afternoon delight but i didn't win that fight. boy, i see what secretary locke was talking about this morning. i feel like i'm the umpire at a tennis match. [laughter] >> in this room.

this morning secretary locke highlighted some of the astonishing statistics about the growth of e-commerce. and our reliance on e-commerce and on the internet. among other statistics, i noted that online transactions today are estimated to total $10 trillion annually. and expected to pass $24 trillion by the year 2020. but these remarkable statistics actually understate the impact of the internet and of the digital economy in this era. they don't measure the massive amounts of data that are moved across the internet and mined by

academics. and by corporations for research taking advantage of the vast increases in computing power. they don't measure the efficiency gains for businesses that use b-to-b techniques for inventory management. they don't measure the welfare gains for consumers from increased choice and competition globally. as the previous panel discussed in the discussion of innovative uses of personal information. increasingly data is being used to personalize online experiences to make product recommendations and to connect people with many different kinds of communities across the globe.

nor do these statistics measure the full impact of the internet on our society today. it's not only a vehicle for internet -- economic transactions. it's the backbone by which we communicate today. it flattens organizations. it decentralizes politics. and it changes the way that we communicate with family, with friends and with colleagues. i've watched this unfold as a communications lawyer going back to the days of the computer inquiry. and as a consumer, back to the days of a text-based delphi internet account. and when i came to the department of commerce, i knew and came there with a sense that

we have a special responsibility of stewardship for the internet and for e-commerce. i recall that in 1997, the department of commerce was a leader in establishing the global framework for e-commerce. and it's with that role in mind a that we have launched the internet task force and launched this privacy inquiry and other inquiries to follow. and in doing that, i've had in mind the role of one of my predecessors at the department of commerce, andy pinkus. andy was a leader in formulating some of the best thinking around a range of internet issues. and along with our morning

panelist, larry irving, when he was the assistant secretary at ntiaa, andy knew that if we were going to build the internet to its potential, the united states government needed the right touch in the process. so it's an honor to pick up that manner of leadership. as one simple message that i want to leave you with today. and that is that in this field, the department of commerce is back. we are back to lead. it's a model that we want to carry forward as we update the framework for global digital --

for the global digital economy in the 21st century. and we're back because our continued economic recovery and tomorrow's prosperity depends on a tech sector that's able to innovate and expand into new technologies and applications. we're back because the internet and e-commerce depend on trust to flourish. we're back because the government has an important but delicate role to play in preserving trust and enabling this digital fabric across our society to flourish. trust and privacy are central to the mission of this effort, central to the mission of the department of commerce. earlier this year, secretary locke established within the

department a department-wide internal-facing privacy council which i chair. and one of our first acts was to adopt a privacy mission statement for the department of commerce. it says that the department of commerce is committed to safeguarding personal privacy. individual trust in the privacy and security of personally identifiable information is a foundation of trust in government and commerce in the 21st century. as an employer, as a collector of data on millions of individuals and companies, the developer of information management standards and a federal advisor off information management policy, the department strives to be a leader in best practices in privacy policy. to further these goals, the

department assigns a high priority it off privacy considerations in all systems, programs and policies. to lead on the external privacy-facing issues, we're committed it off ensuring that we serve as a leader and an example for the u.s. government in best privacy practices facing inward. hundreds of millions of americans entrust the department of commerce with protected and sensitive saysus information. -- census information applicants to our many grant programs trust us with their dreams and with their plans for the future. with this privacy symposium today, we are stepping up our outward-facing work.

our objective in these forms is clear. we want to ensure that we preserve and we protect everyone's access to an open global internet. where innovation and privacy can flourish side-by-side. as we begin this public conversation, i want to tell you about an aspen institute conference that larry strickland and i attended last summer in colorado. our assignment there was to look at four different scenarios for the development of broadband. we were joined by leaders from the public sector, from congressional staffs, from the fcc, from private industry carriers, nonprofit leaders from public knowledge and free press and academics from across the country.

we were divided into four groups. each group analyzed a different scenario. and all four groups independently -- these are people who are not shy about disagreeing with one another highlighted one driver or one risk in common for the continued development of a digital society. and every one of them framed it in exactly the same terms. trust. trust. so for me, this striking convergence consensus validates a guiding principle for our work as we embark on this new framework. it's working for trust. the government has a vital role, a vital role to play in bringing

together many stakeholders like you today. to ensure a foundation of trust that can be a driver for a secure in a sustainable and digital economy. and as evidenced by today's symposium, we're proud to be to serve as a leader within the executive branch in the continuing interagency conversation on these issues. we look forward it off working with our colleagues at the ftc. at osdp, the state department and across the government. i want to recognize some of those colleagues who are here today or who have been here today. the department of commerce and the federal trade commission have had a productive partnership on privacy issues

for many years. it's a relationship that we look forward to continuing for many more. we're fortunate to have here jessica rich, the ftc's deputy director of consumer protection. she's going to appear on the next panel. and i want to extend a special thanks both to the ftc and to jessica. we have worked closely with the ftc on many issues. global trade issues and privacy issues as many of you know. the u.s./european union net framework. the asia pacific economic cooperation, e-commerce steering group. the oecd working party on information security and privacy. the]xd trilateral committee off transborder data flows.

so as general counsel, i look forward to the job of bringing the insights that you offer today, that you offer in response to our notice of inquiry. to the ftc, to the fcc, and across the government. i also want to recognize for their participation today the ambassador who will be here later this afternoon. the deputy assistant secretary and the u.s. coordinator for international communications and information policy. also andrew mcgauglin for international policy. i thank them for their leadership and for their support. on these important issues. and we are truly fortunate at

the department of commerce to have with us the kind of recognized experts in quality thinkers and leaders in marc and in danny. so i want to thank marc, not just for his kind words of introduction but more importantly for his leadership, his vision within the office of secretary. and i want to thank danny. not just for his work on this symposium, but for his brilliance work as a day-to-day leader of the department of commerce effort in this arena. and while there are too many here to acknowledge individually, i do want to

acknowledge the many staff from ntiaa from ita, from nist and across the department of commerce who have worked hard on this issue and in preparation for this symposium. so if you're here, please, will you stand up and be recognized? [applause] >> but finally, i want to thank all of you. your participation in this symposium here today starts a new focus in our conversation. if you haven't done so yet, please submit comments on our noi request for comments. we need you to share your thoughts. to give us your insights as we

grapple with the many difficult issues discussed today. and outlined in the privacy notice inquiry. i said to somebody earlier, one of the striking things in this field is -- and i'm sure you've seen it today. you can put together people with extraordinary intelligence and command of public policy and familiarity with this area. and have a discussion with many thoughtful questions. but still struggling to find answers. so our task is certainly not an easy one. this is nothing less than a comprehensive review of the nexus between privacy and innovation in the internet economy. we're dealing with technology that moves faster than

government policy can adapt, with changing consumer expectations, with multiplying global markets and regulatory regimes. and we need to hear from you. how the u.s. government can strike the right balance between privacy and innovation. we can't address these issues without your help. so thank you for your participation in today's symposium. we look forward to continuing this partnership as we move in to this next chapter of the internet age. thank you. [applause]

>> if the panelists for the next session would come up and populating the seats, i want to raise a point i said earlier, before taking this job i worked in corporate america for 20 years. and 12 of those years with one particular company. and i worked on many, many public policy initiatives. and the public policy initiatives succeeded when we had support as policy advocates from the executive suite. and i think we just saw another indication of the strength of the support that we have as policy staff at the commerce department from our executive suite. cam kerry couldn't have been more articulate and more demonstrable in showing the high level of support for this initiative across the executive tier at the department. with that, we'll return to geek and wonk speak.

[laughter] >> we have pretty much a continuation of the conversation that we had before lunch, although this panel has more folks from the business side than the earlier conversation. and we'll be drilling into brass tax issues and not live technology because that's fraught with challenges but we will be throwing up a few screen shots so people can see what some of the developments in the privacy tools arena have been occurring. but before we move on to the brief demos and the conversation, just a few framing remarks. i'm one of those people who enjoys looking at the internet economy and the internet as a whole through an evolutionary lens.

that we speciesiation on the internet. and new ways of doing things that people actually couldn't have foreseen or predicted five years, ten years ago. and one of the things that paleontologists will tell you human evolution never continued at a continuous rate. there were periods of seeming stability and then what they call punctuated equilibrium. and during these periods of punctuated equilibrium, the pace of evolution speeds up dramatically. and the outcomes are highly unpredictable. and what we've got, i think, in the internet era is we're fortunate in many respects to be living through this is that type of rapid evolution but in the commercial space and in the development of social technologies. ...

>> i think we need to be honest that the development of privacy enhancing technologies is not quite yet at the same pace as development of internet technologies and services. so have raising out ahead of us the development of new services that you technologies. we have at a slightly different pays the development of privacy developing a enhance these.

and we have a development policy and regulation and legislation. so what do we do about the fact that all these three things are in place and moving at different time scales? i don't have the answer. i don't know if any of us do but that's one of the purposes of this inquiry that we are conducting and one of the things i hope our panel can focus on. so with that, let me pass it over to a handful of folks who actually have been in the midst of developing these privacy enhancing technologies. they have been adapting. mike from the internet advertising bureau will lead off. and we move to the represented of bbb, a great example of what i talk about that adaptivity. if that is really a word. bbb, bricks and mortar company, or organizatorganization represent bricks and mortar

companies, yet 10 years ago recognized the internet was a new thing. and they establish a new program and were a leader then. they have continued to adapt it. and we have representatives from yahoo and at&t who are also leaders in this space. and once we get through a few of their presentations, we will discuss what people think about it. so with that, mike. >> thanks, marc. appreciate it, marc. for the opening comments. and i think i would like to, you know, kind of reconfirmed or repeat general counsel kelly's statement that innovation and privacy can stand together. i think there's no question that that's the point that we are at a and industry, and we are looking to in they come looking to push the privacy info. so i think i probably have the best job here today. because i get to stand up and represent the collective wisdom

and work of literally hundreds of companies that have come together to push the envelope on new innovative ways pushing consumer notice, empowering consumers the choice. specifically in the online behavioral advertising space. i don't want to spend a lot of time with the history and the process, suffice it to say we took a lot of from the federal trade commission when they put out their online behavioral advertising principles for for industry self-regulation. it's been a long process, and inclusive process. and really resulting in last july in a setup o.b. a privacy principles that really seven principles i'm going to talk about the choice and the transparency prince will today because that's what we're here to focus on. but these principles truly are revolutionizing the way consumers get information about how data is collected and used online. and it's also revolutionizing the scope in which they are empowered to opt out of that and

say no, i don't want to be targeted. so, you know, just a little bit about the scope. when all is said and done, when you look at the steering committee made up of our partners with the direct marketing association, the council of better business bureau scam association of national advertisers and the american association of advertising agency. when that group too many more trade associations, and literally at the end of the day, hundreds of companies come together to consider these principles at the board level of the steering committees, to unanimously approve these. and as we move towards implementation, and i just want to point out because principles are great but until you have seen in the market place then you don't have a whole lot to stand on. so you look at the collective membership of these trade associations. you're talking about 5000 leading companies, advertisers, agencies, marketers, publishers, ad networks, portal search engines. and i'd also commend the direct marketing association.

they've already incorporated these pencils into their member code of conduct, and so their members are already beginning to come into compliance as are some of the other trade associations putting into good. but let's look at what we're talking about, because fundamentally they are sort of two ways that you can deliver, that you can deliver notice to consumers. you can do it through the website, the first party publisher. or you can do it through a third party. i want to focus you on an example. this went live this week on publishers clearinghouse. a new service, pilot program and hard by trustee, who every knows as enforcement compliance third party program across the industry. and if you look, this is an entire website, but if you look at the and you can see it is targeted. they know i live in vienna virginia. property through the isp address. if you look at the ad itself you'll see the icon of trustee and you will see a notice there. interspace advertisement i think is that particular link.

jessica will hold our feet to the fire if we're not living up to our expectations. but i think the key here is its in real-time. is easily discoverable. and most iortant it's outside of the privacy party. that's something the commission does was real important that you can't bury it in a privacy policy. if we go to the next slide. if the consumer clicks on that link they get an overlay that takes of the entire page. remember, this is a publisher noticed and it has very clear information, plain english about what the data collection practices are. if you click again, if they are concerned and want to opt out, very eas for them to out of this targeting. i think that's a powerful tool. this is not the commonplace. this is not how the industry has worked for the past 15 years. behavioral advertising is not new. but the privacy tools in this space are new and innovative. that's the key here today. let's look at the other example of consumer notice. this third party knows. so whether it is an ad network

or something like that, probably the most common way people think about this. if you look at this, this is not i live demo. we don't have the budget to do advertising. but this is a treatment that was mocked up by company called better advertising which again is a compliance program that helps people come into compliance and live up to the oba privacy principles. if you look you have the notice within the ad. nothing can be more easily discoverable by consumers than a notice of data collection practices within the targeted at itself. and so if you go through, consumers want to find more information, and you click on it, actually on the ad, you get an overlay that takes over the ad. remember, this is different from the first publisher noticed, becae the third party doesn't have access to the entire website. they kind of have to respect that territory. but it takes over the ad itself, and there's playing in which information about how data is being collected. and you can see right there, if

they keep going forward, and if they want to opt out of data collection and out of the targeting, it's very easy for them to do. if we just go to the next slide you will see how easy it is to opt out of all of this target. so this is the landing page. i want to sure to representations of innovative creative ways that industry is implementing new types of notice. and the key with choice is to make sure that for the first time everybody in the ecosystem is complying and participate. and everybody is respecting consumers privacy. that's the real i think evolution. there's nothing new about opt out, but have everybody doing it can even people who aren't sort of front facing or consumer facing is the real key here. so, you know, principles are great. we are seeing notice. we are seeing choice. but in the end, we also need accountability. and i just want to highlight of lee will talk more about better business bureau's, has been a partner from day one to our self

regular program but also highlight the dma so predatory program. it has a long history in this area. and serving trustee. we show the trade or trustee and the service. there's a serious commitment to enforcement here and to compliance. and without i think i will let lee takeover. >> am i on? how about now? [inaudible] >> as marc said -- were in the process of adapting. we will be 100 years old next year. i wasn't there when it started, but close. [laughter] >> but what i wanted to do today is talk to you about how self-regulation can fit in with the department of commerce's

overall look at privacy principles. because i think one of the themes this morning was what this space needs more than anything else is standards and flexibility are and one of the hallmarks of any self-regulatory approach is flexibility. the problem is that when you go out and just do, you know, your basic google search on self-regulation you come up with some pretty pejorative widely held misconception about what self-regulation is. my favorite was an article that come in a newspaper, that describe self revelation as if you bought a -- help it can get much worse than that. but there's a different view of self-regulation we are trying to develop in this process that mike was just talking about. and that's basically making the third party accountability program. and the principles that were adopted, both we and the direct marketing association, have

undertaken to instructed just that. and the idea is that you have a third party, either the bbb or the direct marketing association conducting monitoring and oversight of companies compliance with the principle. that's not very remarkable, but in addition we both committed that will be transparent about monitoring, that if we find violations, we will report them publicly. and if the violations are not corrected we will refer them to the government. now, there's actually a track record here that shows that approach to work. we have administered for years an organization called the children's advertising review unit that looks at all advertising directed to children your and any media. it has a specific set of principles on privacy. and those principles, both parallel, the children's online privacy protection act, and in some instances come beyond this.

these are standards developed by the industry. they're applied across the board. to every industry member, whether or not industry member has said they agree to comply with them. the children's advertising review unit monitors that space. they have had in the last two years more than 50 reported decisions in that area. they have 100% compliant. now, one of the reasons we have 100% compliance is because we get great con wonderful support and backup from the federal trade commission. and certainly that is one version of self-regulation, that self-regulation is something that supports regulation. there is another version of self-regulation that, where it is in love regulation or goes beyond regulation. and, in fact, most of the so predatory activities for children's online privacy do involve provisions that go beyond basic provisions of the children's online privacy act

and require agents screened by sites that may be attracted to a significant number of children. so going back to where i started, i think one of the things the department of commerce could be doing is trying to develop more of an intellectual base of intellectual support for the process of self-regulation, as part of the privacy protections. and i just came from a meeting at the ftc, the international consumer protection enforcement network, which is a groundbreaking organization the ftc put together to bring together consumer protection officials from all over the world to talk about ordinate standards and coordinated consumer protection. i can tell you that the concept of using self-regulation in many countries is not as well-developed as it is in this country. and even in this country, it could not be better developed. so that's an explicit goal of this program that we have undertaken with the support of many of the companies in the room and all of the advertising

trade associations. thank you. [inaudible] [laughter] >> so those of us on the panel can actually see the slides, so we are kind of like reaching over. i wanted to talk, give some examples of how we're dealing with choice today. i've been to a lot of panels like this, and it sort of starts off with this conversation that had notice and choice are dead. they're old, antiquated ideas. and ashley think what nicole said this what was really instructed, that notice and choice 10 years ago was kind of a two-dimensional thing. i don't think, in fact, interestingly enough what is looking to the agenda for this event i did a little search on in tia privacy. i came up with the agenda for an event that was held in 2000. a lot of his same topics are

being discussed eight, 10, 12 years ago. but what i think is different is the way we are approaching them. and so we think about notice approach today we are thinking about it in a different kind of a web world that we were thinking about notice and choice 10 years ago. when i first started at yahoo, we drafted a privacy policy. we put links to it on every single page. we thought that was kind of revolutionary that a company would tell consumers what we collect and how we use it. and i still think it's an important thing to have but we have tool today that we did have available to us 10 years ago because we have the ball. the web is a very different place to give her talk about this two years ago we wouldn't have been dug up facebook or twitter. we would've been talk about very different web expected. so what we have done on yahoo, actually if you go back, i miss my clicker. i missed that control. we have implemented an icon on our front page and on our mail page with the ads that we should do. those are some of the most

heavily trafficked pages on the internet today. we have been thinking about how do we provide contextual privacy notices to consumers. because what it is about to do is not having a document or a number of choices that you go tell csumers can go find it, read it, manage all of them at one place. it's about giving the choices and information they need in the context of their experiences. and advertising and privacy in that context is just one way we're doing that. this is an example of that. so when we first are thinking about this actually was three years ago when yahoo entered into the third party advertising space. now who has been serving ads on yahoo's own site for 15 years. but the idea of serving as off of our site put a squarely into this new camp of being a third party ad network. and we worked with a number of great partners including ebay and wal-mart. and we spent time talking about the about how to provide privacy notice so your consumers know that yahoo! is involved in this transaction that we are

providing services and add services for you. and so what we came up with this idea providing that information and noticed contextually. the challenge in doing this strictly from a publisher standpoint is that every publisher has to go in and make changes on their side, on their templates. that's a rather difficult problem from a salability stamper. we're always thinking in terms of scale because we have, this is a fast-moving medium. a partnership and arrangements are changing daily. and advertising ecosystem has gotten them is different than it was changes ago when you had a publisher and an ad network and it was a contract, and those two entities work together and all the ads were shown but one ad network, or maybe too. today have a lot of different players, and the ecosystem is a lot more complicated. we're trying to figure out how to make a just a. without we could do this better funding and network perspective that we could from a publisher perspective. so we worked, we've been testing a couple of different models.

this is one were working on. the ad choice label appears next to a little eye in a circle. jolt is over here with the future private reform and a number of other companies work together to test this out. i think what was important, if you go to the next click, you will see a blow up your. our friends at hp are very well represented on our front page. the idea was to give consumers a meaningful marker that would let them know here's where you would find more information about privacy. therevey privacy information that are so terribly helpful. i'm sure everyone has a credit card at some point you've got in your statement a privacy notice. am i right? yeah? how many of you read them? okay, this is maybe -- that's still not very many, even in this audience. but many, many trees have lost their lives. many, many billions of dollars have been spent in compliance and i'm not sure consumers are necessarily better off. one of the things we are keen on

doing it is to test this out, to test it with consumers and find out whether it's helpful to them. i know joel can speak more to the process. if you click again this is our landing page and it shows you information, some educational information. our goal, the future, is to boil this down. right now we're not doing, we're testing and developing related, this idea of transmitting with the add some data about the ad, referred to the metadata. the idea is when we serve an ad with an icon we can convey through that adds some information about who the advertiser was, for the ad network is and where you can go to off out specifically of that ad network. so this is round one point oh but will be doing a lot more of this in the next year. if you click one more time, this is after you were take you today. so this is where you would go with yahoo!. we launched the ad in december of last year and our goal here, and this is a longtime in the works. was to be able to convey to a

consumer some of the information that we're using as part of this customization process and let them exercise their choice you. it's very simple. you can still opt out of all. but we're getting a lot more information to consumers about what information we hold and how we are using it. and a few years ago there's a great deal of concern about showing this much information to consumers. but what we find is by being this transparent and giving consumers this much information it's incredibly empowering, and it demystifies this whole process to a large degree. when you talk to the consumer about what information has been collected and used, there's this sense it's going to be awful, everything and i have this message that i clicked on this link and it was a site. i didn't mean to go to a site. that's not what is being used to customize advertising here. we show you what we're using and we give them control over it. and its ally the consumer to engage with that. and we are finding that it is demystify and giving people a great deal more comfort and how

this whole process works. so this is the clear ad notice process, what we launched. i encourage you all to go take a look at it. and i just want to emphasize there's been a lot of conversation about inverses out that. we always try to boil these privacy discussions down into that very buying a set of choices. i think a lot of people in our industry would say there's a spectrum of choice. it's not, there's not one what to do it or another way to do it. we tend to think of our model as being more of an opt out model but we're doing that form of opt out with exceedingly clear i think notice to consumers with this kind of transparency, controlled, i think is a very good way to go.

>> i would also have a slide, but i really do want to be able to look and see what it is we are seeing. go to the first slide. we will start off. transport mentioned the industry is getting really challenging because you have a publisher's, ad networks, isps, all kinds of actors in the ecosystem. i will just save that my company is highly challenging because we are all of those. so within one company trying to manage the different business interest as a talk about privacy has been actually produce i think some pretty good results and with our partnership with yahoo!, which, in fact, att.net is powered by yahoo!, and all the innovation just talk about we get the benefit of, all the innovation that mike was document with the iab, we are good partners with them. i wanted to point out that in practice, we are kind of a living laboratory of this, a large brand name, top five

advertiser online. we are also the number one isp. so we played, and web publisher, with top 50 websites. so we really do play all these roles, how does one navigate through that in a new era of privacy. and it startled in the foundation and our privacy policy. i know it is trying to enter in all of them and what did talk a lot about whether notice is sufficient, but i would like to point out one future. we collapse our privacy policy about a year and half ago from 17 policies into one. we did a huge redraft. we created one-stop shopping for our privacy for all our lines of businesses, wireless, isp, publishing, all of that, all included. and we did so by drastically reducing the number of work. but i can talk a lot about putting our videos up at all that. the one feature i would highlight for this audience that we haven't talked about is the intentional intake to engage our customers in the privacy policy. and we did that by actually rolling out the new privacy

policy with a 45 day review period. we sent over 100 million, that's over 100 million notices to our customers through their bill insert and also through a web campaign to say check out our new privacy policy. drive into our site and on our side, on the site, just when you first got into the single unified privacy policy, we said tell us what you think. them by the way the privacy policy is not going to be effective for 45 days, so if you want to tell us what you think, we will come in fact, way to do what you had to say and we will listen. we answered every one of our customers inquiries, and, in fact, 45 days later when we made the privacy policy effective, we did in fact change the policy reflecting some of the concerns about language that wasn't clear, despite the fact that we had focus groups in early previews of all of this. we found that impact our customers make them a good point

about unclear language. and we changed it. and it created all kinds of work with our lawyers and all kinds of worries integral to the business. you're letting the customers to you how to write a policy. but it turned out to be a tremendously effective tool. it was well received, and as we all know as privacy professionals, changing the terms of service on your privacy policy is a flashpoint in any event, in any corporate life. and the fact that we use the customers really as our own kind of laboratory was highly effective and i would encourage everyone to do so. and it was part of this process, at least for us internally of recognizing engagement is a key to being an effective -- privacy policy advocate for our customers. so flipping. i don't know where we are on this. a couple other things. that's yellow pages.com. a couple other things that are interesting. want is, as a publisher beyond

our att.net we also yellow pages.com now is why pete outcome. and on that we looked hard and said are we in fact looking at our privacy, the most positive toward our customers as a website publisher. and realize in that context that we need to be even clear. so we added a link at the bottom of the page that says advertising choices. if you click on that link you can turn and, in fact, as others described, as tranforty start up comes the ability to do two things. one, clay opt out if you want to be not part of any part of collection of data. it linked into the nai out that. it brings you right there very quickly. it also tells you what our advertising policies are separate from her by the policy. so if you really want to understand that, we tried to do it very clearly. in addition to that you can click. we also worked with our friends at blue to create a profile

manager. we're talking a very different scale than yahoo!'s publishing site, but, in fact, we ended up creating a customer preferences allowing the customers to find out what was being collected, how we were making interstate advertising. and, in fact, a now manipulated of the categories depending upon what the customer felt that they want to include not being part of the interest categories at all. in addition to that, we also -- we are the living laboratory. we also took the icon idea. but let's take an icon, we, working with the privacy forum we picked one of the top three that had been tested. the icons that have been tested well. sadly for us it's not going to be the man. we will move to the eye because that is the industry selection. we like the other one.

but it tested well. like anne we have been testing and the human factor contact we see people, where do their eyes go, where do they drop on the page. are they understanding it, does this verbiage help. so we have been trying to be a living example of what the industry innovation come anytime there is one. we jump in and say we will test the, we will try it. go on. in addition to that, as an ad, yellow pages.com is a search engine very, very popular local search engine. in addition to that we had gone beta in the last several weeks on a byproduct, not the other byproduct. just to be clear. this is a recommended site that allows our customers when they're looking for local search engine entry to act as i want to know recommendation, do you want to participate in the recommendation