and cost issue with american health care. we need health care reform in america because we need much more affordable care. so what should health care reform look like? health care reform to be done well has to have four elements to it. one of them is coverage. we're the only industrialized country that doesn't cover everyone. we need to do that. we need to fix care. look at prs

of care in america. this is the will of congress and going to share some places from other countries. we have the highest unit prices for care in the world. overwhelmingly higher than anyplace else in the world the

factor of two or three. we pay more for each piece of care than anybody in the world. we have an office visit in canada, the doctor gets paid $40 they charge $41 they lose their license to practice in canada. in the u.s. an office visit is anywhere from 60 to $150. if you get physician fees for normal delivery of a doctorate in canada gets the $500. doctor in france, more than twice that, but in the u.s., the number is triple and quadruple the amount doctors could place any in the world for the same procedure. if you look askance and imaging fees', one of the bizarre things in this country is we are talking about rationing access to scams when we are paying two or three times as much per scan than anybody else in the world for this and equipment, technology and the same outcome rationing before re-engineering and pricing is an absurd

strategy to really get great opportunity and if you look at the price continue in the u.s. there's more than enough range an existing prices to make the care affordable if we move the prices further down the existing range. we don't have to have new price levels for care we just need to get it into the right price range. ct scans the same kind of destruction, two or three times as much as anybody else in the care. hospital charges, one of the myths is that we hospitalize people too much if to many hospital beds and to much hospital care in the u.s. the truth is we get fewer hospital beds than anyone, fewer admissions than anyone, shorter lengths of stay and the highest price per day of anyone in the world so the hospital costs are higher than the rest of the world and there's not one country in europe the charges more than a thousand dollars a day for a hospital stay and there isn't one state in the u.s. where the average is less than three so if we're spending

three times as much per day that's why health care costs more in the u.s.. bypass surgery is particularly interesting. incredibly important surgery, very important, has agreed outcome when you look at the pricing on that surgery, most of europe is charging had a very low number. no one is going over 20,000, most are under ten and if you go to india, bangalore, turkey, greece hospitals having good outcome surgery doing it for five. in the u.s., the range is up to 150, and the averages quadruple the rest of the world. since surgery comes an outcome from same safety levels and different price range. when you look a drug prices of the demos the difference of drug prices because that's been talked about in congress but the same is true that point to surgeons and say we only charge twice as much of the church four times as much, we are

underpricing. not likely to use that argument but they could make that point because drug prices are also significantly higher and if we paid in this country the price is the dutch or the swiss pay for drugs we not only could fill the doughnut hole for nothing we could give seniors $50 a month of take-home pay the dues for vitamins. so prices make a difference. how important are the fees'? if we paid the same they do in canada and what we deliver the same care and office visits and scans, the same tests, same drugs, same everything, same hospital days we can take the percentage of gdp stood on this country from 18% to 12 and resolve the care issues. so what we do about that? we need the couple things. we need to start buying care by the package rather than the peace basis where there is incentives to raise the fee for each piece to it makes little sense.

multiple perverse incentives built into that model. and if we are going to continue to put these to pay for care we should do it like the french and have a flat amount and if the ct scanner wants to charge more than the $500 of the benefit to church six or seven or 15 the customer pays out of pocket and what that does is force is the market to the $500 scanners and as people in this country making a profit of three or two so that isn't going to think of the market but what we've done instead is the deductibles where we hiked the difference between the 500 to 1,000 or the $2,000 can and the consumers have no reason to go to each to replace and the providers have no reason to bring down the price of the benefit package is wrong. if we are going to be by the feet of space by fi in a reasonable way and even better thing to do is to buy care by the package, the the package and not for care and let the caregivers do the right stuff.

i would just mention the kaiser permanente in the things we've got the lead could done to bring down the number of broken bones by half for seniors and all six caregivers and three of them there is no bill that we could charge if we were going to charge something. the we are prepared to submit to use the resources and not have to be delivering care and dictated fees and i'm going to close with this. we also need to improve health. we have a population that is increasingly overweight come increasingly inactive but we have chronic conditions growing every single year and the primary driver of health care costs and chronic conditions and we need to improve the health of the population. i'm here to tell you that it can be done. healthy eating is important. we need to move in the directions of getting our kids to eat better and societies to eat better and healthier food, but we also need is a collectivity and physical

activity is the sweet spot. and walking is our very best hope and best strategy. if as a society what we can do to make this population of the year, we need to look to walking as an outcome, scandinavian countries have gone from finland, one from the sltt police will be in europe to the most of the in a decade by getting physical activity levels and to their world but the walking is the best strategy as the most accessible thing to do. you can walk anywhere. it's the most likely to the ku likely to succeed because it works and the chemicals generated by walking or pleasurable and then your of chemicals by dieting are not pleasurable. when you're swimming upstream against merrill chemicals it is a fast stream so the benefits of walking have huge value. when you walk, walking actually

prevents and manages diabetes, heart disease and stroke, it prevents and treats depression and exciting, helps manage asthma and actually lowers the rate of a couple of cancers and you don't have to walk for hours a day. this isn't like the old days, no pay and no game and you need to run. booking by itself creates all these benefits and basically walking 30 minutes a day five days a week can cut the new cases of diabetes in half. we could save medicare if we could cut the cases of these in half, and losing 10 pounds as well cut it by nearly two-thirds. and you can see some of the data, they're really good news and the thing that makes the strategy even more practical, more functional is that the new science so shows you can do the 30 days in 15 minutes. it functions better when we walked, but the biochemistry of

the body is better when we walk. everything about it is more functional when the body gets up instead of being an art and the 215, one in the morning, one am i, one at noon if you break the data into the 50 minutes for the walking you can get the benefit from walking. so i'm going to -- so we need a national agenda for walking, and we need our kids to walk, school buses, we need our cities to be walking friendly and the work places to be walking friendly and encourage workers to walk, walking has incredible benefits and it is the only logical thing we can do that actually will change population health in any big way that we can get our mind behind as a society. so i'm going to close with we need affordable health care in this country. we can't afford to be on the peace we are on and we need to make the care affordable by having better care. it also need to step forward and for the first time in the

history of health reform in the country look at creating a price competitive care. people think that the care fees are absolutely off the table whatever to any health care reform agenda that and people believe there are some inherent legitimacies to the prices. there is no inherent legitimacy except the prices from the multiple care organizations. i know the process. every caregiver knows the process of every caregiver now has half a dozen different prices depending on the pay and the patient. there is no inherent legitimacy to because. thank you very much. [applause]

>> will george walks back to his seat, we would love to get the perspective of mark on bending the cost curve. >> good morning who. i have three headlines for you and i will spend a couple of minutes on each. the first headline as health care reform didn't happen to the industry. it was absolutely necessary. secondly, the affordable care act is a reasonably good approach to creating market based access to health care insurance not necessarily the health care, and third and probably more importantly is the affordable care at is quite frankly an action forcing evin to change the shape of the industry going forward. let's talk about the first. the small group in individual markets in the united states have an extra will decline for the last 15 years. more employers and individuals

have dropped insurance and the cost has risen dramatically over that time. so there was no other way to impact those markets unless we reform them. as a matter of fact, with the underpayments of medicare and medicaid, and the cost shifting going on as well as the decline of the small group and individual markets, the large group employer based market was in trouble as well. it just didn't know it yet. $84 billion a year as the cost shifted for medicare and medicaid on the back of employers who pay for insurance. and individuals who pay part of their premiums for their insurance. so the market needed to be changed and as a matter of fact, aetna, back in 2005, came up with what was then considered an insane notion of having an individual coverage requirement and calling for it across the industry. and in 2006 came out with a ten-point plan calling transforming healthcare in america which has been a blueprint that we have been

putting forward to the administration, both administrations and congress for the last six years. so that leads us to the affordable care act, which we believe to be a good market based approach for providing access to health insurance. it does nothing to address quality and affordability. and if you saw the news this morning on medicare and the changes on medicare, while we change the financing of the health care system, unless we get the underpinnings of the quality of portability will still be on affordable. the cost would be shifted to americans. as a matter of fact in this country over the last five years, more than half, almost half of the increase in health care costs to employers has been shifted to employees through both the reduction of benefits and the increase in the premium

out-of-pocket that they pay. the employee trends are currently running at 31% year over year for the health care costs in the united states. so more of that will continue unless we get the quality and affordability. so, we believe that the affordable care act must now focus on the quality of portability and we believe the action forcing event is its bringing insurers and providers together in unique ways to create whatever version you want to call with of the accountable care organization. now if you have seen one aco, you might have seen one aco. they are very loosely defined as you know the rates were released last week we are still poring through them. if you want to see some interesting video go out on youtube and look at the avatar videos around the accountable care organizations for hospital executives talking to the consultant and house look sick of talking to physicians come still ill-defined, but aetna and other organizations like ours

across the united states is very active in trying to find the opportunity to create a different level of relationship with the provided community. so, for example, why negotiate when we can share intellectual property around managing risks and doing capitation or we will call it a global payments, how do we work together to help with data, intellectual property around risk-management, nurse case management and health information exchanges and technology to be able to provide the data to mss over time. >> would be unique and a potential that we could have not a health plan man on an exchange in 2014 or 15, pick your date, but it could be a hospital system powered by the health information exchange. redefining the notion of keeping what you have where you get to keep your hospital and physician

instead of keeping your health insurance plan. would redefine the health insurance model where we would no longer be negotiating with providers but partnering with them much like intel and insight to use the notion and we wouldn't be selling members, we would be converting patients to their local health system and to their physicians. the problem -- and this is where the affordable care act doesn't go far enough, is we have increased access to health insurance but we haven't increased access to health care. as george noted eloquently in the slide managing the chronic care is a very important aspect where most of the costs are. however we are short 160,000 primary-care physicians over the next decade with little hope of catching up. so how do we design the system through the patient centered medical homes or count organizations to provide the care necessary to individuals who need access to health care once we turn on the spigot and

place 30 million more people into the system? if you think we have a two-tiered health care system now, if we do not address the issue of capacity, there will be people who will pay handsomely to get to the front line to get access to health care paid and by the way they will get it. so we need to do a lot in the way of capacity and the organization of health care delivery to make a change. the second piece of art of the affordable care act is to have payment reform so that we can put the proper incentives in place where we can have indeed a win-win situation and we are experiencing this chris the country. finally, in my last point, for 80% of the people that use the health care system today they use a commodity like service and use of prices that george noted on his slide. another example in the city of

san francisco a routine colonoscopy costs anywhere from 1,000 to hundred $50 to $7,300. now i'm not sure when you get for 7300 dollar kowalski. [laughter] media movie? [laughter] but it shouldn't be that way. so what we need is complete transparency in the system. think of open table for restaurants, think of open table for physicians come for lab tests and x-rays and vaccines, flu shots. as an approach of allowing people to redefine quality as convenience for the routine services that they got. it will do more to redefine between the aco and the consumer marketplace more to redefine the shape of the system and cost structure and pricing of the system than anything with the affordable care act contemplates today.

with that i will turn it over to the next speaker. [applause] >> while dr. bertolini is coming up, we have a real opportunity here to ask questions of the panelists and so please a few questions put to congress, and submit questions and we will answer as many as we can. thank you. john? >> good morning. both previous speakers spoke to the importance of prevention and transparency and the need for that transparency yielding improvement in health care as well as the system where the incentives are aligned to produce that and i want to thank the world of congress for bringing us together to call the question on the cost curve because of what to speak this morning directly to the issue of the relationship between the cost if we could have the first slide i want to talk specifically about the case of

the billion dollar babies and help if everyone used the best evidence that exists today held a billion dollars would be saved on not to be callous about the savings, more importantly, would save the unnecessary. great distress and potential harm to babies and their families so i want to talk about why quality is the best business case, and what can occur in creating a learning system when the value is the driver and how that learning can in turn drive down the cost that was devoted to in both of the previous discussions. if you look at the top, that is a normal distribution of terms. well, where did the evidence for the term comes from? it comes from an authoritative that may not completely the scientific it was defined at least for the western societies

of the bible. it's terrific but in the days of ultra film, the marker of nine months or lunar cycles from the last minstrel. it may not be the best definition. and indeed if one looks at the normal distribution in the top brass, over the last three decades one sees the normal distribution is moving to the left from average about a little over 39 to 40 weeks back to 38 weeks and back to 37 weeks. so a normal distortion but in fact anything but normal. and in fact, if one looks at the risks for bad outcomes, the graph on the left one sees the mortalities actually decrease those as one goes to term, and so there was this question the preterm delivery if postponed if

the holding the deliveries were possible for 39 weeks result in better outcomes for the babies and their families there was some early data to that effect and so the march of dimes and american college of obstetrics and gynecology came to our organization and said if you will deliver about 220,000 babies more than the continent of australia can you put some data together, so over a three month period will get a number of hospitals with frankly representing the population of more heterogeneous than the united states population at large and look at nearly 18,000 deliveries, and in fact we found that the delivery early preterm delivery was in fact not and i will show you momentarily not the most efficient. in fact, they had early preterm that is either induction or induction resulting in c sections at 37 weeks. there was a 400% chance greater

risk of going to the newborn intensive care unit. 200% greater at 38 weeks than if one went full term 49 weeks. suggesting that we need to revise the definition of the term that there really wasn't term earlier than 39 weeks. in fact, looking at the the the what one found is the risk for the hospitalization and special newborn intensive care correlated with that early delivery because the in maturity of longs and the fetal distress resulting in more newborn intensive care units, and in fact we have to ask the question now or their potential water consequences, and certainly the nicu and it is a whole lot more expensive than a regular postpartum sort out service delivery. well, if one read the evidence one has the obligation to use a and we look at the three bays of

the clinical behavior. on the right and the yellow will look at the second and what one sees as the soft intervention were just education was provided. in the second part you can see there was what was called the semi hard stop which was providing the obstetricians with information about the findings that early preterm delivery resulted in the higher risk for newborn intensive care and access poor outcomes. they were allowed to make the decision but any decision to go to the early elected delivery resulted in the peer review of the decision. the heart stop was a policy of each hospital except thou shall not do this, but over the last year converged and against the national backdrop but somewhere between 80 to 85% compliance up to 96 compliance with early preterm delivery. what are the lessons one can

take away from this? that when one thinks about these sorts of questions and questions that have been taken as gospel in this case somewhat literally without challenging that wasn't what is not always the correct how could we go so long without saying that 37 weeks couldn't do as well as a 38-year-old -- 38 week-old as well as for the nine week-old it is that no doctor in his or her experience has enough caseload to detect is going to dig a fairly large sample the power to find the difference and so in my experience is simply not adequate in fact it is sometimes joked a dr. mix is something is in my experience, it means the obscene to of something that and in case after case it means for. that's not evidence, evidence is looking at a power symbol to see what the difference is sort of come. and using that sort of learning

to drive improvements. let me close with this. that both of the previous speakers i agree with completely. in fact, the current environment meter provides the transparency though now pleased to say on the basis of the study on the march of fines efficacy joint commission and others, have created performance metrics looking just at this. the truth of the matter is the incentives don't line up if we as providers do the absolute evidence based finger it is actually financially penalizing. nevertheless, we've pushed that as far as it can go. but we have to be will to call these three transparency and bring data together, something that's challenging and systematically redefined on the basis of evidence the standards of excellence. i found this to eliminate high levels of the the ruben as an avoidable cause of brain damage

and death. we've done this by requiring fetal monitoring and we've done this in a new area of defining the highest risk for complications after a section. we've actually had the data to redefine postpartum and look at the windows for intravenous. we need a set of incentives that support the linkage of the evidence with the best practice. the alternative or both damaged in terms of the quality care that could be provided for or ways that really wouldn't be the best as the bill to legislate when delivery occurs, great intention but i think difficult in terms of the lack of flexibility. but the end is this, good quality should always be good business. when the intent and the consent of selling and the environment of transparency, and if all of the providers were on board with

this u.s. healthcare to pay itself $1 billion even more than the dollar savings, safety effectiveness and indeed the compassionate care would be approved. thank you very much. [applause] >> the title of the panel spending the cost curve i guess i would like to have each of you address the specific question and get to some numbers here. are we talking about bending the trend toward giving to the new cost curve? how much below the current curve does that need to be if it is a new one and if we are just talking about trend what is it likely to be? are we talking about -- i hear that you were out in the industry we have to get the cpr and others to say we have to get to where other countries are and we haven't actually settled on

what are we talking about here which will give us at least some object of a goal to talk about >> i'd start with a very real example of what's in going on in the industry over the last five years. when the bush administration put forward the changes to medicare advantage one of the questions we were asked is how can we get you to take sick patients? and what they put in place was a risk adjustment based on the underlining diagnosis of the medicare enrollee. we started that kind of program and after the first year realized 75-year-olds with to chronic morbidities' in the case of disease management we could dramatically reduce the cost of care. as a matter of fact the industry started competing for 75-year-olds with chronic morbidity by offering them more benefits. where to they can get a plan for 50 to $80 if they bought elkhart it would be $270.

the way we did it is in a bunch of interesting ways but we'd 47 different pilots across the country where we actually paid physicians 125% of the fee-for-service. we put the case management nurses into their offices and reduced the a to the admissions by 31% and by 34%. and that had a dramatic impact on the underlying health care cost. so i think we can do more than just been the trend. i think we can have a dramatic hit to the underlying health care cost if we are able to work together across the whole system and i think that is the biggest issue we have is how do we scale to a level where we can have that kind of impact across the healthcare system. >> thank you. today we talked about the population of those in the onus using by virtue of their illness the health care resources for

the 15% use 85% of the resources of medicare as an example. we've also alluded to the prevention keeping people who aren't healthy from slipping into that latter category at managing the disease. an observation from my former wife is that we need to have coverage because it's not enough just to have insurance today one needs continuity so one can support prevention over the longer haul and management of established disease over the longer haul. a little data to indicate that's what we talk about one in six americans being uninsured if one looks at individuals through the year that is in excess of one of four and the preventive services and disease management one would need to occur would have to be given across the continuum. the lesson i took away as when colin cancer was detected in 1996 and veteran's it was almost invariably advanced stage with access broadly in support for the preventive services by 2004 it was almost earlier stage.

the that safety compassion all of the above, but not to disregard it was a whole lot less expensive and more efficient to care for veterans with polyps than advanced disease so providing the continuity for the disease management service is absolutely imperative. >> i think it is possible to give the cost to the rate of increase of care down to the cpi over a number of years if we actually do a really good job in identifying the basis we need to take the collective care and delivering that care to those people and then don't allow the marketplace to price up to care for the remaining population. if we have half as many heart transplants because we deliver medicare to heart patients and charge twice as much for each transplant we lose the ground.

we have the great care of the fund and then we need to pay the same amount per transplant in the combination of that could get us down to the cpi and we need to do is have a environment that channels the patient still best care and then a provider environment that's providing best care. if the business model of care is rewarded for doing the best care in a team way and if it isn't rewarded for it won't happen. it's a simple business model issue and the only people who can create the business model or the buyers, it's the pay years and the lawyers because that's where the money comes from. as if they restructure the model, the care delivery will follow in a microsecond. care delivery is very nimble in responding to changes in cash flow. so there's a lot of creativity there but it's not going to be

channeled until the business model changes in a couple of basic ways. but once that happens there is a lot of low hanging fruit out there. there's way too many kidney failures and kids having asthma attacks. there's all kinds of opportunities. so i think we can bring down the rate. it's not just been the trend. i think we can get down to it is kind of a cpi sort of number. but we have to do it systematically, programmatic the across-the-board, and we have to stop the cost shifting. if we let the inflation eat up all of the gains, they will be gone. we have the lowest number of hostile bids in the world and lowest number of hospital admissions in the world in this country. we have we less hospital care and we spend twice as much on hospitalization as anybody in the world because we have offset all of the gains and efficiency by doubling and tripling prices. it's been acquitted a question from the audience.

all of you have talked about even in the face of reform and in fact using the market mechanisms to try to help this issue. we the question in the audience apparently some of the earlier speakers said they don't exist which may be the same. if you seen what you've seen one. >> a lot of the first generation documents articles and research was done about it accountable we take the total population, we have the full data for each patient and function so the aco model the rest of the world is trying to get to actually is sort of various versions not cloning but looking like as and the people who wrote the law, people sitting in the little rooms writing the aco law so explicitly in the final days of the testimony they were trying to get the big countries to

function like the guys by two -- guisinger. now the rest of the world is trying to find out how to get that of that and it's a very creative and positive thing working with the care systems to create the business model that was in aco thrive and that is going to be very positive thing. but right now, the other version of aco. >> mark, i'm interested in how aetna picks up the issue of aco when you look at the market. how do you -- are there good relationships you're looking at? is it a strategic kind relationship? >> i think a couple of things. the world would be a wonderful place it for devotee was organized like kaiser permanente the structure of the delivery system and payment mechanism works well it's just that it is difficult to get the model to

scale anywhere else. and so our approach is how do we find the scalable model, how do we think about retrofitting the current system to impact what we have in the united states and a way to get toward the model george has in northern california. that is a big task. i would argue actually in countries like china and india we have a better chance of building this model because we are starting fresh even all the way down to the technology level than we are in the united states where we need to retrofit infrastructure capacity and the whole host of other things. as we have a number of pilots going on. we have seven signed aco deals as we said today, on hundred people on the list that want to talk to us. we are literally involved in moving into the infrastructure of creating sustainable systems of data and intellectual property of and managing risk. the question as which one of

those will work so we are trying to pick our partners well along on to make sure we have people that can be successful that get it so when working with them we can show a produced model and they are all in the different sorts of shapes and sizes so we can find what skills and what doesn't. >> from the perspective on these the were coming at it now on the delivery system. in particular though, the physicians -- hawarden working with your physicians? because this is a huge shift for many cultural shift business processes and practice patterns and so on. our you dealing with that? >> absolutely. the accountable care organization is the of promise of better clinical outcomes and efficient resource utilization. most of the world is not organized as integrated network as well as the world as organized as we are and as the voluntary practice round us. the great equalizer is information systems that allows

one to create a system across the different components of care the it cared at home or an ambulatory care environment and preserve to the conservatism edging and making sure that imaging is used appropriately and efficiently, hospital services as well. information becomes the great equalizer to the managed care in one sense but also the information about risk in the other and i think it changes that possibility frontier from being restricted to what has already been established as a hard wired integrated delivery network to the possibility for more traditional of forms in the world more broadly. and as to be accountable care organization, i'm not sure that i've seen one a singular form. certainly we are interested in the regulations that came out this week but in the commercial there's been many projects that work and just that relationship, the devotee to go to the risks to promised better outcomes and

more efficient resource utilization. >> there's been a question from the audience about among the various players, hospitals, physicians, payers, regulators, who really controls the silver bullet in here for the benefit cost per? >> i think the business model needs to change to reward bending the cost curve and the business model change can only happen from the pay to -- payer, the payer control the cash and needs to identify ways that the cash will flow and then the providers will respond. you can't expect the providers right now to create team care and invest all kind of resources in the care when they don't get paid for team care. i mean, we need to change the business model to make it work and so i think the first step is to the payer, the provider. the second step is the

combination of hospitals and doctors, but we have to start with the money. >> can we do it without cns coming along? >> nope. i think cms is essentials and cooperation with the payer community in order to make it happen. you've seen it happen many times. i mean, the chance to reimburse the for the nuclear medicine and cardiology practices when 55% of the practice revenue tied up in the nuclear medicine all this suddenly not hospitals to become a part of the system. i think that we can't do it without them. never. the upcoming reimbursement create an opportunity to partner and move ahead. if we plan more carefully together on how to do it i think we would have a greater impact and i think we don't act in concert we sort of for a fast follower behind cns when they make these changes. there's a collective the line with a sort of tale following through. >> care in this country is about to get a lot safer because of what cms is and be doing.

in fact come up until now, the business model has been like the car industry with the crash to the car and the reward for the crash of the car is that somebody got two more cars and paid for it. so, you have twice as much per patient you have 1.7 million infections. well, when cms stop paying for those of the hospital world will change the business model, to care will change and get a lot safer very quickly because you change the revenue stream. >> so if you -- how many folks are in the audience of provider organizations? issue with hands? >> pretty good number. if all of you were advising a local community hospital, 300 bed community hospital on what to do about all this, would you say blacks don't talk to george,

taught me? right? [laughter] >> you know, a couple of very interesting things happening. in 2002, 25% of the physician practices were run by hospitals. that number is now 55%. and our view would be that is going to approach 80% over the next five years. so, the institution is going to become the nexus of where this happens a lot of ways accept the large multi specialty groups like the sharks of the world. so i think that is going to have a fairly dramatic impact on how you think about it. so a very small community hospital and 300 bed community hospital in a small community, it depends on what you're surrounding competitive view is whether you're trying to be part of a larger system or create in that community a strong enough model. i would argue and i goals we

back to my days in michigan in the 80's went i went out to talk to the local hospital and the employers who were tired of increase in health care costs used to say you don't need me. you can go to the rotary together and have a conversation because it is all one community. and you all ought to talk to one another about what makes in plymouth and business sustainable and come up with an appropriate reimbursement model. i think would be a great way to think about it and the smaller communities of the our remote enough. if you're close a major writer put the ring and you have to be part of a buddy system, would be my point of view. >> let me answer that question, gary come and to finance. first, the will of the hospital as part of the community and second, the business case for equality. the first is the hospital and the community is probably a substantial employer that community is probably responding to the pressures of the increasing cost of health care. the businesses, the local and state government certainly. and i think the point my colleagues made earlier about the of devotee working with

other health providers and employers to words wellness keeping those individuals and healthiest as opposed to the at risk managing the at risk if they don't become those individuals burdened by chronic disease. for those individuals chronic disease that need to actively manage to keep them from getting to be in the stage. it's going to take the sort of collaboration working within ploy years and the paper to create the census for health and disease management and wellness, the basic engagement in that as well. the second is the hospital itself, in that environment where there is a history of cost shifting where this current environment be for medicare negative, 40, 50 states, structural deficits. there's going to be revenue pressure. and while many have looked on health care, optimizing supply chain and revenue cycle, what better way to get a real value

than try the quality-of-care because of the end of the date the product of the health delivery as health care and the variable costs are almost invariably associated with poor process and poor outcomes. for the safety and quality actually lead to lower utilization of resources and better policies, better outcomes for patient scum a better outcomes in terms of the resources consumed, better health population, better value. >> if i were advising a 200 or 300 bed hospital about next steps, i would say find partners that you like to do the things you don't do to be in the aco world. so find health plans that can give you the backroom infrastructure and do the parts you do very well which is to take care of the patients with acute conditions, chronic conditions who need the care and do it as a partner model. if individual hospitals try to go out into the insurance world

they have to create a sales force and the claims shop and all kind of things that are not of the core competency. the care delivery they won't do them well and they will do them at high cost and on the other hand of the focus on the delivery of achieving care to the right patient and they let aetna get 100% of the population and 20% need care and partnered with aetna, the 20% that need care. so unless you or a hospital in the kaiser permanente a region near someplace we need to build a hospital, and then call us up and see. [laughter] >> i.t. we have time for one last question and then we are going to change this one up a little from looking forward. do you see what is going to have to happen with bending the cost curve as a mythical to the continuing innovation engine, clinically that the united states has been for the last 40 years? >> it is the opposite, the exact

opposite. if we start focusing on rewarding better outcomes, the care of the innovation engine is going to focus on that and we are going to see an explosion of creativity. i don't think it is went back of the innovation. i think we will see innovation be becoming better. >> i agree this is an opportunity to invest in one of the best areas of the united states by medical sector. the pressures will lead to an ovation mechanisms to meeting the challenges of the environment but in terms of organizations but in terms of technology, decision support so that a patient gets the right diagnosis the first time. molecular fingerprinting so that medication that is given today and cancer is matched exactly to the specific disease of that patient. but even things to pick it is like high blood pressure, it doesn't work typically written off as no big deal. it doesn't work 40 to 60% of the time. take that lost waste out of the

system, better outcomes for the patient and use of resources. >> there will be losers in this because the system can't continue to produce some of the things it produces today. and so for some it will be painful and for others who have ideas like mentioned by my two colleagues here i think we are going to have a debate to an opportunity to focus on the right things but they will be consultation among the provider community definitely and in a number of ways which is causing us on the pay your site aco works very effectively. the charred and factors, you've already seen that happen in the pipeline of the medications that have been coming through in the focus on biotechnology. the medical device manufacturers are already thinking about how they fit into the system, so i think the tall order for all of us is where we have the right to

dialogue to find out where this works. who are the players that can come together and actually demonstrate that it can happen and create the momentum to have a different system. >> mark, jonathan mcgeorge, thank you for your dialogue. t twitter.com/

cspan. host: talking now to "sky news" about u.s./british relations. the headline is --

out britain and france are struggling to fill the gap and washington expects them to do more. guest: the u.s. has overwhelming firepower compared to everyone else. we in britain and france have been cutting defense budgets. just the sheer capability to mount an exclusion zone or in this case to provide air cover for what they hope is the mounting rebels is a huge task. that means planes are having to fly from italy or in some cases all the way from england all the way to libya. there is a practical strain on maintaining this particular corporation. that said, i think the point is accepted certainly in the leadership areas of britain and france that libya is more of an

issue for the europeans because it is much closer to home and the military and basin that it is to the united states. -- and the military base that is to the united states. the public was not prepared to stand idly by and see large scale massacres of citizens, which is what look like what happened. i think there was this great moves of something must be done at the same time there is reluctance to get engaged any further than we already are engaged, particularly the whole boots on theof ground. host: our guest will be with us for the next 40 minutes. he is adam boulton, political

editor for "sky news" "skyuest has been with news" since the start in 1989. he has covered many issues. how would you describe u.s./u.k. relations these days? guest: i think there was definitely a cooling off with the changes of leadership. barack obama, sum and britain say because of his history on his father's side with his grandfather being arrested by the british was said not to be particularly warm towards the colonial heritage, in some early i think it was clear that david cameron felt that the relationship between tony blair and george bush and bill clinton had been a little too close. therefore, i think there was a

feeling of standing back. what i think we're seeing now is iraqi president and prime minister are beginning to learn the world is not so easy as that. you cannot say to the rest of the world we will leave you alone. therefore i think there is a process every discovery under way. -- of rediscovery under way. host: we have seen egypt, libya, tunisia, and ivory coast making a lot of headlines. how do the british folks view all of these different -- guest: i think it is a little divided on how the british public see it. on the one hand there is no doubt that when david cameron

suggested britain could no longer be the world's policeman and should not be involved in intervention around the world, there was public sentiment because they knew what went on in iraq been pretty skeptical about what went on in afghanistan, but, and as i think is where things change, britain and british people do like to see themselves as being players in the world community, and therefore we're back to where we started in terms of being prepared to support military intervention. in a small way i think it is quite similar to the trajectory which the obama administration has gone through. host: there is a story out of paris -- what do the british think about

french mindsets now on north africa, on the middle east, on the presidency? guest: there was one headline that was not surrender monkeys anymore. remember that line from the simpsons about the french being cheesy. i think what we're saying is our right off-center presence in france as he tries to be more assertive, partly because he faces a presidential election next year and the polls suggest he is not very strong. i think seeing the french do their bit is something which the british feel more comfortable with band that very difficult time where france was on one side and britain and the united states were on the other. host: before we go to calls, what is the biggest domestic story in the uk? guest: after the credit crunch

of the fallout in 2008, we of course have our election last year, and we elected a government that is giving a priority to cuts. we had big demonstrations on the streets a week or so ago against those cuts, which are not that dramatic, but they are across the board, across the spectrum. everyone is feeling it from education budgets and health budgets and welfare budget spirit and our equivalent to medicare and medicaid. it is proving in the short-term pretty unpopular. one of the fascinating things is at the moment the administration here and the cameron government in britain are really conducting different experiments. you are not dramatically cutting your but it's yet, whereas we

have already started. it is between a rock and hard place. none of the options are particular popular with the country. host: gene on the air with "sky newsadam boulton. caller: i think that britain was dragged into the war by bush. in fact, i think probably a lot of the pri and people feel they're like to -- a lot of the britons feel they were lied to. i thought they were very relieved to have obama in there. in fact, most countries felt it was good. it was wonderful to get a black president and there. i would like you to address

britain's going to war. don't you feel there were not told the whole truth and that is how it got drug into it? guest: i was not aware of having reflected any personal opinion. i tried to reflect what the polls said. i think president obama remains more popular in britain in europe and maybe at home where people are deciding on the day for how they feel. i think there is appealing, which you can trace very obviously and public opinion that the close personal relationship between tony blair and george bush did contribute to britain getting involved in the iraq conflict as deeply as we were. that was unpopular, and therefore i think the wars at the time, david cameron was

picking up on the current popular opinion in terms of stepping back a little bit from a close personal relationship with the close incumbent, president barack obama. i think since then events have brought them more closer together, and both the president and the prime minister had words about no closer ally or special relationship, which to reaffirm that the country's continue to work your closely together. host: new york city on the republican line. i am calling because i look in history and see a lot of conflicts started by the british and by the british empire and how a lot of those conflicts are still complex we're dealing with today, primarily american conflicts. we look at israel and the state of unrest comes from the fact

that england did not properly establish an israeli government. it basically moved people out and said you people take it. -- they basically moved people out and said you people take it. you guys are making military budget cuts, and we are making military increases. i know that the english are not real happy when we pull out of conflicts or ask for shared responsibility, but we have for a very long time pulled the wait militarily for europe. look at world war i and world war ii, and i do not feel american should have the responsibility exclusively. i think there needs to be more of a unified process. nato is always a last resort. i know a lot of the english are not happy about the war in iraq and the money that was sent to troops. i've never once heard an american complain about having

to participate in world war ii. guest: i think you make a very good point. the fact of the matter is if we look at british operations, even in the recent conflicts, the conflict in iraq and afghanistan, the military effort, which britain undertook, in the end, we were not able to see through completely. we have to admit that we had been over ambitious and what we try, and in both cases american forces came in and took over military control. from an american perspective, it is personally -- perfectly understandable about asking if there is a question about britain to do its bit? .

all i can say is that for the size of the country, britain still has a relatively large defense budget. we're something like six in the world in terms of defense spending. what i would say is that except in the case of the first world war, consistently been prepared to act in concert with the united states around the world. you say a lot of the problems might initially have been created by the britons, but i would argue that the problems -- there may be a certain amount of truth in that, but that is because the democratic outlook on world affairs is shared between the british and the

american political culture. host: here is another libyan headline -- this is amid fresh reports of setbacks for anti-government forces, at least in one area to the uk perspective on all of this. is there a link of time, a patient's level with the public and the government level for an operation that may go on for a while? guest: not right now. i do not think people are calling for an exit strategy, for the simple reason it appears that the muammar gaddafi's regime is still in place. it will not budge quickly. there is a feeling that people will be prepared to support

that this is in terms of months. i think all of us, wherever we stand on what is going on in libya, do understand now that if muammar gaddafi manages to stay in place, it will be a mass of humiliation. -- a massive humiliation. host: muammar gaddafi sends a message to barack obama. the front page of "sky news." there is no detail here given on the message. what might the message be? guest: that shows that while everyone is a little uncertain about the extent of the military

conflict in which direction it is going, what we are seeing is a lot of diplomacy being paid. the french party recognized the rebels as an alternative government. the americans and the british are having contact with them. what we understand is this letter from muammar gaddafi is basically trying to generate divisions within the coalition against him by congratulating longer beingon it no longeno part of a crusade against the libyan people. he is trying to say now the americans have handed over military control. this is just a decadent colonialist wart and i congratulate barack on pulling out of it. president obama would deny he is pulled out of it.

host: 25 minutes left with our guest. democrat. andrew, good morning. caller: good morning. i kind of believe, as far as iraq and afghanistan, both conflicts were based on a lot so tof half truths speak. i believe the bush administration and the player administration -- the blair administration were in absolute lie. i think with obama here it is still the same thing. he says he wants to and the wars in iraq and afghanistan. we are still in afghanistan and dragging our feet with iraq. i think the british have been

brought into it and duped into it. i do not think they wanted this. tony blair wanted it. it was not with the people wanted. guest: i think public opinion has changed because of what has happened. if you look at public opinion of the time of 9/11 and certainly at the time of invasion afghanistan, there is no doubt about it at all the british public opinion was to stand shoulder to shoulder with the united states. is i think there was a difference -- i think there was a difference on the question of the relevance of going to war against saddam hussein in terms of connection on what had happened on 9/11. nonetheless, at the time britain did agree to go to war. the british parliament voted for

the decision to go to war, and british public opinion airily supported that decision. since then with the loss of life and really the breakdown that took place in both countries three or four years after the initial invasion in terms of civil order, our public opinion now thinks it is a mistake. there is one big crucial difference between why the british feel more critical of the iraq involvement and american citizens, and that is that we were told by our prime minister that we were going to war because their record to be weapons of mass destruction found. that was the argument consistently. those weapons of mass destruction were not found. at the time the bush administration was much clearer that they felt saddam hussein

was a bad guy who needed sorting out. we have had the same ambiguity this time around about the whole question of the regime change in libya. do this backwards. thoughts of the blair administration. tell us what we will find in there. guest: it was written in the final months of the blair administration, but it goes back over 10 years of his history so there is a lot about domestic events. he was a transforming live prime minister. -- transformative prime minister. it was written from the inside, because i was covering the prime

minister very closely, traveling with him a lot. there is a lot of diplomacy in the arguments he was making and whether they were strictly honest or night. -- whether they were strictly honest or not. there was an election and it was very unclear who had won. eventually you got president bush. we had very similar -- different political system, a similar situation in our election last year were there was not a clear result in the election, there for three political parties -- there for three political parties had to negotiate with each other as to how they would form a government. they formed a coalition, and we have not had for 40 years.

host: jeff, republican. you are on with adam boulton. presented then percentag united states winston churchill after the invasion. it was reported that president obama gave up back to britain. what was the circumstances behind that, and did you except it back? guest: the circumstances are that i think it was tony blair. normally when leaders come to visit each other they have an exchange of gifts. tony blair knew president bush was an admirer of winston churchill and lent him that.

at the end of the administration, the bus was returned to the british embassy. it was made clear at the time that the british would have been happy for president obama to keep it. he chose not to keep it. it was only alone, and that he has a bust of abraham lincoln -- bus of abraham lincoln. i think people try to turn it into a snub of winston churchill, but i do not think that was how the obama administration sought it. -- saw it. host: some in the news recently snub to describe the lack of invitation to the royal wedding that is coming. an invitation to the president. give us insight and expand a perspective on that. guest: i think the royal wedding

between william and kate will be a big event, but if we go back to the wedding of his mother, princess diana to prince charles, what we found is they are not quite full state occasions. on that occasion nancy reagan attended. i have been surprised, i have to say, that michelle obama was not invited. i think the president is making a trip to ireland, england as well at the end of may. i was i surprised that he was not invited. i was a little surprised that michelle obama was not invited. the only thing i can think of is that there is a personal invitation, and perhaps she does not know prince william and kate.

host: we have gone on the line for democrats in missouri. caller: good morning. -- we have donna on the line for democrats in missouri. caller: my first question is doesn't libya send all of their oil to europe? guest: oil is a global market, so i do not think all libyan oil goes to europe. what i can tell you is that because of the rise of the dollar against the pound in britain we are now playing -- the paying the highest prices ever paid because of the libyan conflict partly. caller: my other question is i remember when george bush was bragging about libya was laying

their weapons down,, and i have been watching c-span since the 1980's, but did the european alliance come in and have something to do with that? did they leave? guest: libya is not part of the european union, but i went with tony blair twice to the so- tent that muammar gaddafi sets up as headquarters. he wants to come to terms with the west. there is no doubt about it. tony blair lead that. as a result, we got much of libya abandoning its nuclear and

chemical weapons program, but it also said it would stop supporting terrorism. that of course was very important to britain, because it was known that muammar gaddafi had tried to supply the iraq. -- tried to supply the i.r.a. i have to say i was also at the g-8 some in italy in 2009 where the prime minister of italy invited muammar gaddafi to come to the dinner and president barack obama was in certain circumstances where he cannot avoid shaking his hand. it looks as if after that initial opening toward libya, personally things got a little bit too cozy. host: 15 minutes left. first, ed republican from

georgia. caller: i would like the viewers to know that we will pass to get our statue of winston churchill back. we love the english. they have been our allies for a very long time. you have one of the best queens since victoria i would say. i hope she lives a long life. host: going on to the next call. good morning. caller: i would like to make a comment concerning the second world war. i do not know how you can compare the second world war with what is going on in iraq and afghanistan. we were totally lied to. we stayed out of it too long.

too many people died. host: let's hear from tony in california. i am curious to see if the british people are aware of something that the united states is aware of. back when we went to iraq, muammar gaddafi kept his head down and was getting rid of weapons because he was worried that president bush would take his head off. now that the united states has a weak president, he wants to rise to the test. guest: on the last point, i was saying there is no doubt about it, the opening to muammar gaddafi in libya did come about as a result what happened to saddam hussein in iraq. i am not so sure in either case

that it is really about the strengths or weaknesses of the obama administration, up because by giving up the weapons he also consolidated his position as a libyan leader, because he basically said i am not a threat to you anymore. our reply was we will not put the pressure on you. host: scott on the democrat line. caller: this is not have anything pertaining to what you're talking about right now, but i have been wanting to get this out. i have a suggestion on how to reduce the deficit. have all of the congress, a cabinet, and senate take a 10% pay cut. if they would do that, it would start to bring the deficit down. guest: we have a freeze at the moment for all of our public

employees for fotwo years. the reality is given the number of the people on the hill behind you, that would not cut the deficit even if they did it for nothing. obviously the gestures which politicians make are important. i would say to the fan of the queen that after the excitement of the royal wedding in april, next year will be 60 years of rule for the queen, so there will be more celebrations as well. to the uk. how have all of this talk affected the health of the prime minister? guest: in may we have the equivalent of your midterm

elections. elections for the scottish, welsh, and local government around the country. frankly the opinion polls suggest that the labor party and opposition party will do well in all of those, although i should say it looks as if the people who will be hit hardest are not conservatives but the liberal democrat partners. host: harlem, new york. charles comer republican. you are on the air. -- charles, republican. caller: my ancestors are what we're talking about in africa. the libyans have never had

weapons. all the weapons were talking about are not there. no one even knew how to operate them. guest: what i would say is that it is a known fact that muammar gaddafi supplied the i.r.a. with some sort of weapons. there was a car bomb that killed a roman catholic policeman in northern ireland, and it is circumstantial evidence to suggest that was originally supplied by muammar gaddafi some decades ago. i think it is clearly understood there was a threat. as you are on your way back to liberia, maybe you should be pleased by the french and international involvement currently in ivory coast, because we do know and liberia there is a growing refugee problem.

obviously if there is a political settlement there, that might take some of the pressure off. host: new hampshire. dan, good morning. caller: what does your guest think of the british health-care system? guest: the reality is the british health-care system is extremely popular in britain. it is almost a sacred cow like the british public. almost like the bbc. we do have two national institutions that are effectively paid for by the taxpayer, and are effectively free at the point of use. no health care system is perfect, and it is certainly true that within the n.h.s. because the aim is to provide

care, in some circumstances you could argue that this does mean a certain amount of rationing and waiting for access. at the same time, almost no one in the united kingdom needs to worry about health care bill. they are very different systems. they both have their advantages. they both have their disadvantages. one of the puzzling things about david cameron is there are big changes being proposed in the national health service, which basically is suggesting that your family doctor should really decide on your treatment, but they are not designed to save money. they are pretty difficult to explain. he found himself in a situation where he is reporting a national institution, and no one

can quite understand why he is doing it. a lot of people are predicting a u-turn on the health care reforms. host: we have matt from st. louis. caller: my question is from an editorial perspective, do you believe the u.s. and great britain are becoming stronger allies as far as going forward with the promotion of democracies in countries like libya? i think the world would love to see that between the u.s. and great britain. what is your opinion? guest: i think there has been a change. i think if you look back into the last 50 years, what it came to is areas outside of europe

and north america, there was quite often a view that a leader might be unpleasant, he might be a bit of a root worude word. you could use bad dictators for your own purposes, and perhaps we will see this with the case of president mubarak in eygpt. what has been interesting with this wave of people demanding reform across the middle east is a respected of their position on the political spectrum. whether it is david cameron or barack obama or john mccain, there has been a feeling about in this world where we have much greater communication, much greater understanding that there is no alternative, but for most

mainstream political leaders in the west to support the need for reform. host: time for a couple more calls. st. augustine, florida. jason, a democrat. good morning. caller: you need to comment about muammar gaddafi. in the future, how are we going to work less address the issue of being the enemy of our enemy? we demonized iran, but in the help todidn't the cia overthrow a democratically- elected leader? host: hold that thought. one more question. and caller: i have a question. how could a relationship does britain have with israel, in

which party supports israel of the most? guest: i think both those questions put your finger on how wishes of is when you get involved in events abroad. in hindsight, people thought it was a very exciting prospect to get rid of the leader in iran. they did not anticipate the islamic government that would be formed. in hindsight weather in london or washington, people regard that as a bit of a mistake. of course there is the worry now in supporting change across the middle east that we could end up with infamous governments. i think everyone is aware of what went wrong in iran, and it does not appear at the moment that it is the head of the reform movement in the middle

east. we have a situation where barack obama and david cameron are supporting that. as far as israel is concerned, it is truly that generally speaking western european governments, the western union, is not as closely and automatically supportive of the state of israel as the united states has tended to be. that said, that there is absolutely firm support for israel as an independent, democratic state in the middle east, and i do not think there is a question of that changing. again, a bit similar to the united states, it is not something that tends to be a very strong party political issue, that there are elements of the right who are extremely critical of the jewish state's as they see it, but there are also elements on the left who are extremely supportive of the palestinian cause, but within

that, there is a general consensus that the hope is that israel persists and that israel is allowed to reach an accommodation with its neighbors hos. host: adadam boulton,