susan we'll turn over to you. >> we tried valiantly in the first session and failed, we will probably do that again today, just because of course as we all know there are multiple determinants of higher health care spending and these don't stend to exist in d-- tend to e discrete silos. and as you know, as ed said today, we're going to be talking

about technology and chronic conditions as drivers of health care spending and health care costs. we of course are attempting to understand not just the role that these play in contributing to the health care costs and spending issues but also in particular to start to discuss what is actionable, what can we actually do about these things, are there policy initiatives that would address them that would not contravene some of our own goals in having a robust health care environment that does address our needs. so what we will hear this tension throughout the conversation today as we discuss some of the actionable -- potentially actionable policy solutions but recognize that there are trade-offs involved in embracing them all. to get us started, we're delighted to have two speakers, joe antos from american

enterprise institute and ken thorp from emory to expect about the roles of technology and chronic conditions. and joe, we're very happy to have joe here with us today. he decided to have an authentic health care experience over the weekend in order to have a legitimate grip on his subject, but joe managed to come back from a case of sciatica and be with us today. joe, thank you so much for being here. we know it was only with considerable effort that you were able to join us and we appreciate that. so, joe, we're going to start with you. joe has a presentation and then we'll move directly in to ken's presentation. joe, all yours. >> thank you. what do we aim at? okay. all right. there we are. so i promise to stay on the subject for whole minutes at a time, technology, and of course

you saw the picture of marcus welby. you know, if you got up this morning and took a pill, you used medical technology. that's probably what almost everybody in this room did. i took quite a few pills. they didn't do much good. rick, get to work. but virtually everybody -- what's that? i'll be getting to that in just a second. so rick has already taken me off of technology and out of my favorite topic. marcus welby, that instrument that he's using, that was probably the best one that he had in those days. the reason he went to your home to visit you, he took that black bag, what was in it? a stethoscope, something that had been available sense the greeks. they had a thermometer, too, good deal. health care is not practiced that way anymore. and i think mostly we can say that's a good thing.

so there's the contrast to marcus welby. that is is proton beam therapy chamber. it's somewhat controversial but one thing you can be sure about it is it's expensive. it's always interesting to know how these things work. here's a nice schematic. you can see there are these various ways to treat people. the real power source of course is money. if we didn't have big demand for this kind of technology, we wouldn't spend the money. it's the money at that drives the system. so i'm glad i got past technology so i can now talk about economics. no, seriously, i'll go back to

technology in a minute. so that's the point. as susan said, the various sources of health care cost growth that people have attributed over the years are not separable and in particular they all have their root in either the supply of something or the demand for something and since it's a market economy, it means money. and in this particular case it's both supply and demand. so anyway, here's something that i found in someone else's presentation, i thought it was very interesting. this does reflect the march of cost of technology and of course the march of progress. you know, the traditional technology, which it's not clear that that's really traditional. the real traditional technology of course is something the cave man did so this is really kind

of advanced stuff since about 1910 or so. but, you know, we'll take it. and you can see that over time we've gone to more and more sophisticated equipment and every time there's a new generation of equipment, it seems as if the cost is higher. what i can't tell you for sure is whether this is in price adjusted terms but it probably doesn't matter. i think the impression is undoubtedly correct. when people talk about technology, they usually think about pieces of equipment. it's not just pieces of equipment. it's essentially everything that a doctor does. i mentioned drugs. that's part of technology. equipment is part of technology. not just the equipment that is in the hospital up against the wall of some big thing but also the little things.

the stethoscopes work a lot better these days, to pick on the thing that i mentioned marcus welby had. but also it's medical technique. that's part of technology, too. even if the basic tears are the same as they were 20 years ago but you now know how to do it, that is an advantage in technology and all of that adds to both the supply of services that are available to treat disease and diagnose disease and also the demand for such diagnoses and treatments. now, one of the things that you'll see in the literature, which i've never particularly found useful, i'm an old labor economist at heart, but technology, you'll see the studies that try to parse out how much of cost growth is accountable for -- by various kinds of factors, including technology and technology is

that -- is that one thing that can't be directly measured, although i'd argue that the other factors that people usually point to aren't that measurable either. everybody admit that technology isn't that measurable. so it's not technology, it the i don't know factor. so if you see somebody say technology is responsible for 60% of cost growth over some period of time, maybe. maybe not. it's just not at all clear. and technology alone -- as su s suess -- susan said, technology alone isn't the culprit. if people didn't want it and the money wasn't there to buy it and doctors wouldn't do it, then that technology wouldn't be used.

so when you have better technology, you generally have better care. not uniformly but overs vast span of time we see this to be the case. and my example is cataract surgery. there's evidence that a crude form of cataract surgery that was literally someone putting a stick in your eye, was practiced sometime in the babylonian era but more concrete evidence, there's evidence of something in the 16th century of sticking a fancy stick in your eye. that didn't work too well, probably wasn't used too often and there wasn't anesthesia at that time so you had to really want to do it. in the 60s, vast improvement in enpatient operation, we've

learned something about infection so in the 60s we're far more capable of dealing with infection, that was a technological improvement. but it was risky. this is the kind of thing you used a sharp knife, probably sharper than something you're likely to see on the streets of washington in the evening but it's the same basic principle. essentially because it was so risky, very few patients ever got it, it was always reserved for those patients who literally couldn't see out of that eye, often only had one operation and the idea was to extract the lenz and after the operation, which was highly risky, they sewed things up and then the patient was held in the hospital room with at least two weeks with sandbags so they wouldn't move. very uncomfortable. not so much patients were willing to try it and those who were willing to try it were absolutely at the end of their

ropes. that wasn't too long ago. then we move to today, sometimes within the last 15, 10 year20 ye have a much more sophisticated procedure, doctors are liking through microscopes to make sure they're cutting exactly in the right place, using a more sophisticated procedure to replace the lens theshs replace the lens with something that makes you see better than you ever saw in your life. and even better only the unfortunate few don't make it to medicare before this happens. if you're medicare patient, they pick you up, give you lunch, zap out an eye and two weeks later they do the same thing. so it's the food program. the fact is that better technology is generally consistent with more successful results. and if you have something that works better, you generate

better demand. those the price might be lower on a per-patient case, the price is generally lower. there's no guarantee that the price will be lower. overuse, underuse, misuse. these are the terms that everybody hears and a great example has to do with treating coronary disease. this is from a paper done by skinner and they classified using another study from somebody else, they classified different kinds of treatment according to their cost effectiveness and their cost. and you can see the way they did the classification, and i'm sure anybody could have ample reasons to argue one way or another on any specific intervention but i think the overall sort of pattern here is interesting, that effective low-cost

treatments were, according to them, accountable for more than half of the mortality decline due to coronary disease between 1980 and 2000. of course they didn't have the guts to say that anything was actually not cost effective but less cost effective and probably there wasn't anything that wasn't effective in a sense and the word "cost" i think is probably an issue here. you can see that according to their categorization, the more aggressive treatments, constituents, cardiac rehab, they're much more expensive than aspirin, for example, that they account for maybe 19% of the mortality decline. you want to be a little careful about this kind of display because you have to ask yourself something they didn't ask themselves in the paper, which was what was the condition of the patient? somebody who really needed a

cabbage, you could shove an awful lot of aspirin into their mouth on their way to the morgue. so it's not at all clear -- this is in fact a kind of a resit you'll study. it's not very reliable either, but it does say something about our use of services and it does imply something about economic incentives associated with the complicated things. aspirin, who makes money off that? not even the drug companies. cabbages, who makes money off of that? you know who they are. that's something to think about. nonetheless, would you turn this down? would you go back to marcus welby's day where they had heard about infection but basically couldn't do much? no, of course not. the thing is they want all those things. i'm still sore at rick because he hasn't given me the drug

that's really going to help me. but i'll give you till 2:00. what about evidence? can we find out about evidence? here's a study by elliott fisher looking at regional variations in medical spending. and this is an index called the end of life expenditure index. so these are medicare patients at the end of their life, i didn't read the article close enough to know how close to the end of their life they were but you knew they were. so pretty close. and look at the distribution of tests and procedures that were done on people close to the end of their life. and lo and behold what do you see? very few major procedures, quite a few more minor procedures but a lot of imaging, tests, evaluation and management. that's where the money is for the very sick people and obviously that's where the money is for the not very sick people.

it's not in that -- i mean, there's plenty of money in those fancy machines, don't get me wrong. but where is the real through-put? it's in the seemingly ordinary interventions that we're all used to and expect. that's where the money is. okay. so, well, everybody says, well, let's do some effectiveness research and figure out what we really should be doing and don't do the this evenings we shouldn't be doing. the only problem is that there are an awful lot of things that we do and there are very few studies looking at what we should be doing and i don't care whether you look at the stimulus funding and you look at the billions of dollars that are going into other places. the research can't move fast enough. you can't spend enough money. you'll never get ahead of it because things that we accept for granted we do without question. and occasionally when we

question it, such as the on and off again discussion about the blood test for prostate disease, we get a lot of resistance because that's not the way we do it. the reason is that it's probably more than 90% that we're never going to look at, that 10% or whatever the percentage is the small part, the glamorous part. it's heavily regulated, it tends to be drugs first and that doesn't strike me as being the intelligent way to allocate resources if you're going to look at effectiveness research. this wasn't meant to be a diatribe against skeptical research but i've always been skeptical. these are always highly refined. it's not clear they would tell you what would happen to the

average patient in the average setting and that's a problem. that's what you want to know the answer to. is it going to work most of the time rather than under ideal conditions or is it not going to work? things that would work under ideal conditions might well not work under normal conditions. of course let's not forget about the patient because the patient might not be adherent either. and professional judgment changes all the time. why is that? because there are changes in the way you do things and partly because our experience grows. we see more patients. that experience is accumulated not necessarily systematically but it is and our views, professional views about what to do changes all the time. effectiveness is interesting, it's going to make a lot of people a lot of money, i don't think it going to have any substantial impact on how we spend the money. can we spend or money better? i think there are some things we can do. part of the problem is that

hardly anybody in this country actually pays for what they get. they pay for it, they pay 100% for it but they don't know it. they pay through indirect means. when they go to their doctor, the doctor can't tell them how much it's going to cost them because the doctor doesn't know what he's going to get paid. that's where we have to focus our attention and we also focus our attention, of course, on better information. but if you have don't know the price, you are don't know much of anything. knowing clinical effectiveness doesn't get you halfway to knowing whether that's something i want. because what you want know is value. so there are lots of things we can do. the medicare problem has tried lots of things. they haven't been very successful because it is not a health program, it is a political program and political programs cannot make decisions. they try but they can't.

i was tied up with the centers of excellence project, it was a great project, it worked spurtly and it was shelved. another program, the hard part was not setting it up to phase in something that might not work, the hard part is phasing it out. what can do you? conservatives talk a lot about financial incentives. i think this is a case where we do need to apply financial incentives the whole system. private insurance i think is the more likely place where you're going to see action along these lines. along any of these lines. why? because although they do ultimately report to congress, they don't report directly to congress. so there's a possibility of some progress in making hard

decisions and trying to make them stick. i've got to say i haven't seen much evidence of that but as conditions -- economic conditions tighten, as business conditions tighten, as the resistance of employers to higher premiums thereby necessary stating to keep premiums not so high, necessary stating higher and higher ded t deductibles and co-payments, i think we'll begin to see that turn around. one theory that chandra advances is why don't we attach differential co-payments to measures of effectiveness and that sounds like a great idea until you ask ask can you really trust those measures of effectiveness?

my answer is it's to variable. new business structures that provide real financial incentives for physicians to rethink their style of practice that, makes a lot of sense if we could find the right kinds of structures. i don't think we've found them yet. what about consumers? in the end what's a consumer? it's a patient. i'm a consumer and if i could find the right thing for me today, i'd go out there and buy it and i'd be paying for it with my own money chances are and i'd be delighted to do it. so what i'd like to know wanted to know and what consumers would like to know is not only whoo

what is it going to cost me but how is it going to affect me and that's really hard to get an answer to and that is really the key to understanding how technology works. finally what about expectations? i left that here for consumers because in the end we don't change our views about what we demand as an absolute minimum and, rick, i wanted to assure you it's a complete cure immediately but until we get reassurance about those things, we will not get control over cost. thank you. >> thank you very much, joe. as joe said, technology adds to both supply and demand and one of of the things we know we have an unending supply of right now are patients with chronic disease. so, ken, over to you to talk about that. >> okay. first of all, thanks, ed and others, for inviting me. it's a pleasure to be here on this panel. great to see everybody that you

often don't see all the time so welcome back to work. i'm having a tough time making the transition myself so i'm delaying this a little bit. susan mentioned i'm going to talk a little bit about another angle of this but it's really not unrelated to what joe talked about, as you'll see in a minute. it always fascinated me in health care some of the most fundamental big questions get the least amount of attention in study. six years ago i went and looked at the literature of what do we know about public data about what's driving the growth in health care spending. one of the last few pieces i saw was a piece that joe did, i guess it was '92, '93, looking at the time period between 1940 to 1990. and if you think about it, that was a very different time period than the most recent experience

that we've had. the number off uninsured over that time period went from 19% to 15%. so the amount of induced spending as our whole system changed overtime was roughly rerelated to insurance and demand and innovation. we brought medicare, medicaid on and we had new innovations that fundamentally changed hough we treat patients, neonatal intensive care units, treatment of low weight babies, treatment for cardiovascular disease and so on. it was a different time period. i'm going to spend my time looking at the time period between the early 1990s and today. i think the point i'll make is that even during that time peefrd the year-to-year changes

in what's driving the growth in spending is somewhat different. i want to look at the long-term drivers here that are more recent. i've sort of taken -- you can decompose this into a lot of different ways. i've looked at this and tried to sort the data into three buckets, looking at the change in spending linked to the chang in the prevalence of treated disease, looking at the the change in spending linked to how much we spend to treat a case and obviously the interactions between the two of those. and if you look it-from-the late 80s to today, about 60% of the growth is linked to rising prevalence of treated disease. we'll go into what accounts for that. some of that is going to be good, i'll argue, some of that is going to be bad that we can go in and potentially do something about. so just to give you a sense of some of these -- the magnitude

of the changes here u, you can down by medical condition and see the prevalence increases and in each of these condition, the factor driving the growth are somewhat different. if you look at the treatment of cholesterol, mental disorders, those have obviously increased very dramatically. much of that is technology related. we have new approaches for treat, patients with cholesterol, we have new medical innovations to treat people with mental disards that we didn't have 30, 40 years ago. diabetes, i'll come back and talk about that, that's almost all incidence increase. it's not anything to do with detection, largely more patients we're seeing with diabetics, one of the key drivers of rising spending and medicare is rising incidents of diabetes and other

cardiovascular related incidences. there are enormous increases in prevalence of treated disease. if you take a step back and say what's driving this growth? some of it as i mentioned is going to be things that we should be happy about, some of them are going to be things we shouldn't be happy about. so the first one, diabetes, our detection rates of diabetes really haven't changed much in the last 20 or 30 years. we're today detecting about 72% of total cases of diabetes. that's gone up from the upper 60s 10, 15, 20 years ago but we're not doing a whole lot better in detecting diabetes so the prevalence -- treated prevalence numbers we see for that are really just incidence increases, not detection increases. the second one is debatable and controversial but there's no

question that over time we've changed the definition of disease. particularly cardiovascular disease. most of the studies i've seen that have looked at that think that's a good thing that, a more aggressive treatment of cardiovascular risk factors has been a leading cause of declining rates of card your vascular mortality over the last 20 years. new medical technologies, the treatment of mental disorders and joe went through that, provide more fools for to us treat pishs that we didn't have and changes of disease. if you look at something as simple as diabetes, that's changed a little overtime in

terms of the clinical blood sugar levels that kick off a dying of diabetes versus prediabetes. one of the things that's very different in this time period that we're looking at is increases in obesity. if you look at the 1960s, 1970s, 1980s, that whole time period the share of adults considered obese was about 17%. really didn't change for about 30 years so clearly not a corrector over the time period that joe was looking at to rising health care costs. it was just not changed. it was a constant. that's not the case most recently. if you look at the long-term trends here and hopefully we're stabilizing it a little bit, it's doubled since the mid 1980s and if you look at some of the calculations that are just linking or looking at hope of the growth in spending is due solely to obesity holding

technology constant, holding treatment intensity constant, depending on the time period you want to look at, it accounts for about 7% to 10% of the rise in spending. cbos did an estimate of it and came up with 8 %. of all the things that we can actually quantify, to joe's point, of the things that we can try to quantify, it is an important contributors. about a third of the growth of medicare spending is linked to cardiovascular conditions that are lifestyle related, diabetes, arthritis, kidney disease, hypertension and mental disorders. the things that are interesting about those conditions in the medicare program is those are largely conditions that are ambulatory treated with appropriate medication. unless you botch it up somehow, with the exception of kidney disease, you really have nothing

do with inpatient hospitals here. this is dealing with am latory care, primary care, medication management. the ultimate irony of that is traditional fee for service medicare is really the only major payor, unless you're home bound, that has no care coordination. so it just doesn't do it. we'll tell you you've got a problem in your personalized care plan but we don't have anything available to engage people in medicare to help them deal with these conditions. as i've mentioned, the share of spending increase leaninged to disease prevalence does differ over the period period you're looking at.

over the last couple of years, spending per treated case is a more important place but if you go back and look at the long-term trends, it's disease prevalence increases that are driving it. if you try to drill down a little bit more and say, well, we f we can look at treatment intensity, meaning how much are we spending to treat a particular case of diabetes or heart disease over time and how much of it is just due to increases in obesity, again, holding technology constant, as i mentioned about 7% to 9% is due to obesity alone and if you look at the 1987 to 2001 time period, about a quarter of the growth in spending is due to increases in the intensity of treatment. of how we're engaging and working with patients. now, some of that is due to changes in technology, clinical

threshol thresholds for treatment, clinical judgment of how aggressive we should be on treatment. if you look at obesity and treatment intensity, anywhere from 20% to 30% of the growth is linked to both of those two combined. so what are sot of the challenges here? that we face? we know that any given year that obese adults spend about 40% more in health care and depending on there's a whole range of different estimate of how much is in the base of spending linked to obesity. the last piece i saw was certainly around 20s are 21% is due to obesity alone in the base of health care spending. as a productivity component we spend a lot of time focusing on the health care piece but if you look at the total kors every

dollar we spend on the dollar side, we're losing productivity. >> let me go back to my medicare alcohol ng and look at life time health care expenditures and if you compare the lifetime spending of an obese adult versus a normal weight adult, anywhere from 20% to 40% more spending over the course of a lifetime at age 65 on medicare. so the point is is that this is a very different story than smoking. smoking is a mortality discussion, this is a morbidity discussion, that there's not really the huge differential mortality rates linked to obesity. steems to me if you think about

medicare, there's two opportunities that i think are important. one is to find ways to change the incoming health profile of people coming into the program because there are long-term potential savings with a healthier population coming in at the age of 65. i'm sure melanie with l talk about this, they're doing a great job of trying to build in more coordination, think about the opportunities of putting into place care coordination inventions. i think in programs like medicare, they enorm as you. medicare is going to spend roughly $ billions on and the frustration is that we actually

have interventions that are effective. we have a program that eric holman has developed out of university of colorado denver that has several randomized trials that shows we can cut readmission rates by 50% to 60%, we have a more advanced nurse practitioner model that comes up with similar results. that should be a major component that is -- i think there's opportunities here but we have to focus on it would have the problems we can actually do something about. one is preventing and alerts disease in the first planned lot to have a discuss and, second ssh to really build into programs look medicare evidence-based components and care coordination that we basically have decades worth of

randomized trials that show that they work. things like transitional care, medication management therapy management, health coaching. so we know the elements that are effective. i think we just need to find ways to integrate them and build them into medicare. so with that i'll keep this short and i really look forward to the discussion. >> great. well, thanks to both of you. so we now have some time for clarifying questions if people want to ask questions specifically of ken or joe to draw them out on points they made. we don't want to get into a lot of deep analysis of what they said at this point or debate, but just again clarifying questions. if you do have a question, please introduce yourself briefly by name and affiliation and be sure to switch on your mic. let my me take a quick look

around. i'll take the moderator's prerogative to ask one to you, joe. if i look or at your slide "high cost of technology" and i look at current technology, i see surgery robot and treated constituent, both of which recent studies have shown do not materially produce better outcomes for patients. and, in fact, with respect to the treated accident constituenconstituent johnson&johnson stopped making them. that underscores that we have technology that does not produce better results but costs more or could be harmful. the institutes of medical tell

us about half of the efforts we engage in, there's no proof that they work at all. i was curious why you didn't put more emphasis as some -- i want to make the somewhat counter point that what we're going to focus on is in fact the treated stent and actually less so the surmgry robot, since that's such a great marketing tool for big hospitals and people want to believe that somehow putting a machine between the surgeon and their body is necessarily an improvement. they really would like an improvement there because they think they could be seriously harmed or killed. but, you know, the fact is that we do have a tendency especially

on stents, for example, smaller things, we do have a tendency to look at them. for one reason it's easier to examine the effect of the stent because it is a purpose. it doesn't have multiple purposes. it is less dependent on the skill of the physician to place it for example. there's some skill involved but it's somewhat more singular product that is more amenable to testing. that i think is maybe the point i'm trying to make, that we have a tendency to examine the things that are easy to examine and not the things that are really hard to figure out. and the hardest thing to figure out are the things that are standard practice. so there's some hope for technology assessment. there's -- in my view there isn't much hope in going from assessment to sound medicare policy, but there could be plenty of hope going from good

technology assessment to good professional standards. >> kent, quick question for you. you have used the phrase "treated prevalence" here a lot, suggesting that you're distinguishing between just prevalence and treated prevalence, obviously, we treat people. can you dissegregate those two pieces? for example, potentially possible, we're giving statins to a lot of people for high cholesterol and there's debate whether that is the correct set of interventions. how much of this is treatment independent of actual prevalence versus treated prevalence? >> i'm confused. >> i'm getting hammered. >> it's not even happy hour. >> are you sensitive about these

hard issues? >> well, the phrase for me, treated prevalence is to distinguish the fact that we really are only engaging a fraction of patients that have different conditions. go back to my diabetes example, 28% of people that live with diabetes have not been diagnosed and don't have a medical intervention. so at some point hopefully they will. but at any point in time, they're not. so that's the distinction. the other part of is it, you know, is an important issue. i tried to distinguish in this discussion that there are components of prevalence that we could intervene and do something about aand we want to, issues around obesity, diabetes and lifestyle, things like diabetes we can reverse the curve on. other components, go back to my slide, look at treatment of

cholesterol are hypertension, that are you know a medical call that says, if we are more aggressive at treating those diseases, plus we have the new technologies to do it, that it does produce better value, that we're reducing cardiovascular mortality, improving the quality of life and so on. i think some of the stuff that david cutler and others have done looking at the impact, hyper tensives and cholesterol are good investments. but those are part of the discussion here, is that we have changed and made a medical decisions and treatment decisions that say if we're more aggressive at treating certain types of cardiovascular risk factors, that they do pay off. >> yes, brad.

>> brad stewart, we're building systems of care coordination for seniors. my question to you is, i'm a primary care doc for a third of a century and research as well, all of our discussion -- and i'm coming from a provider place -- is focused on the providers. what about preference of patients, particularly seniors who are in this near-end of life population where our data is showing now that they would prefer not to be patients they would like to be comfortable and stable and safe at home, and i think we have systems to begin to do that. but my question around the data is, we have a lot of studies now on effectiveness, in other words, is the treatment necessary and valuable? what kind of data do we have on preference where we know -- we begin to know whether these

treatments are actually wanted or unwanted which, to me, is much less controversial than trying to decide what's necessary. you often can't know what's necessary until after you do it and it hasn't worked. it's not controversial to know that people really don't want this stuff and as it turns out, many of them don't. >> that's a -- that's a great question. you know, as i think about these different models of primary care and care coordination, and to your point about take palliative care and giving people options and decisions about the type of care, how aggressive they want care to be toward the end of their life, lord knows i don't want to bring up death panels, but yo know, that's a legitimate discussion that needs to be built into the coding of medicare, needs to be part and parcel of how families and patients and health care providers talk about options. and you know, i think that's a

classic example of working with patients to give them options and give them information and have the time to be able to have the time to from a physician's standpoint to talk about that, is important. and we're -- you know i've seen more and more interesting palliative care models k s comeo place. hospice, again, another important component of that. but having the time to have that discussion in a fee for service system is a real problem. i mean it's just not built into the coding. it's not built into the amount of time physicians spend on counseling with patients on important decisions like that and it should be built into how we think about doing care coordination and primary care with patients to give them options, and then have options out there available. another example on the other side of this, if you think about to me the incompleteness of the

medicare wellness benefit, we built in a welcome to medicare physical, we're going to do app personal care plan that says you're overweight and diabetic but we don't cover anything to do anything about it. there are programs like the diabetes prevention program that the ys and united health group have put into place that we shown in randomized trials, including community-based randomized trials they generate a 5% to 7:00% weight loss. that should be an option, built-in to the medicare program that would give people a choice of, geez, if i want to make a difference in terms of changing you know lifestyle or improving my blood sugar levels, that should be a component of what medicare covers. on both extremes we don't give people a whole lot of options because of the way that medicare coverage policy works. >> rick smith.

>> hi, rick smith. ken you have references several initiatives around the cluster of chronic conditions that you identified as significant cost drivers. can you speak a little bit to what happens to utization and outcomes as these interventions take place and, you know, how does care change and what is that ultimate will add up to? >> it's a good question. you can look at the -- look at the prevalence data in terms of how we're treating patients with cardiovascular risk factors and the important questions, what are we getting from it? is it worth it? i referenced david's work on in this and others, i think on balance the more aggressive of treatment of patients with cardiovascular disease is worth it. we're getting improvement in

longevity, improvements in the quality of life, that those are investments that not only are clinically driven but generating better outcomes, so that those are sort of parsing my prevalence increases into two components, things that are good increases, things that we want, you know, make investments in, should be happy about, that would be a series of them that we've done on statins and cholesterol and there's a series of prevalence increases that are bad that we should try to do something to reduce our incident increases linked to lifestyle and diet and exercise and smoking like, diabetes. there are different -- there are different issues how we think about them i think are very different. >> let's see, tom miller. is your head up there? we'll come back to mary ellen. tom miller, a.i. we've gotten good and clever coming up with new names to call chronic conditions, got a code,

we can find a technology and bill to throw at it. you have a list of the ones that have had greater treated prefb lens. when you do your time series, what have we had any reduction in, in term of treated prevalence? what's gone off the list. great savings in smallpox. is it an added key to the keyboard? >> that's a good question. we've probroken these into i gu we have 260 that we've looked at, and i'd say most of them are fairly constant. i mean, obviously big ones like heart disease and cancer are getting improvements in. the one that has been the biggest decline which actually adds to, you know, actually adds to a lot of the cost is trauma. the prevalence of trauma cases has gone done fairly substantially. that's a big redux. but most of these have seen, you

know, fairly substantial increases over time. a lot as i mentioned have been owe decemberty related and a lottery lated to cardiovascular risk factors. i think kind of the interesting thing is, is that if you look the spending growth of the united states, going back to '40s for '50s, not that it's a whole lot difference. it's 2, 2.5 percentage points above gdp, you're not out of whack internationally either, we have seen differences in what's generating that delta. so if you look at a medicare patient in 1965 versus today, they're very different. i mean the clinical profile's different of the patients. the typical patient, driving in spending medicare today is overweight 70-year-old hyper tensive diabetic with bad

cholesterol, yas asthma, back problems, pulmonary disease and is depressed. those are all conditions that really require behavior change engagement, appropriate ambulatory care, nothing that medicare does. >> let me add something, though. this is a pitch for a technology. one of the reasons we have more treated prevalence on nearly everything is, it's easier to treat. also there's the push for so-called prevention, which means earlier diagnosis, so it's hard to know where all of these fit in. i do think that the march of medical progress is contributed considerably to this trend. >> so mary ella payne and i think dan callahan has a hand up, as well. >> should we be thinking more about targeting hot spots or targeting populations or targeting industries? a lot of what we generally talk about is broad policy changes in

medicare and other areas. but certainly the obesity and other risk factors seem to be located in certain parts of the u.s., i would argue. should we start to focus on those areas and maybe not have across the board sort of improvements but in order to get you know given limited resources to think about that a little bit more? >> that's a good question. i'll give you my pitch on the diabetes prevention program. so here -- we have a population of 80 million people nationally that are predebettic. we have a program that we know through ten years of clinical trial follow-ups that has accumulative reduction in incidence of diabetes of 34%. it works at a point in time, a ten-year follow-up study that shows over time we can reduce it. united health group and ymcas have put these into place in 25 states. we can reduce weight by 5% to

7%. we can reduce incidents of diabetes in a short period of time by 58. for older populations 71%. that program could be scaled nationally in the next 12 to 18 months for $80 million. not "b," "m." why in the world don't we do that out of the public health fund? that's something that is an investment that we should do, build that one simple program in nationally, have it available so that small employers could use it medicare patients could be referred to it, and exchanges, plans in exchange could refer patients to this. now that's a simple example of something we should be doing because we know it works. i guess my point of saying that is that, we have a whole variety of interventions that would target these programs that i've

talked about that we have years of data to show that they work, transitional care models, diabetes prevention program. we need to flip the switch here and get into implementation mode, not pilot project mode. we're not going to pilot project ourselves into a solution here. i mean, we need to sort of take things that we know that work, target them, to at-risk populations, and we could make an enormous difference. >> that was my point, it's not doing pa moo more pilots it's a getting package of services that works to people at highest risk and certain parts of the country. >> that would be great. i live in the obesity triangle. if you take the cdc, cdc data on obesity rates over time, looking at changes and diabetes preferen preference, they're the same charts. we have things that we can do right now that would make a difference. you know we just need, as i

said, flip the switch and focus on implementation and you can tell from what i'm saying i have pilot fatigue. sure, we need more information and we need to pilot other different projects but we have so much data on programs that we already know that work, that we should just implement and bill into how we do business in the exchanges. if you think about on the exchange side something that we're not talking about is that, in the definition of essential health benefits, we have in-patient, outpatient usual services but a component of certification for plans to be and exchanges prevention and care coordination. what do we mean by that? what are we certifying and asking plans to do in exchanges on prevention and care coordination? geez, there's really simple things that would make a lot of sense that we would hope plans would do, like transitional care models and lifestyle programs

like the dpp. >> dan cal lanlahan then the rer panel. >> one issue not touched on, how do we -- i'll take ken's example of the 70-year-old withall of the things wrong. talk about coordinating care. how do you assess care with multiorgan failure or multidiseases at same time? we're very good at individual cases but a team of physicians together and trying to coordinate them, how do they assess the overall work and interaction? >> i'll put my m.d. hat on for a minute. ken, i think this is a great example of why having team-based compare, and if you look at some of the health systems that do, i think, a pretty good job of that, whether it's marshfield clinic or guisinger, where you are building teams to deal with

multiple multiple problems and treating patients holestically, is probably the best way to go with this. think about, take medicaid, a good example, even a medicare when we do care coordination a lot of care coordination segments off of care coordination into different buckets. you'll have behavioral health care contracted out, pharmacy contracted out, acute care. you know dealing with a patient that has all of those problems. so even coordinated care sometimes and medicaid is not coordinated at all, fractured. to the extent that you continue to drive this towards payment reforms that really move us towards team-based care, that really engage patients for the whole range of medical problems is probably i think our best bet. it's not fee for service medicare, that's not how that program works at all. >> thank you. 'r